Datasets:

mimiklee

/

masterthesis_clean_text_20k

like 0

Introduction There is a prevailing view that women are less tolerant of shift work than men, i.e. female shift workers tend to report greater effects of shift work on sleep, fatigue, accident risk and health, although the evidence is mixed [1]. A commonly discussed source of gender-specific effects of shift work is gender roles [2]. Women in employment commonly experience a 'double burden' of having to cope with the demands of their job , while at the same time undertaking more work at home, particularly if they have children or other adults to care for [3][4][5]. For example, female shift workers may be more likely than their male counterparts to forgo recovery opportunities to undertake childcare activities. Clissold et al. [6] reported that female nurses felt unable to use their later starting afternoon shifts as an opportunity to repay the sleep debt incurred in the night shift, opting instead to use their free time to engage in domestic chores and childcare. One of the few studies to compare males and female shift workers doing the same job found that females up to 50 years of age had shorter sleeps, were drowsier on shift, more chronically fatigued and reported poorer health, compared to their male colleagues [7]. However, the gender difference was reversed after the age of 50, which may reflect the lessening of the females' double burden as their children grew up and eventually left home [2]. Shift work affects workers' health, well-being and safety through three pathways: disturbance of circadian rhythms and the body clock; shortened and disturbed sleep; and disturbed family and social life [8]. These pathways are moderated by individual differences and situational factors . The current study examines whether gender and the presence of children at home moderate the second and third of those pathways, i.e. whether the combination of being a shift worker and having young children at home affects the sleep, fatigue and work-family conflict experienced by women more than it affects men. --- Methods Data were drawn from the Swedish Longitudinal Occupational Survey of Health . SLOSH is an open cohort survey of an approximately nationally representative sample of the working population. Follow-ups have been conducted every second year since 2006. All labour market sectors and occupations are represented, and the number of men and women is approximately equal. Baseline data and follow-up data were drawn from five waves of SLOSH. Additional data concerning previous exposure to shift work were obtained from the 2008 wave . Participants were classified as being either dayworkers, shift workers who did not work nights or shift workers who did work nights ; see below for work schedule category definitions. The process of categorizing participants with respect to their work schedule is illustrated in Figure 1. If a participant reported in any of the five waves 2010-18 working something other than either daywork, shift work with nights or shift work without nights, their responses for that wave were excluded from the analyses. We then identified all participants who indicated being shift workers in any of the five waves 2010-18. When all shift workers in the dataset had been identified, the sample of dayworkers was drawn from the remainder who had not been categorized as a shift worker at any time. We sought to limit selection effects [9] by excluding responses of dayworkers with prior or subsequent exposure to shift work. This was to ensure that the shift workers were not being compared with dayworkers whose health may have been affected by prior exposure to, or a subsequent transfer to, shift work. Hence two additional exclusion criteria were applied to respondents classified as dayworkers. Participants classified as dayworkers were excluded if they had either: indicated in response to a question in the 2008 survey that they had previously worked night shifts for a year or more, or if they had not answered the question; or reported working any schedule other than daywork in any of the six waves 2008-18. The final sample after exclusions was N = 8938. Baseline data were based on responses from the first survey in which the respondent indicated being a dayworker/shift worker, while their outcome data were based on their responses at baseline and in the subsequent two waves . Ethical approvals for SLOSH and the current study were obtained from the Regional Research Ethics Board in Stockholm. Work schedule was ascertained by asking respondents about their normal working hours. Response options were daywork , evening work , nightwork , --- Key learning points What is already known about this subject: • Shift work has negative effects on workers' sleep and consequent fatigue, due in large part to the disruption of circadian rhythms. It can also increase work-family conflict as a result of the need to work unsocial hours. • Some studies have found that shift work impacts women's sleep, fatigue and certain other aspects of their well-being more negatively than it does men. • Women tend to undertake more unpaid domestic work at home, including childcare, and this increased burden has been proposed as a reason for them suffering more problems with shift working. --- What this study adds: • While shift work negatively impacts sleep, fatigue and work-family conflict, there is no evidence from the current findings that childcare exacerbates those effects, either for women or for men. • The current study did not show that women were more negatively affected by shift work than men, with respect to sleep, fatigue or experience of work-family conflict. --- What impact this may have on practice or policy: • Shift working parents of young children may not be at greater risk of impaired sleep, greater consequent fatigue or work-family conflict than their non-shift working counterparts. • The findings should be interpreted in the context of the data having been obtained in Sweden, a country with high levels of gender equality and state subsidized childcare provision. Gender was obtained from registers linked to questionnaire responses by means of the unique Swedish 10-digit personal identification numbers. Presence of children under 13 years at home was determined from a series of items asking about the number and ages of any children at home, from which participants were categorized as having either at least one child at home under 13 years or as none. Age was also obtained from registers. Educational level was determined from registers indicating the respondents' highest level of education attained, categorized as <3 years of higher education or ≥3 years of higher education. Employment status was self-reported, with participants categorized as working either full-time or part-time. Sleep disturbance, mental fatigue and sleep insufficiency were measured with items from the Karolinska Sleep Questionnaire, which assesses sleep problems experienced in the last 3 months [10,11]. Sleep disturbance was calculated as the mean of four items assessing the frequencies of: difficulty falling asleep, disturbed sleep, premature awakening and repeated awakenings; while a fifth item measured the frequency of experiencing mental fatigue . Sleep insufficiency was based on a single item asking whether the respondent felt that they got enough sleep . Work-family conflict was calculated as the mean of four items assessing the frequency with which work negatively affects life at home , adapted from Fisher et al. [12]. Mixed linear regression models with random intercepts examined the combined effects of work schedule, gender and childcare status on sleep insufficiency, sleep disturbance, fatigue and work-family conflict across up to three measurement occasions. In each analysis, an initial model was implemented with three between-subject predictors and one within-subject predictor . A second model additionally included a set of interaction terms that were relevant for the purposes of the current enquiry. Lastly, a full model was implemented that additionally included the four covariates . Interactions were explored with pairwise comparisons using Sidak adjustment for multiple comparisons. Mixed model analysis has the advantage of being flexible in handling missing data in longitudinal studies and is superior to imputation methods [13]. --- Results Descriptive statistics for the final sample, by schedule, are presented in Table 1 The main findings are summarized below, and a full account is presented in Supplementary Material . Table 2 presents the results from the third models that included interaction terms and covariates. In the analysis of sleep insufficiency , greater sleep insufficiency was predicted by shift work without nights 0.041-0.125, t = 3.90, P < 0.001), shift work with nights = 3.49, P < 0.001), presence of young children at home = 11.26, P < 0.001) and female gender = 4.32, P < 0.001). In the second and third models, there were no significant interactions involving the combination of schedule, gender and childcare status. In the analysis of sleep disturbance , greater sleep disturbance was predicted by shift work without nights = 4.37, P < 0.001), shift work with nights = 3.44, P < 0.01), absence of young children at home = -4.81, P < 0.001) and female gender = 12.21, P < 0.001). In the second model, there was a significant three-way interaction between schedule, gender and childcare status = 5.84, P < 0.01; see Figure 2). Among respondents without young children, females in all schedule groups reported more sleep disturbance than their male counterparts; whereas among respondents with young children at home, there was only a significant gender difference for dayworkers. The same interaction was observed in the third model. In the analysis of fatigue , greater fatigue was predicted by shift work without nights = 4.03, P < 0.001), presence of young children at home = -5.58, P < 0.001) and female gender = 15.30, P < 0.001). In the second and third models, there were no significant interactions involving the combination of schedule, gender and childcare status. In the analysis of work-family conflict , greater work-family was predicted by shift work without nights = 7.24, P < 0.001), shift work with nights = 5.16, P < 0.001), presence of young children at home = 4.41, P < 0.001) and female gender = 9.78, P < 0.001). In the second model, there was a three-way interaction between schedule, gender and childcare status = 3.48, P < 0.05; see Figure 3). Among respondents without young children, females in all schedule groups reported more work-family interference than their male counterparts; whereas among respondents with young children at home, there was only a significant gender difference Red horizontal lines represent pairwise comparisons between subgroups with-and without young children at home; blue horizontal lines represent male and female subgroups; solid horizontal lines represent significant differences , dashed horizontal lines represent significant differences . for those working shifts without nights. The same interaction was observed in the third model. --- Discussion Shift working was associated with shorter and more disturbed sleep, greater fatigue and greater work-family conflict, in accordance with the model of Barton et al. [8]. However, the results provided no support for the contention that having young children exacerbates these effects of shift work, either in men or in women. Females were more likely than males to report insufficient sleep, disturbed sleep, fatigue and work-family conflict. However, there was little indication that females were more negatively affected by shift work than males, irrespective of childcare status. While this is inconsistent with the prevailing view of women being less tolerant of shift work [1], it is consistent with previous findings of limited gender-specific effects of shift work on health found in SLOSH [14,15]. Moreover, recent evidence from meta-analyses suggest that gender-specific effects of shift work may not be as pervasive as previously suggested, at least with respect to sleep [16,17], cardiovascular disease [18] and cancer [19]. Similarly, a recent large-scale study found no gender-specific effects of shift work on accident risk [20]. However, other recent metaanalyses have shown that the links between shift work and metabolic disorders [21,22], and between shift work and mental ill-heath [23], are stronger in women than in men. There was little or no indication of an accumulation of negative effects across successive measurement occasions. This is perhaps unsurprising, as the anticipated effects were likely to be relatively acute. While the presence of children in combination with a demanding schedule could be expected to affect sleep and work-family conflict, there is little reason to anticipate these problems getting worse with prolonged exposure. Indeed, the opposite could be argued, on the assumption that the effects might diminish as children get older and become more independent. A sensitivity analysis found that changing the cut-off age for the definition of young children from 13 years to 6 years made no substantive difference to the patterns of results obtained. The strengths of the current study include a prospective design based on multiple repeated measures that consider the time-varying nature of the studied effects. The analytic approach accounts for missing values, making it possible to draw upon a large, heterogeneous and broadly representative sample of the working population in Sweden. The current analysis sought to limit selection effects by excluding from the day working sample any respondents with a history of working night shifts. This was to ensure that shift workers were not being compared with dayworkers whose health may have been impaired due to previous exposure to nightwork, as a result of which they may have transferred into daywork [9]. However, selection effects cannot be completely ruled out. It was only possible to exclude dayworkers reporting prior exposure to nightwork in 2008, but not those who worked shifts that did not include nightwork. It could be suggested that the failure to find the expected pattern of results reflect insensitivity of the outcome measures, particularly as two of the four were based on single-item measures. However, counter to that suggestion, it is notable that all four outcome measures did show negative effects of shift work; but that these effects were not exacerbated by either gender, childcare status or a combination of the two. Nevertheless, the majority of measures were self-report, which introduces the possibility of reporting bias or recall error, as well as bias due to common-method variance [24]. The measure of shift work exposure was crude, with no possibility to account for variations in schedules such as the sequence of shifts, intensity of nightwork, etc. It is possible that female shift workers, who primarily work in healthcare settings where self-scheduling is common , had more possibilities than male shift workers to adapt their schedules to having young children, e.g. by limiting nightwork. The measure of work-family interference does not focus specifically on children, which limits its sensitivity in the current context. The measure of part-time working lacked a definition in terms of weekly work hours which may limit its sensitivity, given that part-time working in Sweden can involve working as much as 35 hours per week. While the analysis excluded dayworkers who subsequently changed to shift work during follow-up, it remains a possibility that some shift workers may have transferred out of shift work during follow-up, which could have reduced the apparent effect of shift work. Female and male shift workers tend to work in different occupational sectors and so it is often argued that gender comparisons of the effects of shift work are confounded by occupation. The current study did not adjust for occupation, as we have found that, in the SLOSH sample at least, differences in the occupational characteristics of female and male dominated occupations do not account for gender differences in associations between shift work and sleep disturbance or health [15]. It could be argued that with such a relatively large sample, the statistical power of the current study design may have contributed to the finding of effects that, though relatively small, were statistically significant. It is notable, however, that the observed significant main effects were in accordance with previous findings of associations between shift work and sleep/fatigue [25]; between shift work and work-family conflict [26]; between gender and sleep/fatigue [27]; and between gender and work-family conflict [3,4]. The current findings offer no basis for treating women and men differently with respect to work scheduling or the provision of support for those working non-standard hours. However, while we failed to observe the predicted pattern of interaction between schedule, gender and childcare status, it should be noted that these data were collected in Sweden where there is universal subsidized childcare for children from a very early age, which may serve to mitigate the double burden of demanding work hours and childcare responsibilities. Moreover, Sweden has high levels of gender equality which may mean that the added burden of childcare is relatively evenly distributed between the sexes, such that neither experiences excessive disruption of sleep and family life. Thus, caution is advised when attempting to extrapolate from these findings to other countries with different socio-political contexts. An alternative explanation for the absence of predicted interactions is that the women in this study did experience greater strain as result of a higher 'double burden', compared to the men, but that they were able to adopt effective strategies to cope with or compensate for it [28]. In conclusion, shift work, female gender and presence of young children at home were all associated with negative effects on sleep, fatigue and work-family conflict. However, contrary to expectations, neither female gender nor presence of young children exacerbated the effects of shift work. It remains to be seen whether these three factors act synergistically upon other more chronic aspects of health. --- Competing interests None declared.

Background Shift work may impact women more negatively than men due to the increased burden of coping with demanding work schedules while also undertaking more of the domestic chores, including childcare.To examine whether the combination of shift working and caring for children affects the sleep, fatigue and work-family conflict experienced by women more than it affects men.Using data from a survey of the Swedish working population, mixed linear regression models examined work schedule (daywork, shift work with nights, shift work without nights), gender and presence of children <13 years at home as predictors of sleep insufficiency, sleep disturbance, fatigue and work-family conflict, over up to three successive measurement occasions. Adjustments were made for age, education, full/part-time working and baseline year.In fully adjusted models (N = 8938), shift work was associated with insufficient sleep (P < 0.01), disturbed sleep (P < 0.01), fatigue (P < 0.05) and work-family conflict (P < 0.001). Interactions in the analyses of sleep disturbance (P < 0.001) and work-family interference (P < 0.05) indicated that among participants with no children, females reported more disturbed sleep and more work-family conflict than their male counterparts, irrespective of schedule; while among participants with children, female dayworkers reported more disturbed sleep than their male counterparts, and females working shifts without nights reported more work-family interference. Conclusions Having young children did not exacerbate negative effects of shift work, in either men or women. This may reflect high levels of gender equality and childcare provision in Sweden.

Introduction A greenway is a unique linear green open space with ecological value, transportation value, and historical and cultural preservation value. The cross-connection of greenways to form a staggered and integrated green network is of great significance to improve the relationship between people and nature, safeguard the ecological environment, and improve quality of life [1,2]. Greenways serve a variety of purposes, including those related to the environment, tourism, history, culture, economic value, and so forth. The cultural role of greenways has also drawn more attention from academics in recent years [3]. Regional culture encompasses both material culture and spiritual culture in a broad sense. It is made up of all the material and spiritual accomplishments that a community has made via physical and mental work over the course of long-term historical development, which have been steadily gathered, developed, and sublimated [4]. Regional culture, which also refers to local people's behavior and mind patterns, is spatially bound. There are distinctions in regional culture because of the various geographical environments, which also affect people's behavior patterns and ways of thinking [5]. A greenway can be used to convey regional culture, reflecting the distinctive elements of regional culture in the design of the greenway's landscape, which can gather information about local historical occurrences, folklore, and other aspects, turning the abstract information into concrete design elements and enhancing the excursion [3]. Diverse research on the cultural manifestation of greenways have been conducted by academics. Sharma [6] suggested a method to make the design syntax or materials of greenway design culturally diverse, in order to create landscape variability and unique local 2 of 15 characteristics in greenways. Keith [7] proposed to increase the diversity of place landscape and slow walking facilities along greenways to increase social interaction opportunities and cultural benefits. In order to generate collective memory and increase public engagement and vibrancy, some experts also suggested scheduling some cultural festivities and other activities in the public space of greenways or other unused public buildings [8]. Many greenways' landscape designs place a high value on the expression of details in terms of practical investigation. Utilizing local resources to the fullest extent, slow-moving infrastructure designs such as benches, railings, ground paving, signage, and interpretive signs also incorporate regional cultural traits into the design of landscape nodes to ensure consistency in the cultural expression of greenways [8][9][10][11][12]. The satisfaction level of tourists with the cultural expression of the greenway reflects the quality of the regional culture construction of the greenway, and the satisfaction influence factor reflects the perception and experience of tourists with the greenway. Therefore, the investigation of tourists' satisfaction and the influencing factors is of positive significance to improve tourists' visiting experiences, increase regional cultural awareness, and enhance the social influence of the greenway. Regarding cultural perception, Altunel MC et al. [13] argued that tour quality and satisfaction in cultural tourism affect tourists' engagement and promotion intention. Liu Tao [14] used a structural equation model to investigate tourists' perceived quality of red cultural landscape and came to the conclusion that the perceived quality and overall image of red cultural landscape affects tourists' satisfaction and willingness to revisit. Hultman et al. conducted an empirical study on the interrelationship between destination attributes and tourist satisfaction and tourist destination perceptions [15]; Wu T. E. et al. conducted a tourist satisfaction study on theme, product, and design as the three major factors affecting the attractiveness of salt heritage tourism on the southwest coast of Taiwan [16]; Ramseook-Munhurrun P. et al. used tourists to Mauritius as a research sample to verify the island destinations as influencing factors of tourist satisfaction and loyalty [17]; Chen C. et al. studied the interrelationship between tourist satisfaction and tourism place resources, attractiveness, and competitiveness in Kinmen Island, Taiwan Province, China [18]. While most of the relevant studies focus on parks and scenic areas, this paper explores the interrelationship between tourists' experiences of cultural expressions of greenway landscape construction and satisfaction and loyalty, with a view to improving the quality of tourists' experiences and providing reference for the promotion and construction of Pingtan's regional culture. There is limited research on the cultural expression of coastal greenways among studies on the cultural functions of various types of greenways. By utilizing their unique natural terrain, islands may fully realize their tourism potential through the building of greenways. Islands are cut off from the mainland; therefore, their cultural traits exhibit both strong ties to the mainland and unique qualities [19]. The zigzag coastline [20], which is a part of the urban open space, has a greenway created along it. The coastal greenway should be built with urban culture, mountain, and sea qualities in mind, and it should make effective use of these features' spatial characteristics to promote and influence local culture [21]. The creation of the coastal greenway provides a wonderful opportunity to showcase and pass along the intangible and folk cultures of the region. The island's historical culture can be protected and improved through the mix of tourism and exchanges [22]. In order to make recommendations for the growth of the regional cultural tourism industry, this study uses the northern Pingtan Greenway as the research object. It explores how tourists perceive and are satisfied with the cultural landscape construction of the coastal greenway by building a structural equation model. --- Materials and Methods --- Study Area Pingtan is situated in Fujian Province's eastern sea, at 119 • 32 -120 • 10 E and 25 • 15 45 -25 • 25 45 N. The entire region is the largest island in the Fujian Province and the fifth largest island in China, with a land area of 371 km 2 and a sea area of 6064 km 2 . By the end of 2013, the total number of households in the area was 11,831 with a total population of 418,391 [23]. The people of Pingtan migrated from the motherland and have been under the jurisdiction of Fuqing and Fuzhou since the Tang Dynasty. Therefore, the living habits of Pingtan people, such as clothing, food, housing, transportation, and festival customs, are very similar to those of Fuzhou, but some of the ancestors from eastern Fujian, central Fujian, and southern Fujian still retain some of their ancestral customs while integrating into the regional culture of Fuzhou [23]. The unique marine geography and climate environment also created many Pingtan folk customs with strong island flavor [23]. In 2015, Pingtan was awarded the title of Fujian Provincial Geopark. Pingtan Geopark is a comprehensive island geopark with rich typical sea erosion landforms, sea accumulation landforms, and prominent sea erosion relics, supplemented by granite landforms and volcanic landforms, and is a comprehensive island geopark with both marine cultural relics and humanistic landscapes such as stone alley communities. In recent years, the government of Fujian Province has proposed to actively explore cross-strait regional cooperation, establish a regional platform for closer cross-strait cooperation and exchange, set up the Pingtan Comprehensive Pilot Zone, and strive to build Pingtan into a demonstration area for exploring new modes of cross-strait cooperation [23]. As the external gateway of Pingtan Island, the construction of the Pingtan Northern Greenway is conducive to building an internationally competitive tourist destination in Pingtan. Compared with other domestic islands, the policy support for the construction of Pingtan Island is stronger, and its regional culture is simpler and more distinctive, which is more attractive to domestic and foreign tourists. An essential link in the creation of Pingtan International Tourism Island is the northern Pingtan Greenway, which is situated in Pingtan, Fujian Province. The three national openness and development strategies of "21st Century Maritime Silk Road, Free Trade Zone, and the development of marine economy to establish a strong marine state" may all be implemented in Pingtan thanks to its construction. The project is designed to turn the island of Pingtan into a livable and visitable worldwide tourism destination by utilizing the benefits of nearby tourism resources such island scenery, beaches, bays, and sand views, sea erosion landforms, and Fujian-Taiwan culture. The cultural resources in this region are abundant, and they include archeological sites, wharf culture, the history of the spread of Christianity, the culture of seaside fishing, etc. The cultural and historical values are exceptional. According to the estimation, the total length of the planned greenway in the long term is about 37.5 km, the total area of the greenway is 112,369.5 m 2 , the per capita land index is 10 m 2 /person, the instantaneous capacity is 11,236 people, the average passenger turnover rate is 2.2, and the passengers are expected to be about 25,000 per day [23]. However, as development has progressed, it has more served as a means of transportation, and the manifestation of ancient culture is still absent. Relevant studies show that tourists can relax and cultivate themselves by understanding and feeling the regional culture in the process of visiting tourist places, so tourists pay more attention to the construction of regional culture in tourist places. An urgent issue that needs to be resolved in this study is how to better promote area culture and incorporate regional cultural components into the greenway landscape design . --- Structural Equation Modeling --- Influence Factors In order to examine how visitors perceive cultural expressions in the landscape design of the northern Pingtan Greenway, this study analyzes red cultural landscapes using Liu Tao′s conceptual paradigm of "perceived quality-perceived value-satisfaction-loyalty" [14]. Tourists from various cultural backgrounds have different perceptions of the landscape [24], and cultural landscape perception is the process of sensory experience and cognition of environmental material elements based on people′s own cultural literacy and way of thinking when they are in a specific cultural atmosphere [25]. Perceived quality, cognitive image, and perceived value are the three key factors this study focuses on. From a landscape gardening perspective, visitor satisfaction is influenced by the visitor′s perception of multiple dimensions, and these factors interact with one another. Additionally, the perceived dimensions have a direct or indirect impact on the gardening components [26], which are the tangible items through which visitors can most readily experience the local culture. The quality of the landscape and the quality of cultural services are determined to be the two main influencing factors of tourists′ perceptions of the site′s quality in this study, along with the site′s unique circumstances. The quality of the landscape primarily comprises two elements: slow walking facilities and cultural perception of landscape points. The perceived worth is primarily demonstrated by the sense of relaxation and enjoyment that visitors to the island′s natural and cultural setting experience. According to Kyoung-Shin et al. [27], visitors′ perceptions of the healing feelings associated with cultural heritage tourism sites have an impact on their satisfaction and propensity to return, and the sites′ vibrant cultural milieu soothes visitors′ bodies and minds. The tourists′ assessment of the island′s historical and cultural development is mirrored in the cognitive image. According to studies, visitors who are open-minded and in awe of the surrounding natural and cultural environment will form an impression of the tourism destination [14]. Numerous tourists are drawn to the island for travel, vacations, relaxation, and stress relief because of its distinctive regional culture and stunning natural surroundings. The experience of traveling is influenced by how people perceive the local culture. Loyalty affects a visitor′s inclination to return and promote a destination to others, whereas satisfaction is the perception and appraisal of the consequences of the difference --- Structural Equation Modeling --- Influence Factors In order to examine how visitors perceive cultural expressions in the landscape design of the northern Pingtan Greenway, this study analyzes red cultural landscapes using Liu Tao's conceptual paradigm of "perceived quality-perceived value-satisfaction-loyalty" [14]. Tourists from various cultural backgrounds have different perceptions of the landscape [24], and cultural landscape perception is the process of sensory experience and cognition of environmental material elements based on people's own cultural literacy and way of thinking when they are in a specific cultural atmosphere [25]. Perceived quality, cognitive image, and perceived value are the three key factors this study focuses on. From a landscape gardening perspective, visitor satisfaction is influenced by the visitor's perception of multiple dimensions, and these factors interact with one another. Additionally, the perceived dimensions have a direct or indirect impact on the gardening components [26], which are the tangible items through which visitors can most readily experience the local culture. The quality of the landscape and the quality of cultural services are determined to be the two main influencing factors of tourists' perceptions of the site's quality in this study, along with the site's unique circumstances. The quality of the landscape primarily comprises two elements: slow walking facilities and cultural perception of landscape points. The perceived worth is primarily demonstrated by the sense of relaxation and enjoyment that visitors to the island's natural and cultural setting experience. According to Kyoung-Shin et al. [27], visitors' perceptions of the healing feelings associated with cultural heritage tourism sites have an impact on their satisfaction and propensity to return, and the sites' vibrant cultural milieu soothes visitors' bodies and minds. The tourists' assessment of the island's historical and cultural development is mirrored in the cognitive image. According to studies, visitors who are open-minded and in awe of the surrounding natural and cultural environment will form an impression of the tourism destination [14]. Numerous tourists are drawn to the island for travel, vacations, relaxation, and stress relief because of its distinctive regional culture and stunning natural surroundings. The experience of traveling is influenced by how people perceive the local culture. Loyalty affects a visitor's inclination to return and promote a destination to others, whereas satisfaction is the perception and appraisal of the consequences of the difference between the visitor's expectations prior to the visit and the experience afterwards [28,29]. tourists' propensity to return and recommend visited locations can increase their attrac-tiveness and highlight local traits. The landscape design of the tourist destination and the tourists' spiritual satisfaction are both considered in this study's evaluation of satisfaction. --- Cultural Experience Satisfaction Model A multivariate statistical model called a structural equation model may deal with complex interactions between many variables and provide solutions for variables that are difficult to directly observe. The model, which has been extensively employed in the social sciences and other sectors [30], permits both the independent and dependent variables to contain measurement errors in comparison to conventional statistical methods. The goal of this study is to better understand how tourists' perceptions of the perceived value, perceived quality, and cognitive images of the coastal greenways' landscape relate to their satisfaction and loyalty. Creating the five sets of hypotheses listed below, then use the structural equation model to verify their validity : Tourists′ propensity to return and recommend visited locations can increase their attractiveness and highlight local traits. The landscape design of the tourist destination and the tourists′ spiritual satisfaction are both considered in this study′s evaluation of satisfaction. --- Cultural Experience Satisfaction Model A multivariate statistical model called a structural equation model may deal with complex interactions between many variables and provide solutions for variables that are difficult to directly observe. The model, which has been extensively employed in the social sciences and other sectors [30], permits both the independent and dependent variables to contain measurement errors in comparison to conventional statistical methods. The goal of this study is to better understand how tourists′ perceptions of the perceived value, perceived quality, and cognitive images of the coastal greenways′ landscape relate to their satisfaction and loyalty. Creating the five sets of hypotheses listed below, then use the structural equation model to verify their validity (Figure 2 --- Questionnaire Design Before distributing the questionnaire, the researchers conducted a field trip to the northern Pingtan Greenway to obtain a preliminary understanding of the design of the landscape on the Greenway and also talked deeply with the tourists to understand their visiting preferences, mainly including 6 aspects: whether you pay attention to the cultural expression of the landscape design on the Greenway; whether you pay attention to the cultural experience of visiting on the Greenway; whether you think the cultural experience of visiting on the Greenway How much do you know about the traditional culture of Pingtan Island and whether the cultural expression of the greenway landscape construction helps you understand the history and culture of Pingtan Island? Compared with the natural scenery of the island, do you think that the inculcation of regional culture helps to relax to a large extent? Compared with other islands, do you think the history and culture of Pingtan Island are simpler and have a greater sense of history? The preliminary research results show that most of the visitors are very concerned about the cultural expression of the landscape construction of the northern Pingtan Greenway and the history and culture of Pingtan Island, and they show great interest in it. Based on the results of the preliminary research, this questionnaire was designed. Two sections make up the questionnaire study. In the first section, which examines the H5: Satisfaction is positively correlated with loyalty. --- Questionnaire Design Before distributing the questionnaire, the researchers conducted a field trip to the northern Pingtan Greenway to obtain a preliminary understanding of the design of the landscape on the Greenway and also talked deeply with the tourists to understand their visiting preferences, mainly including 6 aspects: whether you pay attention to the cultural expression of the landscape design on the Greenway; whether you pay attention to the cultural experience of visiting on the Greenway; whether you think the cultural experience of visiting on the Greenway How much do you know about the traditional culture of Pingtan Island and whether the cultural expression of the greenway landscape construction helps you understand the history and culture of Pingtan Island? Compared with the natural scenery of the island, do you think that the inculcation of regional culture helps to relax to a large extent? Compared with other islands, do you think the history and culture of Pingtan Island are simpler and have a greater sense of history? The preliminary research results show that most of the visitors are very concerned about the cultural expression of the landscape construction of the northern Pingtan Greenway and the history and culture of Pingtan Island, and they show great interest in it. Based on the results of the preliminary research, this questionnaire was designed. Two sections make up the questionnaire study. In the first section, which examines the demographics of tourists, we learn about their fundamental features, such as gender, age, level of education, and country of origin. The second part is the satisfaction evaluation factors of the northern Pingtan greenway's cultural expression, which includes 26 measurement items and covers 7 major areas, including the perception of slow walking facilities, the greenway's landscape, regional cultural services, perceived value, and satisfaction and loyalty. The Five Point Likert Scale is used in the research scale . Distribution of viewpoints [6,9] Regional characteristics of ancient villages [33] Viewpoint geographical appreciation perspective [34] View the regional cultural atmosphere of the site [6,9] Native plant landscape creation [35] --- Cultural service quality Greenway Cultural Activities enrichment [8,36,37] Types of transportation to reach various cultural attractions on the greenway [38] Distribution of food and beverage on the greenway [39] --- Questionnaire Survey The questionnaire survey was conducted in a combination of online and offline methods. The offline survey was selected for June and July 2022, mainly during the peak tourism period of Pingtan Island from 3:00 p.m. to 7:00 p.m. The number of tourists was high during this period, and the new crown epidemic was effectively controlled during this period, so the questionnaires were distributed more efficiently. There were five researchers, all of whom had engaged in social surveys related to greenway planning and were more experienced in interviewing tourists. Both survey methods took the form of questionnaire interviews. Before filling out the questionnaires, information on four aspects of the visitors' gender, age, education, and place of origin is known, which mainly takes into account that different groups have different comprehensions of regional culture, and the subsequent research results also show this. Offline survey: five people randomly distributed questionnaires to tourists at various spots on the greenway. Before conducting the survey, the consent of tourists was firstly obtained to understand the degree of tourists' knowledge about the history and culture of Pingtan Island, to ask tourists' interest in the history and culture of Pingtan, to focus on this category of people for questionnaire distribution, and to provide necessary explanation and clarification of the survey content to ensure the respondents' understanding of the purpose of this survey and the questionnaire content. A total of 329 questionnaires were distributed offline, and 308 valid questionnaires were collected after eliminating the invalid questionnaires that were filled out repeatedly. To ensure effective online questionnaire distribution, visitors were also asked about their use of WeChat during the offline research process. The results showed that the interviewees all used WeChat as their main communication software, which facilitated online research. Online survey: an online survey through questionnaire star was used, and WeChat's two platforms were used to issue the questionnaires. WeChat is a free application that provides instant messaging services for smart terminals, supporting the rapid delivery of free voice messages, videos, pictures and texts over the Internet across communication carriers and operating system platforms, as well as the use of profiles via shared streaming content. Before issuing the questionnaire, we first confirmed whether the survey respondents have visited the destination and have familiarity with the destination. To confirm this point in the questionnaires, photos and videos were used to help respondents recall the study site overview and explain the meaning of the relevant factors of the questionnaire one by one. A total of 123 copies were distributed online, there were some tourists that could not recall the status of the relevant attractions, so this part of the questionnaire was excluded, and 109 valid questionnaires were collected. A total of 452 questionnaires were distributed in both ways, and 417 valid questionnaires were returned, for an effective rate of 92.26%. The sample size was in accordance with the required sample size in the structural equation modeling study. SPSS 19.0 and AMOS 24.0 were used for data processing and conceptual model validation analysis. The study followed the basic procedures and principles of scale development in designing the questionnaire. Construct validity was mainly expressed as convergent validity and discriminant validity. The Cronbach's coefficient of the questionnaire was greater than 0.7, indicating good stability of the measure. The SEM was evaluated based on theoretical perspectives and quality criteria. The maximum likelihood method was used to estimate the parameters of the structural model. --- Results --- Demographic Characteristics The questionnaire survey results in the northern Pingtan Greenway show that : the respondents were mainly concentrated in the age range of 18 and 40 years , and the education of people with a Bachelor's degree or above was dominant; there were more visitors who were local residents and relatively few foreign visitors ; and there were more visitors who were male than female . Using an independent sample T-test in SPSS 19.0, the impact of gender on the accuracy of cultural perception was examined. The quality of cultural perception is significantly influenced by gender, as shown in Table 3, and women have a significantly higher level of cultural perception than men. --- Age Factor The results of the one-way ANOVA test for the impact of age on cultural perception quality revealed a statistically significant impact of age on the variability of cultural perception quality . Tourists under the age of 18 years and those over the age of 40 years have significantly different cultural perceptions from those groups of travelers, and those between the ages of 18 years and 40 years and those over 40 years have significantly different cultural perceptions as well. The group of travelers between the ages of 18 years and 40 years has the strongest perception of regional culture. The visitors over 40 years had the worst perception, while the visitors under 18 years had the second-best perception. --- Education Factor The findings of the one-way ANOVA test for the influence of different educational backgrounds on the quality of cultural perceptions reveal that there is a substantial difference in how tourists with only a high school diploma and those with a bachelor's degree or above perceive the local culture. The perspective of local culture is stronger the more education one has . --- Measurement Model Analysis --- Reliability and Validity Analysis Using SPSS 19.0, the results of the 417 questionnaires that were gathered were examined for consistency and reliability. The findings demonstrated that the questionnaire's reliability was high, with the overall scale's Cronbach's coefficient of 0.989 and the Cronbach's coefficient being less than 0.989 after removing any question item. The findings of Bartlett's sphericity test and KMO value analysis on the survey data indicated that the scale's KMO sampling appropriateness was 0.984 . Bartlett's sphericity test and KMO analysis results revealed that the sample data were appropriate for exploratory factor analysis because the KMO sampling suitability quantity was 0.984 , the Bartlett's sphericity test's approximate chi-square distribution was 15,977.054, and the significance probability value of P = 0.000 < 0.001 reached a significant level. The validation factor analysis of the fictitious model using AMOS 24.0 revealed that the standard factor loadings of each item ranged from 0.742 to 0.944, the construct reliability and average variance extraction tests were used to detect the convergent validity of the test variables, all of which were greater than 0.500; the average variance extracted was greater than the standard value of 0.500, indicating that each observed variable could explain the corresponding latent variable more effectively; and the combined reliability was greater than 0.800. The fact that all three sets of data satisfy the minimal standard criterion suggests that the questionnaire is very reliable . --- Structural Equation Model Goodness-of-Fit Analysis Using the great likelihood method for parameter estimation through AMOS 24.0 software, the structural model was examined for its structural relationships. Table 6 displays the comparison between the calculated results and the standard fitting coefficient values. The measurement model has a good fit degree, as evidenced by the measurement model's root mean square error of approximation of 0.069, goodness of fit index of 0.862, normative fit index of 0.947, and the other indicators all falling within the range of the fitting criteria . Further evidence that the model has strong discriminant validity comes from the fact that the root values of each latent variable in the judgment matrix are higher than the correlation coefficients between the latent variables and other latent variables . --- Path Hypothesis Testing The results of the path hypothesis test were obtained in this study using the significance level of p < 0.050 as the test standard to test and analyze the hypothesis path . The outcomes demonstrated that the five path coefficients were all less than 0.05, supporting the validity of the path hypothesis. Figure 3. displayed the final hypothesis model. --- Discussion --- Perceived Quality, Perceived Value and Cognitive Image The standardized path coefficient from perceived quality to cognitive image is 0.98, as seen in the final model diagram . The greenway landscape, the cultural design of the facilities, and the regional cultural services all have a direct impact on how tourists perceive and comprehend the local culture, rising by 0.98 units for every unit increase in perceived quality. While the standardized path coefficient from perceived quality to perceived value is 0.36 and the standardized path coefficient from cognitive image to perceived value is 0.65, respectively, this suggests that the perceived value of regional culture, or the restorative experience of regional culture obtained by tourists, is more difficult to The standardized path coefficient from perceived quality to cognitive image is 0.98, as seen in the final model diagram . The greenway landscape, the cultural design of the facilities, and the regional cultural services all have a direct impact on how tourists perceive and comprehend the local culture, rising by 0.98 units for every unit increase in perceived quality. While the standardized path coefficient from perceived quality to perceived value is 0.36 and the standardized path coefficient from cognitive image to perceived value is 0.65, respectively, this suggests that the perceived value of regional culture, or the restorative experience of regional culture obtained by tourists, is more difficult to obtain directly through the regional landscape and requires a certain cognitive base of regional culture before the perceived value of regional culture can be attained. This outcome is mostly driven by the demographics of visitors, many of whom are from outside the area and are not well-versed in the local culture. Visitors also have varying levels of education, age, and other cognitive abilities. These make it difficult for visitors to understand the value of the local culture directly from the greenway landscape, which necessitates accurate interpretation to comprehend the region's historical changes and to recognize the restoration of physical and mental health during the perception of history. According to Kaplan [43], research findings also demonstrate that the constructed environment has restorative qualities similar to those of the natural environment. Pingtan is very reminiscent of a restorative environment, which influences travelers' experiences while they are there. This is due to its extensive history and rich culture, as well as the beautiful island scenery. --- Perceived Value, Satisfaction and Loyalty From perceived value to satisfaction, the standardized path coefficient is 0.98. According to research, satisfaction rises by 0.98 units for every unit increase in perceived value, demonstrating a relationship between the pleasure and physical and mental relaxation that may be attained through cultural tourism and satisfaction with the tourist destination. The standardized path coefficient from satisfaction to loyalty is 0.96, meaning that for every unit increase in satisfaction, loyalty increases by 0.96 units, indicating that a person's level of satisfaction with a particular aspect of the culture of a coastal greenway influences their propensity to return and recommend. The study's findings concur with those of Wu Jing [44] and Gu Yaqing [45] in that loyalty is largely influenced by satisfaction, which in turn is largely influenced by perceived value. The perceived importance of the island greenway's cultural expression among visitors also strengthens their bonds with the tourist location, resulting in greater destination loyalty. --- Conclusions This study investigates how tourists' cultural perceptions of the northern Pingtan Greenway are now holding up and comes to the following conclusions: Tourists of different genders, ages, and educational levels have very different perspectives on the culture of the coastal greenway; in general, women have a stronger perception of regional culture than men; those between the ages of 18 and 40 have a stronger perception of regional culture; the elderly and children are less likely to feel the regional culture; the higher the education, the wider the experience, the stronger the perception of culture, and the older the tourist, the less likely they are to feel the regional culture. tourists' cognitive image and perceived value are favorably impacted by how well they perceive the island culture. On the perceived quality, the three factors barely differ. The architecture of the coastal greenway's slow-walking facilities, vistas, and cultural service conditions thoroughly reflects the regional culture of the area. tourists' perceptions of the local culture are somewhat influenced by the design's excellence, which both directly and indirectly influences perceived value. tourists' assessed the value of the coastal greenway as a cultural manifestation is strongly correlated with contentment. tourists' contentment with the coastal greenway's cultural expression has a favorable impact on their loyalty. The protection and promotion of the island's natural and cultural landscape should be highlighted by the coastal greenway, a type of recreational linear open space, on the basis of fulfilling the general greenway's role as a green infrastructure function. The following recommendations for greenway development are made in light of the study's examination of tourists' opinions of cultural manifestations in coastal greenway landscape design. Make the landscape nodes of coastal greenways more diverse in terms of their cultural themes. Choose to place landscape nodes at the best vantage point for ornamental and distant views so that tourists can appreciate the stunning natural scenery of the island. Appropriately add artificial facilities, the material, color, shape, and other design elements fully integrating into the regional culture, presenting different regional theme characteristics. Enrich the public space of the landscape by including a range of basic service facilities along the greenway, such as food and beverage distribution, cultural exhibitions, entertainment bars, etc. Additionally, introduce social and cultural activities to foster communication between people by increasing the opportunities for social interaction and the benefits of culture. On the other hand, the island's ecological environment needs to be protected. So that the ecological and cultural functions of the greenway can be more clearly demonstrated, the topography and native vegetation of the site should not be altered during the planning and design of attractions. Enhance the greenway landscape design's science education and interpretation framework. The previous study demonstrates that tourists' perceptions of the cultural expression of the landscape are influenced by age, gender, educational attainment, and other sociocultural factors, and that there are differences in how various groups view regional culture. Regional characteristics can be promoted through voice broadcasting, staff interpretation, video interpretation, and other means. Virtual reality technology can also be used to create digital interactive experiences, virtual scenes, and other means to further tourists' historical and cultural knowledge, enhancing their understanding of the region's history and culture without requiring in-depth cultural knowledge. Make cycling a part of the coastal regional culture traits. Many visitors come to the island for sightseeing because of its stunning natural surroundings. Utilize the creation of the greenway to build a cycling segment with a cultural theme using coastal features, such as sea silk culture, fishing folklore, island village landscape, and other elements. While it is advisable to choose lots with undulating terrain that can easily lead to cycling risks, and to concentrate on the construction of pedestrian and vehicular paths, it is not advisable to place shared bicycles, electric bikes, and other cycling transportation and parking spots to provide convenient cycling conditions. Increase the greenway's usage rate while lowering risk and meeting a variety of access demands. This enables visitors to take in the local natural beauty and appreciate the local culture, giving them both physical and mental fulfillment. Reasonable modification of the ratio of commercial, inventive, and spaces for cultural experiences. The coastal greenway's construction intends to give visitors somewhere to unwind, and a little amount of commercial activity can meet some of their recreational needs. However, it should not go overboard. It should primarily construct private leisure and cultural experience spaces in the greenway experience to feel the island's natural landscape, experience the island's historical and cultural changes, and escape the hustle and bustle of urban life. --- Data Availability Statement: The project has not yet been completed, and the research data are not yet available. ---

The island-type greenway should emphasize the role of maintaining and promoting the island cultural landscape as it serves the function of a general greenway green infrastructure while also having a unique landscape appearance. The northern greenway of Pingtan is used as an example in the paper to illustrate how regional culture is perceived. The first part of the analysis looks at how demographic factors affect the quality of cultural perception. The study reveals that: from a gender perspective, women are more likely than men to perceive regional culture; from an age perspective, people between the ages of 18 and 40 are more likely to perceive regional culture; older people and children are less likely to perceive regional culture; and from a level of education perspective, the higher the education, the stronger the perception. The relationship between tourists' perceived quality, cognitive image, perceived value, satisfaction, and loyalty to the cultural expression of the greenway landscape is then analyzed by building a structural equation model. According to the findings, visitors' perceptions of the island's cultural quality have a positive impact on their cognitive images and perceptions of value, while their satisfaction with the cultural expressions along the coastal greenway has a positive impact on their loyalty.

Introduction The 1948 Universal Declaration of Human Rights states that: Everyone has the right to education. Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit. A number of further declarations restated the ideas that 'education is a right' and 'education shall be compulsory', enshrining these in international law and reinforcing the international community's will to make it good. In the past few decades, this has gained a new impetus through the Education for All movement, which is officially sponsored by UNESCO, but also supported by a number of development agencies and non-governmental organizations. Meetings held in Jomtien , Dakar ), Brasilia , Beijing , Cairo and Oslo , amongst others, urged governments to prioritize investment in basic education, achieve inclusion and gender parity in education, and aim at providing primary elementary schooling by 2015 . Needless to say, these targets were not achieved because of a lack of investment and commitment by parties. The problem is compounded by the fact that understanding education as a right implies an interconnection between this right and other rights -that is, 'the requirement for there to be a right to education , rights in education and rights through education ' . This demonstrates the complexities involved in this issue and the mammoth task faced by educationists. 1 Further, I note that there is a tension between 'right' and 'compulsory' in Article 26 of the 1948 Declaration, and this has been a source of contention for commentators discussing issues such as understanding education as schooling, and turning schooling into something compulsory , compulsory education and infringement of other rights, especially in connection with social segregation, indoctrination, and class inequalities , or perhaps even more telling, making elementary education compulsory but not education in general, especially adult education or higher education . 2 --- McCowan has noted the tension: A right to something is an entitlement and not an obligation . . . [But] there is a counterfactual aspect to rights, in the sense that it is important that one has the right to freedom of religious worship, even if one does not actually exercise it. At the same time, it is argued that human rights are inalienable: for example, one cannot voluntarily give oneself up into slavery. Nevertheless, even if one cannot voluntarily give up the right to, say, healthcare, one can choose not to exercise that right in a particular moment. The reasons why education is an exception to the rule are never explained by McCowan, or by other commentators. They seem to take it for granted that education is, indeed, a right, perhaps because it is stated in the 1948 Universal Declaration of Human Rights and other such documents. In this article, I wish to turn the problem on its head and take issue with the idea that education should be understood as a right. My argument is, rather, that education should be understood as a duty -an obligation that all human beings have towards themselves and their communities. In order to do this, I will refer to the works of Johann Gottlieb Fichte ), the German post-Kantian idealist, whose works in education have been long neglected and forgotten. However, they are of great help to us in trying to make sense of education not as a right, but as a duty. I will argue that such understanding dissolves the tension present in Article 26 between 'right' and 'compulsory', and that, perhaps, a reframing of our understanding of 'what education is' needs to occur not just at the individual, but also at the societal level. --- Fichte and education Fichte developed his understanding of education in several of his writings in both his early and later philosophical phases. 3 However, Fichte's views on education remain fairly unappreciated by contemporary philosophers of education, perhaps because of Hegel's and Schelling's assessment of these as being somehow secondary to his purely philosophical writings . That said, this was not always the case , and this is better appreciated if we acknowledge that Wilhelm von Humboldt, whose plans for changes in the German education system were implemented between 1809 and 1910, was very much influenced by Fichte's ideas . For both Fichte and Humboldt: Education is to be democratic in nature and universal and compulsory in application . . . [it] is the very life-blood of the State [because] . . . [t]he individual is not only an individual; he is at the same time a member of a community and as such must be educated to take his place in it; otherwise the future of that community is doomed. These views would later influence changes in many other countries, including the USA and Japan. Despite Hegel's and Schelling's assessment, I note that Fichte's views on education remained intrinsically connected to his wider philosophical project: the Wissenschaftslehre project. The project encompasses some 17 writings, reworking some of the most important themes of Kantian philosophy dealing with issues connected with the possibility of consciousness, the subjectivity-objectivity relationship and the attainment of knowledge. These issues are used as a foundation for his wider philosophical views, including those on education and political philosophy. The connections between these various aspects of Fichte's thought will come to the fore as this article unfolds. --- Is education a right? In the Foundations of Natural Right , Fichte presents his argument for the emergence of 'natural rights'. Following on from the tradition of the Wissenschaftslehre project, the text begins with an account of 'consciousness', leading Fichte to argue that the rise of self-consciousness can only occur through a meeting with external reality, which mirrors Kant's view in Critique of Pure Reason . 4 His argument proceeds in three stages and is outlined in very fine detail . Firstly, self-consciousness requires that a rational entity posits itself as an individual that is different from the rest of reality. 5 To use Fichtean terminology, this means that the 'I posits a not-I'. Secondly, Fichte comments that when an entity posits itself as rational, it necessarily posits itself as a free entity and, in doing so, it infers that there are other entities like itself in the world. In Fichtean terms, this means that the 'I perceives other Is in the not-I'. As such, freedom is established as something shared by all rational entities in reality . The third and final stage of Fichte's argument is that, originally, the conception of freedom referred only to a power , and it was only this power that rational entities ascribed to each other -that is, the phenomenon of rationality necessarily requires that it is not caused externally. However, when entities move into the social sphere, the conception of freedom is further developed. Freedom requires that an outcome of the thinking activity be perceived tangibly in reality, in the external world. This is to say that freedom necessitates that an entity's will be effective in the world. But if other free rational entities are present in the world, and thus interfering and opposing each other, freedom, as the implementation of the I's will, is only possible when these entities restrict their causality by setting up some limits to freedom. This means that they must divide the world amongst themselves so as to avoid conflict, and the notion of 'rights' emerges as a form of 'entitlement'. At first, this limitation is not imposed from the outside, and all free rational entities chose to limit themselves, making it a rule not to disturb the freedom of other entities with whom they share reciprocal relations. This is what ends up giving rise to society -to the commonwealth. The influence of Kant's second formulation of the categorical imperative is quite evident, demonstrating the Kantian influence on Fichte's thought: 'Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end' . But this situation can only continue to occur in an ideal setting -in a Utopia -because some human beings will not abide by it. Ultimately, Fichte was a pessimist about human nature. This can be seen in his first book, Attempt at a Critique of All Revelation , 6 where he discusses in great detail the nature of revelation, as well as theology, and natural and revealed religion. Fichte understands that evil is ingrained in human nature, and thus, by and large, human beings are bound to diverge from the moral law. 7 As a consequence of this, the commonwealth decides that any disturbance to an I's sphere of freedom, such as a coercion or a crime , is dealt with in such a manner that the disturbing-I gets exactly the opposite of what it desires; ultimately, it loses its social freedom . For this to happen, rules and obligations are created externally by the commonwealth, and all individuals must abide by them. I note that Fichte's account of freedom has connections with Berlin's notion of 'positive' freedom. In 1957, Berlin delivered his paper 'Two concepts of liberty', his inaugural lecture for the Chair of Social and Political Theory at the University of Oxford , where he comments on the notions of 'positive' and 'negative' freedom. Berlin did not create the terms 'negative' and 'positive' freedom; however, his characterization has become a classic in the canon of political philosophy. Berlin's essay was written during the Cold War years and it associates 'negative' freedom with the kind of freedom in liberal democracies, whereas 'positive' freedom is connected with that of communist societies. Ultimately, Berlin is very critical of 'positive' freedom. The notion of 'negative' freedom is associated with the liberal thought of Hobbes, Locke, Mill and Tocqueville , who argued that a minimum 'negative' freedom is required and essential for human well-being, as it is 'the area within which a man can act unobstructed by others' . Thus, 'a person is free in the negative sense when he or she is not prevented, by human act or omission, from doing what he or she may wish to do' . In short, 'negative' freedom is freedom from constraints. Contrasting with this is the notion of 'positive' freedom, which is founded on the individual's desire to control his or her own life, 'from the wish on the part of the individual to be his own master' . However, this kind of self-control can be diminished by both the interference of other individuals and by one's own faulty character or lack of control over one's own passions. This notion of freedom can be traced as far back as the Stoics 8 and Plato , who discussed self-mastery and the case of 'false pleasures'. 9 'Positive' freedom is freedom to control one's own life. Berlin is critical of 'positive' freedom as he understands that, in some cases, it might lead to authoritarianism, inverting the conception of liberty into its very opposite . This happens because the kind of philosophy behind 'positive' freedom usually understands the self as divided into two halves: a higher part, associated with reason, and a lower part, connected with passions and emotions. And once this is presumed, the higher part needs to conquer the lower part; reason must dominate the passions. Crowder notes that the 'slippery slope' happens when 'dictators . . . suppose . . . they know the requirements of the true self better than the individual concerned . . . The doctrine of the divided self does not guarantee authoritarianism, but it offers authoritarianism aid and comfort'. 10 It might be clear to the reader by now that Fichte was a staunch defender of 'positive' freedom in the Foundations of Natural Right, and this was noted by Berlin in Freedom and Its Betrayal . Berlin traces Fichte's standpoint, and his critique of 'positive' freedom and the 'inverted thesis', to Rousseau, who understood that: liberty is social cooperation and right action. The vulgar idea of liberty as negative noninterference refers merely to an amoral, animal liberty, consistent with acting wrongly. But to act wrongly is to depart from the standards of the 'inner, better, more real self' which necessarily seeks the good [Berlin, 2002a: 46]. Truly human liberty entails the liberation of that which is distinctively human, namely a person's capacity for self-direction in accordance with moral rules, the will of 'the true self'. For Rousseau, the 'lower' part of the self needs to be conquered by the 'higher' part of the self, and this can only be done in a commonwealth where all individuals seek a common good. This opens the door for individuals to be 'forced to be free' , because the commonwealth believes it knows what is best for the members of the group. Hence, freedom is inverted and becomes mere obedience to the commonwealth's will. Berlin concluded that Rousseau was one of 'the most ardent and passionate lovers of human liberty who ever lived', but also 'one of the most sinister and most formidable enemies of liberty in the whole history of human thought'. The same could be said of Fichte, since he followed in Rousseau's footsteps in the Foundations of Natural Right, arguing that obligations must be created externally by the commonwealth and all individuals must abide by them. Some years later, Fichte added a nationalistic tinge to this in Addresses to the German Nation , where he talks about complying to the 'spirit of the nation', and for Germans to the 'German nation '. 11 But what does this have to do with the understanding that 'education is a right' and 'shall be compulsory'? It is arguable that the 1948 Declaration's understanding of education as a right, and as compulsory, follows the school of thought that defends the notion of 'positive' freedom. A 'right to something is an entitlement and not an obligation' , but education became an exception to this characterization because the international community -the established commonwealth -understands that it knows what is best for individuals. As such, education became something compulsory and no longer an entitlement that all human beings have in order to fulfil their humanity and something they can choose to subscribe to if and when they wish. Education became an obligation that all human beings have to conform to, because the commonwealth understands that it is important that all its members are educated . This is at the very heart of the philosophical tension between 'right' and 'compulsory'. The original idea of 'right' as 'freedom not to be interfered with and to choose and implement one's will' is still used with reference to education in speech and documents related to education, but it has become secondary to the ideas of 'compulsory' and 'obedience to the law'. This is a prime example of the 'inverted thesis' discussed by Berlin. In connection to this, it is perhaps worth ending this section by referring to Foucault, who also noted how a system of rights can be imposed on all members of the commonwealth by those who are in control of the community. I will come back to this point when I discuss the aristoi and the pseudo-aristoi. Lechner says: [a]ccording to Kant's classical definition, the law, the agency guaranteeing individual rights, is made up of 'the whole of conditions under which the . . . freedom of choice . . . of the one can coincide with the [freedom of choice] of the others according to a general law of freedom' . Foucault argues [in Discipline and Punishment] that disciplinary power constitutes a 'counter-law' by invoking 'insuperable asymmetries' and excluding 'reciprocities' . For this purpose disciplinary power establishes coercive relations between individuals that essentially digress from the formally sanctioned contractual relation in which the idea of universal rights is embedded. Disciplinary power thus renders both the volitionality of the contractual relation and the contract itself fictitious. Therefore Foucault summarizes: '[I]t would be hypocritical or naive to believe that the . . . [system of rights] was made for all in the name of all; . . . it would be more prudent to recognize that it was made for the few and that it was brought to bear upon others' . --- Is education a duty? In order to resolve the philosophical tension between 'right' and 'compulsory', I wish to propose a different understanding of education -that is, not as a right, but as a duty that all human beings have towards themselves and their communities. I will turn to Fichte's writings again and look in detail at 'Some lectures concerning the scholar's vocation' . Fichte and the Rousseauian school of thought might have generated the problem through their defence of 'positive' freedom, but, I believe, Fichte might also provide us with the solution to the problem. Fichte arrived in Jena in 1784 just before the start of the summer semester to take up his appointment as Professor of Philosophy. He had spent the previous months perfecting his new philosophical system -the Wissenschaftslehre project -and preparing his private lectures on this. Fichte, however, did not want to use his newly appointed position to teach his system to a handful of students; rather, he wished to have a more profound influence on the whole of the university community. It is for this reason that Fichte devised a series of public lectures, in addition to his private lectures, which were entitled 'Morality for Scholars', and the first five of these were published as 'Some lectures concerning the scholar's vocation'. He did the same thing, but on a larger scale, in Addresses to the German Nation, with the aim that his interaction with the wider public would spread the message even further . In this connection, Dimic´notes: Fichte is the first philosopher after Plato and Aristotle who, in his philosophical practice, made a difference between exoteric and esoteric lectures as they were called in [Plato's] Academy, that is, lectures for all interested citizens, i.e. the broad public, and highly specialised lectures for professional philosophers. Prior to Fichte's efforts during this period, 'philosophy and science scarcely reached common people', and he was keen to realize the ideal of 'the school for everybody' not just in theory, but also in practice. This was based on a new understanding of education, advocating that it 'would become available to absolutely everybody and not only the circle of the educated and rich' . The influence of Fichte on Humboldt is quite evident here, and triggered significant changes in the German education system soon after, as previously discussed in my introduction. Fichte's motivation for choosing the topic 'Morality for Scholars' in his public lectures is explained in the following passage of another text, his Concerning the Concept of the Wissenschaftslehre . Fichte says: The sciences, as you all undoubtedly realize, were not invented as an idle mental occupation to meet the demand for a refined type of luxury. Were they no more than this, then the scholar would belong to that class to which all those belong who are living tools of a luxury which is nothing but luxury; indeed, he would be a contender for first place in this class. All our enquiries must aim at mankind's supreme goal, which is the improvement of the species to which we belong, and students of the sciences must, as it were, constitute the centre from which humanity in the highest sense of the word radiates. Every addition to the sciences adds to the duties of its servants. It thus becomes increasingly necessary to bear the following questions seriously in mind: What is the scholar's proper vocation? What is his place in the scheme of things? What relation do scholars have to each other and to other men in general, especially to the various classes of men? How and by what means can scholars most expeditiously fulfil the duties which they incur through these relationships? And how do they have to develop the skills which this requires? These are the questions which I shall be trying to answer in the series of public lectures which I have announced under the title 'Morality for Scholars'. Further, the word Gelehrter in the original title of 'Morality for Scholars' [Einige Vorlesungen u¨ber die Bestimmung des Gelehrten], which is usually translated as 'scholar', requires explanation . The word 'scholar' is meant to refer here not only to academic professionals, researchers and teachers, but also to someone who is educated, who spends their life pursuing knowledge and who is concerned with sharing any gained knowledge with the rest of humankind, because they understand that knowledge is the central pillar in humanity's continuous pursuit of self-improvement. Commenting on Fichte's understanding of Gelehrter, Fichte notes: 'thus it is the especial responsibility of the scholar to supervise and to regulate human progress toward perfection, and in order to do this he must at least strive to be the ethically best man of his time'. Let me now look in detail at these lectures. In his first lecture, Fichte aims to answer the question 'What is the vocation of man as such?' The answer is given at the end of the lecture: Man's final end is to subordinate to himself all that is irrational, to master it freely and according to his own laws. This is a final end which is completely unachievable and must always remain so -so long, that is, as man is to remain man and is not supposed to become God. It is part of the concept of man that his ultimate goal be unobtainable and that his path thereto be infinitely long. Thus it is not man's vocation to reach this goal. But he can and he should draw nearer to it, and his true vocation qua man, that is, insofar as he is a rational but finite . . . being, lies in endless approximation to his final goal. Now if, as we surely can, we call this total harmony with oneself 'perfection', in the highest sense of the word, then perfection is man's highest and unattainable goal. His vocation, however, is to perfect himself without end. He exists in order to become constantly better in an ethical sense, in order to make all that surrounds him better sensuously and -insofar as we consider him in relation to society -ethically as well, and thereby to make himself ever happier. Human nature, or the vocation of man qua man, implies, according to Fichte, that human beings are in a constant pursuit of self-improvement -self-improvement towards 'perfection' . Presumably, Fichte understands that, by perfecting oneself, one becomes a better and well-rounded individual, one overcomes one's inherent evil and, as such, becomes a better moral agent. 12 Moreover, Fichte understands that the path towards self-'improvement' is endless and eternal, and this is so because human beings are finite and, as such, they can never achieve perfection, because perfection requires infinity and only God is infinite and perfect. Fichte is making reference here to the ontological argument for God's existence -that is, the predicate 'perfection' is not part of the concept of the human being, but is part of the concept of God. Hegel took issue with Fichte's understanding of the human condition, and some of my readers will be in agreement with him. I quote Harris: The 'infinite progress' in morality, which Fichte accepted as the destiny of humanity, was for Hegel an endless treadmill of internalised slavery; it placed man in the situation of Sisyphus or Tantalus, it deprived him even of the rational possibility of a real self-fulfilment that could be known and enjoyed. I believe that such criticisms are unfounded and Fichte would reply that, if one fulfils one's nature, one must feel some sort of self-fulfilment. It would be something paradoxical if one followed one's nature and did not enjoy it -did not feel some sort of self-fulfilment. The process is what is important, not the final goal. Each achievement is a conquered milestone, leading to another, and, as such, a sense of self-fulfilment is gained with every conquest. In the second lecture, Fichte poses the question: 'What is the vocation of man within society?' In doing so, Fichte puts forward an account of human beings' social nature and their drive towards the improvement of society: One of man's fundamental drives is to be permitted to assume that rational beings like himself exist outside him. He can assume this only on the condition that he enter into society with these beings. Consequently, the social drive is one of man's fundamental drives. It is man's destiny to live in society; he ought to live in society. One who lives in isolation is not a complete human being. He contradicts his own self. The true vocation of man within society is . . . unification, a unification which constantly gains in internal strength and expands its perimeter. But since the only thing on which men are or can be in agreement is their ultimate vocation, this unification is possible only through the search of perfection. We could, therefore, just as well say that our social vocation consists in the process of communal perfection; that is, perfecting ourselves by freely making use of the effect which others have on us and perfecting others by acting in turn upon them as upon free beings. In this lecture, Fichte presumes that there is a 'state of nature', a pre-society , and establishes that human beings are social beings, craving the encounter with other rational and free beings, and hence forming societies. For Fichte, not to do so is to diminish oneself as a human being and go against one's very nature. After establishing this, Fichte reinstates his argument that human beings aspire to achieve a state of perfection through the powers of pure and practical reason -that is, the human being tries to achieve a state of absolute unity and harmony with himself. However, this is something that it is impossible to achieve, leading to an everlasting struggle to achieve the impossible -the infinite quest for improvement of the human being qua human being. Fichte concludes that human beings do not only aim at their personal and constant self-improvement towards perfection, but they also, as social beings, aim at the constant improvement of their societies . 13 In this respect, it is arguable that self-improvement is something inescapable -a duty -and that it is also a duty to improve one's society. 14 Now that Fichte has dealt with the issues of the vocation of man qua man and the vocation of man within society, he is in a position to deal with his main concern in the lectures -that is, the vocation of the scholar. This is done in the fourth lecture: We have already shown that the purpose of all human knowledge is to see to the equal, continuous, and progressive development of human talents. It follows from this that the true vocation of the scholarly class is the supreme supervision of the actual progress of the human race in general and the unceasing promotion of this progress. Thus, since the role and duty of the scholarly class within society is to supervise, direct and promote the development of human beings' talents, it has a prominent position in humankind's continued pursuit of self-improvement towards perfection. This means that the scholar has a duty to encourage and facilitate human progress on the eternal and endless road to perfection. Moreover, every scholar must strive to promote and facilitate progress within his own class. Fichte places a heavy weight on the shoulders of the scholarly class, as it must promote and facilitate the improvement of its own class, as well as supervise, direct and promote the betterment of the other classes. But this does not mean that all human beings need to become scholars and, as such, Fichte's argument might appear to bear some elitist overtones and to resemble Plato's argument in The Republic. It thus has implications for sociopolitical thought, and particularly for education. The Platonic idea of society and citizenship is fundamentally based around the concepts of the aristoi and the pseudo-aristoi, and it is in direct contrast to Aristotle's, which is centred on the concept of a polis. White comments on this as follows: The Aristotelian idea of citizenship, which combines, at once, ruling and being ruled [forming a polis], is not, however, the only model on offer. The Platonic version of citizenship, for instance, draws a sharp distinction between rulers and ruled, or the aristoi and the pseudo-aristoi. As will become clear later in this section, Fichte did not envisage the commonwealth as divided between the aristoi and the pseudo-aristoi in a Platonic fashion. In fact, I would argue that he strongly defended a republican Aristotelian conception of society and citizenship based on the idea of a polis. However, with regard to the point about him being 'elitist', I believe this is not the case and he was merely being 'realistic' about the possibilities of human societies. Fichte commented: The scholar is especially destined for society. More than any other class, his class, insofar as he is a scholar, properly exists only through and for society . . . The scholar should now actually apply for the benefit of society that knowledge which he has acquired for society. He should awaken in men a feeling for their needs and should acquaint them with the means for satisfying these needs. This does not imply that all men have to be made acquainted with those profound inquiries which the scholar himself has to undertake in order to find something certain and true. For that would mean he would have to make all men scholars to the same extent that he himself is a scholar, and this is neither possible nor appropriate. This brings us to the fifth and final published lecture, where Fichte discusses the claim that education and culture have corrupted, and not improved, human beings. He does not mention Rousseau by name, but this view is usually attributed to him and his prize-winning essay of 1750, A Discourse on the Moral Effects of the Arts and Sciences. 15 In truth, Rousseau's position is much more subtle than that demonstrated by Fichte, but this does not stop Fichte from exploring the 'internal contradictions and external limitations of such a position'. This leads him to conclude that 'Rousseau's ideal of harmony between reason and sensibility' is something that 'lies ahead of, not behind, us'; it is 'an ideal we should infinitely approximate, not a natural state from which we have fallen' . 16 By doing so, Fichte emphasizes the idea that we, as human beings, are in a constant and eternal pursuit of perfection, advocating that education and culture play a pivotal role in this. Thus, although Fichte, like Kant, was an admirer of Rousseau's writings and influenced by them -as we saw in the previous section where I discussed the issue of 'positive' freedom -Fichte was also very critical of Rousseau, taking issue with his position on education and culture. Fichte's argument in favour of education and culture leads him to claim that, within the commonwealth, the individual is at the same time a teacher and a student, in constant interaction with others and permanently exchanging these roles . Fichte was not defending a version of Platonic citizenship because there is no division between the aristoi and the pseudo-aristoi -between an educated class and a pseudo-educated one -but something much more Aristotelian, democratic and egalitarian, and ultimately polis-centred. I note that Fichte's views contrast with contemporary developments in the field of education and the move from traditional republicanism, based on Aristotle's views, to modern liberalism, founded on Plato's thought . It is perhaps worth quoting the following passage from Ignatieff, who instantiates this by contrasting both positions: The one defends a political, the other an economic definition of man, the one an active -participatory -conception of freedom [traditional republican and the homos politicus], the other a passive -acquisitive -definition of freedom [modern liberal and the homos consumus]; the one speaks of society as a polis; the other of society as a market-based association of competitive individuals. Indeed, I would argue that Fichte's views on education seem to be very supportive of traditional republicanism and could be used as a defence against modern liberalism and the dangers for education, institutions and democracy that come with it. Fichte's framework suggests that we are in a constant pursuit of self-perfection and the improvement of our societies, as well as constantly exchanging the role of teacher and student, and, as such, it is very much a form of traditional republicanism based on democratic egalitarianism and the polis. However, Fichte's version of republicanism does not happen just because we agreed to a 'social contract' specifying it; rather, there is something more fundamental to it, as it occurs because it is part of our very essence as human beings. This means that we should not try to escape from our human condition, but embrace it. The vocation of the human being qua human being is to educate oneself, in a constant personal, and social, pursuit of perfection. As human beings, we have a duty to improve ourselves and our societies through education. --- Conclusion When the 1948 Universal Declaration of Human Rights was being drafted, some parties manifested their uneasiness about some of its wording. For instance, the American Anthropological Association warned that the Declaration could become 'a statement of rights conceived only in terms of the values prevalent in Western Europe and America', and that values are culturally dependent. In connection to this, and as I have previously argued, the Declaration, at least insofar as Article 26 on 'education' is concerned, could be viewed as a prime example of the kind of authoritarianism that is based on 'positive' freedom. This is because it conceives of education as a right, but also understands that people cannot be trusted to take up this right, turning it into something compulsory. Bergstro¨m commented on this last point, whilst noting the tension between 'right' and 'compulsory': By the end of the nineteenth century, education was not only elementary and free, it departed from laissez-faire and became compulsory. The word compulsory could be 'justified on the grounds that the free choice is a right only for matured minds, that children are naturally subject to discipline, and that parents cannot be trusted to do what is in the best interest of their children' . It is such distrust in parents' ability to do what is in the best interest of the child that invoked, among the delegates on the UN [United Nations] drafting committee, a fear of totalitarianism, authoritarian governments and political paternalism . . . [thus] the meaning of the word 'compulsory' became an issue. The concept of compulsion appeared contradictory to the statement of a right. This problem is compounded by the rise of a Platonic conception of commonwealth and citizenship, dividing society into the aristoi and the pseudo-aristoi. Neo-liberalism's hegemonic rise in the past decades has only made matters worse by turning education into a 'market tool' and something to be 'consumed'. The consequence of this is that the aristoi -the elites -have access to the most valuable, 'highly prized educational commodities', whilst the pseudo-aristoi -the masses -by and large, need to content themselves with 'educational commodities of lesser value', thus creating an untenable division that is difficult to overcome within the commonwealth. This situation can be traced back to Plato, because he 'conflated state and individual, public and private, politics and psychology on the foundation . . . of civil society and theory of the state' . This is at the centre of many of the problems faced by modern societies, including that of 'marketization' in education and the deterioration of the homos politicus into the homos consumus. I would argue that this makes it easier for the aristoi to maintain their privileged position over the pseudo-aristoi in society because, in an 'educational market', they have access to more valuable 'cultural, social and economic capital' , leading them to possess more 'knowledge', and 'knowledge itself is power' . Furthermore, the aristoi can make use of education as a disciplinary mechanism and power, so as to normalize and discipline individuals, pretending to protect, empower and stimulate their personal development . This set-up turns teachers into 'technicians of behavior: engineers of conduct, orthopaedists of individuality' and, through this atmosphere of surveillance and observation, the conduct of pupils is directed and coordinated, while in the mean time a stock of knowledge about the individual students is being built up. In this way discipline is formed, which produces enslaved subjects and at the same time generates reliable knowledge about them. This means that '[t]he objective of the educational system is to produce productive, effective and obedient subjects' -that is, the pseudo-aristoi. Fichte's position represents a rejection of all this and a recovery of the Aristotelian conception of commonwealth, citizenship and education. It can be argued that Fichte's framework, and its traditional republicanism, advocates that the unity of the commonwealth is, as Bauman argued in Liquid Modernity, achieved daily anew, by confrontation, debate, negotiation, and compromise between values, preferences and chosen ways of life and self-identification of many and different, but always selfdetermining, members of the polis. This is . . . the republican model of unity, of an emergent unity which is a joint achievement of the agents engaged in self-identification pursuits, a unity which is an outcome, not an a priori given condition, of shared life, a unity put together through negotiation and reconciliation, not the denial, stifling or smothering out of differences. Therein lies the importance of education for traditional republicanism -that is, it can only be achieved if individuals understand that to educate themselves is a duty to themselves and their communities, and something that is achieved through a constant exchange of roles between teachers and students. Further, the commonwealth must recognize that it can only continue to exist if it provides its members with the opportunity to fulfil this duty . This means that investment in education at all levels, from child to adult education, should be an absolute priority for any commonwealth because '[t]he individual is not only an individual; he is at the same time a member of a community and as such must be educated to take this place in it; otherwise the future of that community is doomed' . This also means that the relations between teachers and students in education must be conceived in less asymmetrical and more egalitarian terms, because the line between teacher and student, and teaching and learning, is a very fine one in Fichte. Perhaps he could even be understood as a visionary and a forerunner, sowing the seeds of what would become critical pedagogy. Finally, by understanding education as a 'duty', the tension between 'right' and 'compulsory' is dissolved and discussions about how to understand 'compulsory' in education become nonsensical. Notes 1. Progress has been made slowly in this direction, and certain parts of the world, such as Latin America, have made good progress. Developments in this area are not always driven by governments, but by grass-roots movements, such as the Landless Movement in Brazil, which implemented a large network of primary schools, early years provision, and teacher education and adult education courses with the aim of equipping people to be valuable members of the community and to fight for social justice : 290). 2. By definition, one cannot speak of a 'right in degrees' -that is, either one has a right to something or one does not, because a right is something absolute. For instance, one has a right to vote, to get married or not to be tortured, and these are absolute. One cannot cast 'half a vote', get married 'partially' or be tortured 'a little bit'. To defend one's 'right to elementary education' whilst arguing that 'higher education is a privilege' seems to be inconsistent and arbitrary. 3. It is generally agreed by Fichte commentators that his philosophical development can be divided into three phases. His first phase is the Kantian phase and it encompasses his earlier writings such as the Attempt at a Critique of All Revelation . The second phase is usually referred to as the Jena period , in which Fichte develops his Wissenshaftslehre project, and includes his more popular writings such as 'Some lectures concerning the scholar's vocation' . The third phase is normally referred to as the Berlin period , which is also known by commentators as the eclipse of Fichte's career, and includes texts such as Addresses to the German Nation, written in 1808 during the Napoleonic occupation . 4. This position can be explained through a simple example: imagine a human being devoid of all interaction with physical reality and other human beings from the very moment of birth. Could we conceive that this human being can say 'I'? Certainly not. This insight is something that permeated German post-Kantian idealism . 5. In a very insightful and innovative way, Fichte introduces the idea of Anstoss, the 'challenge' and 'obstacle' posed by reality to the activity of the 'I', as an important aspect for the rise of selfconsciousness. This was something that Kant had neglected to discuss in detail in his writings. Fichte defines Anstoss as follows: 'The Anstoss occurs to the I insofar as it is active, and is thus an Anstoss only insofar as the I is active. Its possibility is conditioned by the activity of the I: no activity of the I, no Anstoss. And vice versa: the I's activity of determining itself would, in turn, be conditioned by the Anstoss: no Anstoss, no self-determination. Moreover, no self-determination, nothing objective'. Once one cuts through Fichte's philosophical jargon, the same thesis defended by Kant in the Critique of Pure Reason is established; that is to say, self-consciousness is dependent on one's contact with reality. 6. The story of the publication of this work is perhaps better known than the work itself, since it was written as a sort of self-introductory note from Fichte to Kant. Kant thought the text was a wellwritten piece of work, and suggested that Fichte should sell it to Kant's own publisher. The first edition had very strange omissions: the title, publisher, city and date appeared as usual, but Fichte's name and signed preface were missing. Whether this was due to a true printing mistake or a cunning ploy by the publisher, one will never know. The second and subsequent editions corrected these errors and acknowledged Fichte's authorship. However, by the time this was done, the book had already proven to be a huge success, partly because it was assumed by book reviewers and readers to be yet another of Kant's works. The written style, the terminology , the fact that it was published by Kant's own publisher, and the fact that it had been widely expected that Kant was soon to publish a Critique of religion led to the conclusion that Kant was the author . 7. Fichte's views have a clear foundation in the Christian belief of original sin. Contrasting to Fichte's views are Schelling's, who understood that evil has a metaphysical foundation in reality because both Satan and Jesus were begotten by God and, as such, these two forces are always at play in reality, and are not something ingrained in human nature as a condition bestowed on humanity by Adam and Eve's original sin . In this first work, Fichte also argues that theology is not enough and religion -especially revealed religion -is necessary to reconnect individuals to morality. The root of the word 'religion' is the Latin religare, which is translated as 'to reconnect' in English. 8. Available at: http://classics.mit.edu/Epictetus/discourses.html. 9. Available at: http://classics.mit.edu/Plato/philebus.html. 10. Mill's account of higher and lower pleasures in his version of utilitarianism is another classical example of this school of thought. 11. Crowder notes that the section on Fichte ends with Berlin citing 'a series of quotations from Heine, who warns the French against underestimating the destructive potential of the ideas emerging in Germany. ''Armed Fichteans will come, whose fanatical wills neither fear nor selfinterest can touch . . . A drama will be performed in Germany in contrast with which the French Revolution will seem a mere peaceful idyll'' [Berlin, 2002a: 72]. For Berlin, this is a ''genuine vision of the doom to come'' [Berlin, 2002a: 72]'. 12. Fichte's argument seems to have been influenced by Aquinas' Summa Theologica, where he argues against ignorance: 'it is evident that whoever neglects to have or do what he ought to have or do, commits a sin of omission. Wherefore through negligence, ignorance of what one is bound to know, is a sin; whereas it is not imputed as a sin to man, if he fails to know what he is unable to know. Consequently ignorance of such like things is called ''invincible,'' because it cannot be overcome by study. For this reason such like ignorance, not being voluntary, since it is not in our power to be rid of it, is not a sin: wherefore it is evident that no invincible ignorance is a sin. On the other hand, vincible ignorance is a sin, if it be about matters one is bound to know; but not, if it be about things one is not bound to know' . 13. Fichte's views seem to mirror the Jewish concept of Tikkun olam . This is a Hasidic and Kabbalistic aspect which understands that the 'shards' or 'sparks' of the divine remain contained in the material world, and that rightful deeds by the pious will help in releasing this divine energy . It is not possible, however, to ascertain if Fichte was familiar with this concept. 14. It must be noted here that one must seek to perfect society according to the moral law, or acting in accordance with practical reason . One cannot seek to perfect oneself and society without taking this into account. Not to do so would be 'un-reasonable' to Kant and Fichte, incurring a whole range of criticisms, such as relying on 'emotions' or 'moral luck'. 15. Available at: http://oll.libertyfund.org/titles/638/71079. 16. As already mentioned, Rousseau's position is much more subtle than Fichte portrays. This is noted by Osterwalder : 'in Emile . . . the pupil [is] . . . educated in unity with and for himself as well as in unity with the whole, with an order like the absolute moral order manifested in nature, in which humanity ought to live, beyond the decadent reality of the existing society. In Emile the education culminates in the educator's confessed commitment to an absolute moral order beyond the order, or rather disorder, of a decadent society'.

The 1948 Universal Declaration of Human Rights states that 'Everyone has the right to education' and it 'shall be compulsory'. I note that there is a tension between 'right' and 'compulsory' in the Declaration because, by definition, a right is an entitlement and not an obligation. The reasons why education is an exception to the rule have not been explored in detail, and efforts seem always to concentrate on the 'compulsory' side of the tension in trying to understand exactly what it would entail, and fail to direct attention to the 'right' element of the problem. In this article, I wish to turn the problem on its head and take issue with the idea that education should be understood as a right. The argument is, rather, that education should be conceived as a dutyan obligation that all human beings have towards themselves and their communities. In order to do this, the author refers to the works of Johann Gottlieb Fichte (1762-1814), the German post-Kantian idealist, whose works in education have been long neglected and forgotten. Nevertheless, they are of great help in trying to make sense of education not as a right, but as a duty. I argue that such understanding dissolves the tension between 'right' and 'compulsory', and that a reframing of an understanding of 'what education is' needs to occur not just at the individual, but also at the societal level.

Introduction According to meta-analysis of research studies, clinical depression and sub-clinical depressed mood were associated with higher body mass index in adults. 1 -4 Several mechanisms explain how psychological distress influences obesity. First, depressive symptoms may promote fat storage in the body by increasing cortisol levels. 5 Another explanation is that negative emotions may lead to the consumption of high-calorie meals and binge eating. 6,7 In addition, people's sadness and hopelessness might decrease their motivation to exercise, thus contributing to higher BMI. 8 -10 The influences of socio-demographic factors on the association between depressive symptoms and higher BMI are not well understood. 1,2,4,10,11 Research on the influence of sociodemographic factors such as race/ethnicity may inform the development of effective interventions. Mental health interventions that provided services to a specific racial/ethnic group were four times as likely to be effective in alleviating depressive symptoms compared with interventions that targeted people of different racial/ethnic groups in meta-analysis of 76 studies. 12 Since weight gain was a late consequence of depressed mood in a meta-analysis of longitudinal studies, 4 implementing timely strategies based on the cultural context of the participant to prevent and manage psychological distress may help reduce depressive moods and subsequently obesity. Research on the influence of socio-demographic factors on the association between depressive symptoms and obesity had conflicting findings. 1,2,4,10,11 Female gender either had no influence 4 or was a greater risk factor 1,2 in the relationship between depressed mood and obesity. Some reasons for the gender difference in the association between depressed mood and obesity may include disparities in genetic predisposition to both depressed mood and obesity; stigmatization; access to care and choice of providers. 1 Educational attainment had no influence on the association between depressive symptoms and obesity in most 1,4,10 but not all studies. 11 One study on racial/ethnic differences reported a more pronounced association between depression and obesity among Latinas; 1 two other studies found no racial/ethnic differences. 10,11 People of lower educational attainment and Latinas may have reduced access to mental health care. The depressive symptoms of people of lower educational attainment and Latinas thus may remain untreated for longer periods of time, which subsequently could lead to reduced exercise and increased BMI. These prior studies with conflicting findings had important limitations. A meta-analysis of nine longitudinal studies found that depression increased the likelihood of becoming obese. It found no differences in the association by gender and age. Limitations of the meta-analysis included a small number of publications, a statistically significant trend of publication bias and the inclusion of only age and gender as co-variates. 4 In another meta-analyses of 17 studies, which also only focused on gender and age differences, the association between depression and obesity was especially pronounced among females; the relationship did not differ by age. 2 Three studies focusing on racial/ethnic differences in the association between depressive symptoms and obesity were identified. In an investigation of 4651 US middle-aged females in a health plan in Washington and Northern Idaho, race/ethnicity, age and educational levels were not risk factors in the association between depression and obesity; the study consisted primarily of middle class and White women. 10 A study of 4162 US adults aged 65 years and older found that being African American was not associated with having comorbid depression/high BMI. 11 Lower education was, however, related to having such comorbidity. 11 The findings of this study, which was administered in five counties in North Carolina, may not be applicable to other parts of the US and to adults younger than 65. 11 The third study focusing on racial/ethnic differences performed analysis in a sub-set of the 2001 Behavioral Risk Factor Surveillance Survey participants in the USA. 1 Among 44 800 subjects, being Latina was a risk factor in the association between depressive symptoms and obesity. 1 One limitation was that the study sample was not representative of the BRFSS because the particular question on depressive symptoms 'During the past 30 days, for about how many days have you felt sad, blue, or depressed' was administered in a limited number of states. 1 Given these conflicting findings and the limited research on racial/ethnic influences, we investigated the sociodemographic differences in the association between depressive symptoms and BMI. We conducted the cross-sectional research in a demographically representative sample in Genesee County, Michigan, USA. The socio-demographic determinants included age, gender, race/ethnicity and education. The participants completed a survey, which included items on depressive symptoms. --- Methods --- Setting Genesee County and its most populous city, Flint have experienced significant economic and population declines in part due to the closure of automobile manufacturing plants. 13 The unemployment rate in the county more than doubled from 4.1% in December, 2000 to 9.8% in December, 2011. 14 The county's population decreased by 10 351 people from 415 439 in 2000 to 425 790 individuals in 2010. 15 Between 2000 and 2012, the rate of violent crime increased by 9% in Genesee County. 16 --- Cross-sectional design To monitor and assess residents' health and health needs, a committee composed of academicians and community members developed the Prevention Research Center of Michigan's Speak to Your Health! Survey. 17 -19 Previous manuscripts provided details on the Speak to Your Health! Survey. 17 -19 The survey was administered among residents aged 18 years and older across all residential Census tracts in Genesee County, MI. Random samples of households were drawn from these tracts to represent all areas of Genesee County. In this cross-sectional study, three waves of survey data were combined into a sample of 3381 adults. A total of 4585 completed the survey in 2007, 2009 and 2011; these 4585 participants were part of the complete sample. Of them, 3381 had complete data on all variables; these 3381 participants were part of the analytic sample included in the present analysis. The complete and analytic samples were similar in terms of age, education in years, gender and BMI . Participants were asked if they had previously taken the survey and if so, in what year they had completed the survey. No participant reported to have previously taken the survey. Self-reported measures and data analysis BMI, a continuous variable, was calculated using the respondents' reported height and weight . Sociodemographic variables included age, gender, race/ethnicity and education. Ethnicity was categorized as 'non-Latino White' and 'African American'. Participants were asked for their highest level of education completed . Depressive symptoms were assessed with Brief Symptoms Inventory items. 20 Composite scores were calculated using these Brief Symptoms Inventory items. A two independent samples t-test was conducted to compare the mean BMI between African Americans and non-Latino Whites. The bivariate Pearson's correlation coefficients between variables were calculated. Stepwise linear regression was used to determine the unique predictors of BMI. In stepwise regression, predictor variables are determined by an automatic procedure in the form of a sequence of t-tests. 21 In this study, bidirectional elimination was used, in which a combination of forward selection and backward elimination was carried out to test for variable to be included or excluded at each step. 22 Forward selection begins with no variables in the model, tests the addition of each variable and adds the variable that would improve the model the most. Backward elimination starts with all variables, tests the deletion of each variable and deletes variable that would improve the model the most by being deleted. The standardized regression coefficients in the stepwise regression were calculated. Because the coefficients in the b column are all in the same standardized units, they can be compared to determine which one has a stronger effect. The ultimate goal of stepwise regression is to identify the regression model that best predicts the outcome. 21,22 BMI was the dependent variable in stepwise linear regression. In Model 1, the step-wise linear regression identified the --- About how much do you weigh without shoes? Enter weight in pounds. . . influence of age, gender, race/ethnicity, education, depressive symptoms and the interaction terms for demographic variables with depressive symptoms on BMI. Model 2 included all predictors as those in Model 1 in addition to the variable 'year '. 'Year ' was added as a predictor in Model 2 to account for including three waves of survey data . Age , education , year and depressive symptoms composite scores were continuous variables in the linear regression. Statistical significance was defined as P , 0.05. The statistical analyses were conducted using SPSS . --- Results Most participants were non-Latino White and female. The mean age of participants was 55 years. The mean years of education among participants were 12 . The mean BMI was higher in African Americans than in non-Latino Whites. Specifically, the mean BMI among African Americans was 29.82 and that among non-Latino Whites was 28.65 . The Chronbach's alpha of the depressive symptom items was 0.89. As depressive symptom scores increased, BMI increased as well . In Model 1, gender and the interaction terms of race/ethnicity  depressive symptoms and gender  depressive symptoms uniquely predicted BMI . Once these factors were accounted for, no other demographic characteristic or interaction term explained a significant proportion of the variance in the association between depressive symptoms and BMI. In Model 2, increasing year was a significant unique predictor of higher BMI . Gender and the interaction terms of race/ethnicity  depressive symptoms, gender  depressive symptoms remained statistically significant in Model 2 . In both models, therefore, women had a higher BMI than men, and depressive symptoms were more strongly associated with BMI among African Americans and women than among non-Latino Whites and men. The interaction term depressive symptoms  race had the largest standardized coefficient among all statistically significant predictors. --- Discussion --- Main findings of this study A more pronounced relationship between depressive symptoms and obesity among African Americans existed. The presence of a gender difference in depressive symptoms and obesity is consistent with most prior research. 2 The lack of age and education differences in the association between depressive symptoms and obesity in the present study also supports most prior research. 1,4,10 The correlation between depressive symptoms and BMI was positive and statistically significant; however, the correlation was relatively weak. Such weak correlation may imply that factors other than depressive symptoms contribute to higher BMI. Increasing survey year was associated with higher BMI. --- What is already known on this topic An African American individual may gain more weight than a non-Latino White individual suffering from the same depressive symptoms. The reasons for the greater weight gain in African Americans may be their stronger stigma related to having depression, reduced likelihood to seek mental health services and lower quality of received mental healthcare services compared with non-Latino Whites. Stigma, defined as the perception of having a 'spoiled identity' 23 and undesirable traits, 24 is an obstacle to seeking mental health care. 25 The US Department of Health and Human Services identified reducing stigma as a major goal in increasing mental health care. 26 African American patients reported greater stigma related to depression than non-Latino Whites in prior research. 27,28 As a result of such stigma, African Americans are less likely to seek mental health services than non-Latino Whites. 29,30 Once African Americans do seek mental health services, they receive lower quality of care than non-Latino Whites. 29,30 As a result of these disparities, African Americans' depressive symptoms may remain untreated or undertreated, while non-Latino Whites' depressive symptoms may be successfully managed. African Americans' experiences of stigma and lower access to adequate and quality mental health care may exacerbate their risk for having untreated/undertreated depressive symptoms and subsequently obesity. The gender difference in the association between depressive symptoms and obesity may be explained by the stronger genetic predisposition to depressed mood and obesity in women than in men. A significant increase in anxiety and depression scores for females homozygous for certain genes existed in one study. 31 A statistically significant association between BMI and homozygosity for these genes for females but not males was present. 31 The study concluded that genetic factors played significant roles for obesity and psychological distress, particularly in females. 31 In addition, females' depressed mood may persist over time due to social factors such as greater peer pressures during adolescence and lower wages and reduced career opportunities in adulthood compared with men. 32 These social factors may contribute to the stronger association between depression and obesity among females. Future research should investigate the reasons for the racial/ethnic and gender differences in the association between depressive symptoms and obesity. --- What this study adds The findings have implications for intervention research. Interventions to reduce obesity are much needed in areas such as Michigan. The rate of obesity increased from 20% in 2000 to 31.3% in 2012 in the state. 33 Only four other states, specifically West Virginia, Alabama, Louisiana and Mississippi, had higher obesity rates than Michigan in 2012. 33 The obesity rate in Genesee County was even higher than that in Michigan; the rate of obesity was 35.9% in Genesee County in 2012. 34 Most interventions to decrease obesity rates in Michigan do not target the pathways from depressive symptoms to obesity. The Michigan Nutrition, physical activity and obesity program, for example, enhanced public parks and improved walking trails. 35 It initiated the planting of neighborhood and school gardens and the creation of farmer's markets. The Faith-Based Initiative, through partnership with African American churches, increased access to fresh fruits and vegetables and places for physical activity. 35 Such programs are much needed but cannot fully succeed in decreasing obesity rates if people's depressive symptoms prevent them from consuming healthy meals and engaging in exercise and outdoor activities. The findings on the racial/ethnic and gender difference in the association between depressive symptoms and obesity support the development of tailored interventions among African Americas and females. Compared with non-Latino Whites, African Americans have expressed lower acceptability of antidepressant medication, 36 greater preference for professional counseling 37 and increased interest in counseling from clergy. 38 Future research should assess the effectiveness of quality improvement programs in physician offices, offering a choice of mental treatment options that consider preferences of African Americans. Interventions to prevent and treat mental health problems among females may be especially important in adolescence. The higher prevalence of depression in females compared with males first emerged in puberty in prior research. 39 The most effective interventions to reduce depression in adolescent girls provided cognitive-behavioral therapy. Others were multi-faceted interventions targeting negative stress responses and family conflict. 40 Yet different effective programs provided coping classes teaching adolescent girls how to overcome unconstructive thoughts and behaviors. 40 Future research should assess the effectiveness of these interventions on healthy weight maintenance. Decreasing stigma related to having depressive symptoms may be another viable intervention among females. Women who had family/friends with depression felt less stigmatized than women without family/friends with the condition in a study of 3047 adults. 41 In the same study, females who were completely in agreement with their physicians on the treatment for their depression reported less stigmatizing attitudes than women not in complete agreement. Therefore, programs seeking to increase social support and improve patient-physician communication on the appropriate treatment may decrease obesity rates by improving mental health care among women. Residents' increases in weight over the years may be attributed to the worsening economic situation in Genesee County. Future studies should investigate pathways that may explain how people's health may have changed over the years. One hypothesis is that people may be discouraged to exercise in their neighborhood because of the worsening crime, thus contributing to increased BMI over the years. --- Limitations of this study The survey response rate was 25%. The results may not be generalized to all US areas. All measurements were selfreported. People tend to overestimate their height and underestimate their weight. 42 No question on participants' income was asked in the 2007, 2009 and 2011 surveys because there was a high refusal rate to the household income question in earlier survey waves. We used the education variable to assess socioeconomic status. Another limitation is that the results of this study cannot be generalized to clinical depression. They may be better generalized to individuals experiencing subclinical depressive mood who are at risk for depression. The full depressive symptoms scale was not used; however, the four items used to assess depressive symptoms exhibited a high reliability with a Chronbach's alpha of 0.89. Causal and temporal associations could not be assessed in this cross-sectional study. The direction of the association between depressive symptoms and obesity may be opposite to that reported in this study. Stigma is attached to obesity, particularly among non-Latino whites and people of higher socioeconomic status. 43 -46 Studies on the influence of obesity on depressive symptoms had mixed findings. In the Third National Health and Nutrition Examination Survey , obesity was related to depression primarily among individuals with severe obesity. 44 In the National Comorbidity Survey, obesity was associated with major depression; the association was more pronounced among non-Latino whites and college graduates. 45 In a representative sample of 2020 adults, there was no influence of obesity on depression. However, being overweight increased the likelihood of depression among the more educated adults. 46 Future studies should investigate socio-demographic differences in the bi-directional relationship between depressive symptoms and obesity. Interventions to reduce obesity rates in the USA as a whole and in Michigan in particular are much needed. Depressive symptoms were stronger predictors of BMI for African Americans and women than for non-Latino Whites and men. Interventions to prevent and manage physiological distress among African Americans and females may decrease obesity rates. In addition, clinicians may consider monitoring weight gain among patients with depressive symptoms over time.

The study investigated the socio-demographic differences in the association between depressive symptoms and higher body mass index (BMI).In Genesee County, Michigan, random samples of households were drawn from all residential census tracts. The Speak to Your Health! Survey was administered among adults aged 18 years and older in these households. To conduct this cross-sectional study, data from three waves of survey data collection (2007, 2009 and 2011) were combined resulting in a sample of 3381 adults. Self-reported height and weight were used to calculate BMI. Depressive symptoms were assessed with Brief Symptoms Inventory items. Socio-demographic factors included age, race/ethnicity, gender and education. Results Using stepwise linear regression, gender (b ¼ 0.04, P ¼ 0.02) and the interaction terms of race/ethnicity  depressive symptoms (b ¼ 0.15, P , 0.001) and gender  depressive symptoms (b ¼ 0.05, P ¼ 0.01) uniquely predicted BMI.Women had a higher BMI than men, and depressive symptoms were more strongly associated with BMI among African Americans and women than among non-Latino Whites and men. Tailored interventions to alleviate depressive symptoms in African Americans and females may help decrease racial/ethnic and gender differences in depressive symptoms and obesity.

INTRODUCTION In 2016, the United Nations reported that safe access to drinking water, sanitation and hygiene was fundamental to improving standards of living across the world, but it was felt that there were large disparities in WASH globally, particularly in marginalised groups . Improving access to clean water, sanitation and hygiene facilities is central to achieving Sustainable Development Goals 6 , 3 , and 10 and also indirectly related to other goals such as 1 , 2 , 5 and 12 . With competing demands on water from population growth in some of the most vulnerable countries along with increased industrial and agricultural demands, there is a need for greater investment of time, activities and finance to reduce water pollution and ensure equitable access to water, hygiene and sanitation facilities . Data for Malaysia from WHO/UNICEF showed that around 99% of Malaysians live in modernised housing and communities with direct household access to water, sanitation, electricity and utilities such as electricity and a gas supply. The remaining 1% of the population does not have access to such facilities; this group would include the indigenous Orang Asli. Orang Asli are the oldest indigenous inhabitants of Peninsula Malaysia. There are around 95 subgroups with their own distinct language or dialects and culture. In Johor, they mainly comprise Jakun people, Orang Kuala, Orang Kanaq and Orang Seletar. Historically, most earned a living in agriculture fishing or through trade, but most live in rural areas . A recent UN study looking at the Orang Asli population found that their health situation was significantly poorer than the rest of the Malaysian population with a higher prevalence of parasitic infections often related to water supply. A recent systematic ) found that Orang Asli communities were often excluded in governmental national surveys and recorded WASH data may not be representative. The systematic review found that Orang Asli suffered from a greater number of tropical diseases and non-communicable diseases and had poorer nutritional status than the general population often related to socio-economic factors. Common illnesses related to untreated water included stunted growth, acute diarrhoea illness and chronic enteric infection . Most studies looking at disparities of health in indigenous communities in Malaysia have been taken in Selangor, Perak and Pahang. To our knowledge, no studies have been undertaken on WASH facilities for Orang Asli living around the Johor River Basin in Johor State. The aim of this study was, therefore, to evaluate WASH provision for residents of the Johor River Basin and evaluate the disparity in facilities between indigenous Orang Asli and more modernised communities. --- METHODS Following ethical approval and informed consent from Newcastle University, residential communities around the Johor River Basin were contacted through village heads and housing associations to seek participation in the study. In each community , a data collector was appointed from the village by the village head to collect the questionnaires digitally from the community between October 2021 and June 2022. Questionnaires were completed and collected using the ArcGIS Survey123™ platform with data anonymously uploaded to a secure cloud-based database. A copy of the questionnaire adapted from the United Nations Children's Fund and World Health Organization questionnaire is shown in the Supplementary Information Appendix A. Data were analysed with descriptive statistics using SPSS 2 Software. Comparisons between Orang Asli and more modernised communities were undertaken using Chi-Square analysis. Tests for the normal distribution of data were undertaken with a Kolmogorov-Smirnov test. --- RESULTS --- Demographics of the populations Eight hundred and ninety-nine respondents completed questionnaires in this study comprising 799 from more modernised communities and 100 from indigenous communities . Data were not normally distributed in this study . In the indigenous community, 63% of respondents were male, but there was a more even gender balance in the modernised communities . In the indigenous community, 91% were under 55 years of age compared to 80.7% in the modernised community . Most commonly, 4-6 people lived in around 60% of households in both communities. Unemployment affected 38% of respondents in the indigenous community and 36.2% of the modernised communities. With regard to the personal income of respondents, more than half of the indigenous community had no fixed monthly income when compared to 32.9% for more modernised communities. The differences in mean personal income between the communities were statistically significant with the modernised communities earning significantly higher amounts . For household income which included household contributions from people other than the respondent, there was again a significant difference in earnings between the two communities with 58% of indigenous households having no fixed monthly income, but only 11.6% of modernised communities having no fixed income . The most commonly reported household income for the indigenous group was less than RM 1,000 when compared to the modernised community where 43.2% of people reported earning between RM 2,000 and 20,000 . Regarding the level of education, there were significant differences in education level between the indigenous group and modernised populations . About 98% of indigenous respondents were educated up to the end of secondary school, with 2% having achieved diplomas, whereas 74.2% were educated up to secondary school in the more modernised community and 25.7% acquired diplomas and/or a university degree. --- Water use and sanitation facilities A significant difference existed in access to toilets between the indigenous group and the modernised communities , as summarised in Table S2 . Almost all of the indigenous community used buckets and only one respondent had a mechanical toilet. In the modernised community, 38.9% used a mechanical toilet with a flush that drained to a piped sewer system, 26.2% used a bucket, and 24.4% used toilets with mechanical sewage leading to a septic tank. When asked about using shared toilet facilities, all indigenous respondents shared their toilet facilities with people outside of their household, whereas only 24.9% of the modernised respondents shared their toilet facilities with outsiders on a daily basis . Unsurprisingly, there was also a significant difference in the number of toilets in each household between the indigenous and the modernised communities ; 98% of the indigenous people had only one toilet in the household and 2% of them had two toilets, compared to the modernised group where 87.8% had more than two toilets in the household . When asked about toilet and sewage systems in the household, 52% of the indigenous people did not know where flush toilets are connected to, compared to 40.9% of respondents from modernised communities . When asked about the condition of the toilet in the household, almost all of the indigenous population did not know the condition of the toilet basement in their households, the other 8% said that their facilities are in very good condition. For the modernised population, most think that their toilets were in very good condition, followed by 35.2% who do not know the condition of their toilets, 6% have damaged plumbing that needs repair, and the remaining 1.9% have damaged and leaking toilet facilities. Regarding the main source of drinking water for household members, while all houses had a tap with water, this water was not necessarily considered safe to drink. Table S2 compares the water usage between the indigenous and modernised community. About 62% of the indigenous respondents depended on their spouse to bring drinking water in the household either as bottled or boiled drinking water from the tap, but this responsibility was taken on by all family members for 19.0% of the indigenous households. For the modernised group, 56.7% relied on their spouse to bring drinking water to the household, 20.4% relied on parents and 5.3% relied on children . For cooking and washing, there was a significant difference in the main source of water for household usage between indigenous and the modernised groups . About 96% of the indigenous population had tap water as the main source of water which may have come directly from the river, a local pond or public water supply. For the modernised community, 86.2% used tap water from the municipal water supply as the main household water source. There was a significant difference in the recent household water supply shortage between indigenous and modernised groups . About 15% of the indigenous community said there had been household water supply shortages in the past month. For the modernised population, 22.8% had experienced a household water supply shortage. There was a significant difference in hand-washing between the indigenous and the modernised communities . In the indigenous community, 97% used a kitchen sink. For the modernised population, 98% used either kitchen sinks, bathroom sinks, or both to wash their hands. Regarding the use of soap for hand-washing, there was a significant difference in the routine use of soap and detergent between the indigenous people and the modernised people . About 18% of the indigenous people did not use soap/detergent when washing their hands, compared to 5.8% of the modernised community respondents. For showering or bathing, 92% of the indigenous people showered two times per day, but for the modernised population, 62.1% showered two times per day and up to 36.8% showered three times or more each day, as a matter of routine . There was a significant difference in showering time between the indigenous and the modernised communities . About 78% of the indigenous people said that they would take a quick shower , and the remaining 13% showered within 10-20 min. However, for the modernised group, 50.1% showered within 10-20 min, 45.9% showered for less than 10 min, and up to 4% of them showered more than 20 min at a time. There was a significant difference in the frequency of weekly household laundry undertaken between the indigenous group and the modernised communities . About 70% of the indigenous people did laundry 1-4 times per week, and 30.0% did laundry 5-8 times per week. For the modernised group, 59.2% of laundry was undertaken 1-4 times per week, followed by 28.7% doing laundry 5-8 times per week. The remaining 12.1% said that they did laundry 9-12 times per week. When asked about car washing, 62% of the indigenous community found this question not applicable because they did not own a car. About 18% of the indigenous people answered 'once a week', 1% answered 'once every 2-3 weeks' and the other 19% answered 'once a month'. For the modernised community car owners, 14.1% washed their cars once a week, 23.0% washed their car once every 2-3 weeks, and 30.7% washed their car once a month. When asked how water was stored in this study, 89% of indigenous respondents boiled their water from the tap which may have come from the municipal supply or the river. About 9% of the indigenous community did not treat their water at all from the tap or river and the remaining 2% used an electronic water filter. In the modernised communities, 45.7% boiled tap water and 34.3% used an electronic filter. The difference in water storage methods was significantly different between the two communities . Given the greater water usage by the more modernised community, it is perhaps not surprising that there was a significant difference in monthly water bills between the indigenous group and the modernised group . In the indigenous community, 91% of respondents paid less than RM 100 per month compared to the modernised community where only 81% paid less than RM 100 per month. A comparison of WASH practices related to income status irrespective of community type is presented in Table S3 . This study showed that a greater proportion of households with lower household incomes lived within walking distance of the Johor River Basin than those requiring transport to get into the river basin , whereas a greater proportion of higher-income households lived at a distance from the Johor River Basin requiring transport. This difference was significant at the p , 0.001 level. There was not much of a difference between lower-and higher-income households with respect to the main source of household drinking water. In both groups, the majority of respondents had tap water in the house . There was a similar small difference in the main source of water for household water. In both the lower and higher-income groups , tap water was used for household water requirements. Interestingly, in the lower-income households, female spouses were more often, responsible for ensuring that there was clean drinking water in the house . In the higher-income group, a greater proportion of parents were enlisted to ensure clean drinking water for the household compared to the lower-income group . In all cases, these differences, however, were non-significant . There was no significant difference in the experience of water shortage between lower-and higher-income households in this study . With regard to water storage, both household income groups stored water most commonly in open buckets and plastic bottles to store water and the refrigerator. A greater proportion of lower-income households, however, used glass containers to store water. This study showed that higher-income households had higher water bills than the lower-income households with 47.3% paying less than RM 50 per month versus higher-income households with 51.8% paying RM 51-100 monthly . --- Health risks and perception of risk When asked about health concerns of contaminants in drinking water, a significant difference existed between indigenous and modernised communities with regard to the nature of the concerns . Indigenous respondents were most concerned about metals polluting water, whereas modernised communities were more concerned about chemicals such as arsenic and petrochemicals . Only 1% of indigenous respondents were concerned about bacteria or sewage contamination, whereas 9% of the modernised community were concerned about bacteria. Concern for bacteria, however, was significantly higher within the modernised community group for respondents with higher educational levels. Chemical concern was conversely higher in those with lower levels of education, i.e. primary or secondary school level . These patterns were also reflected in the household income level compared with those of no fixed income and less than RM 1,000/month concerned primarily about chemicals and the higher earners concerned about bacteria. Interestingly, the predominant health concern in both communities was diarrhoea , and both communities felt those under five years old were most vulnerable. In both communities, the lack of access to water and the contamination of water were said to affect mood, but a greater number of the modernised community respondents felt that water contamination was a health concern compared to only 78% of indigenous respondents . When asked where they mostly received information from regarding water pollution, the indigenous community mostly relied on television programmes , whereas the modernised communities mostly received information from the internet and then from television , with the remainder getting information from newspapers, the community, advertisements and friends . This difference between the two community types was significant . Additional questions and responses are tabulated as Supplementary Information . --- DISCUSSION The communities involved in this study provided a proportionally representative sample of people living in the Johor River Basin. While the study did not capture every village and riverside community, access provided by village heads and the Johor Orang Asli Association allowed the study to be undertaken with a relatively large sample size. There is a disparity in sample sizes between the modernised and Orang Asli communities, but this is reflective of the relative population ratios of people living in the area of the river basin sampled. More men were proportionally higher respondents in the Orang Asli communities than women, this is compared to a more equal divide in the modernised communities. It likely this is because the village head of the Orang Asli communities were male as were the data collectors and sampling was probably more convenient than random in those communities based on where data collectors decided to undertake their questionnaires. Women were often at home while men were sitting out in social areas. In the modernised communities, due to the larger population, it was easier for data collectors to sample equal numbers of men and women. The electronic questionnaire used in this study was beneficial in the sense that it could be used by data collectors in the community to obtain information and data could be uploaded to secure cloud-based storage, minimising contact between the researchers and vulnerable communities during and immediately after the COVID-19 pandemic. Data collectors found the electronic questionnaire easy and convenient to use. This study has shown significant differences between Orang Asli and modernised communities in almost all variables measured in this study. In the second Malaysian Plan in the 1970s, the Malaysian government attempted to reduce the disadvantage to Orang Asli communities by making plans to increase educational standards and job opportunities. They also made plans for upgrading basic facilities such as utilities, clean water access and sanitation facilities. Attempts were made to improve medical facilities and health too, but the plan involved resettlement programmes and only 0.7% of Orang Asli were willing to move and live in the urban or semi-urban community . As a consequence, many Orang Asli are still living without basic facilities that are reflected here in the Johor River Basin. Water usage was considerably lower in the indigenous communities with the less frequent use of mechanical or flush toilets, showering and car washing. While this questionnaire has not examined every possible use of water in a household, it gives an indication of the differences in community water usage for common activities. In general, the indigenous communities tended to be more conservative about using household water for everyday tasks, which may reflect lower personal and household incomes to pay water bills. Indigenous communities hand-wash laundry using river water or tap water, but electric washing machines were commonplace in more modernised communities. While the Ministry of Rural and Regional Development has implemented a rural electricity supply programme to serve remote rural areas of Peninsula Malaysia and Borneo, there is no universal provision and communities who do not want to live in resettlement areas still do not have a reliable electricity supply . Regarding drinking water, it is interesting to note that more of the indigenous community did not treat their water prior to drinking. Several studies have reported increased higher rates of parasitic infection and diarrhoea infection in Orang Asli populations . While the current study showed awareness of unclean water causing diarrhoeal-related illnesses, this has not necessarily translated to a behaviour change in terms of maintaining high levels of sanitation. In this study, the Orang Asli community was more worried about chemical contamination in their water supplies. Chemical pollution is episodic and frequently reported in local newspapers or in television, so awareness of chemical pollution is likely to be more common in this group who rely on television more than internet sources for news and information. In addition, it affects more highly populated modernised communities too, so journalists are more willing to report on such issues. Bacterial contamination is a long-standing problem affecting a minority of the population , so may not be considered to be newsworthy. A striking difference between the two communities was toilet facilities. All but one indigenous respondent was using a single bucket for the whole family and all were sharing their bucket toilet facilities regularly with their communities. This was in contrast to the modernised communities who shared toilet facilities much less frequently and most households had more than one toilet. Due to the smaller size of the indigenous community dwellings and the ability to use toilets in neighbouring properties, it is perhaps not surprising that indigenous communities felt that they did not need more than one toilet, despite having a similar number of people in the household as the modernised communities. In this study, toilets were felt to be in a better condition in the more modernised communities than the indigenous homes, and while not specifically asked about in this study, it is possible that more of the modernised community homes were owneroccupied, and thus responsibility for maintenance and function was with the owner. While many of the indigenous respondents were homeowners who had purchased basic homes on a government scheme, these homes only included very basic toilets as standard sanitation facilities without adequate connection to any sewage treatment plant. Such responsibility falls to the homeowners. The current practice is either a self-prepared underground wood storage box to contain the sewage, or sewage is directly released into open water. Without proper drainage and sewage management, it is unlikely that the indigenous communities will install such toilets now or in the future . When WASH data were compared between high-and low-income households irrespective of community, it was found that more households with a higher monthly income were located away from the river. This may be a reflection of the types of employment in these communities. Those in modernised communities were commonly employed in service industries and factories, whereas those living near the river were mainly dependent on retail and fishing for household incomes which are consistent with findings from Masron et al. . Interestingly, female spouses were responsible for ensuring clean drinking water supplies in the lower-income communities, a behaviour consistent with findings from other low-income communities in low-and middle-income countries . In this study, water storage did not differ greatly between higher-and lower-income households, but the use of the refrigerator was more common in the higher-income households and water was probably less likely to be contaminated since the refrigerator is a sealed compartment. Lower-income households did not use the refrigerator due to lack of electricity. While most of Malaysia has electricity readily available, pockets of rural areas have unpredictable access ). Unsurprisingly, the lower-income households had lower water bills than the higher-income areas, but this may be not only a reflection of budgeting, but that they use the river water to carry out laundry and washing practices rather than a washing machine or a shower facility. Bathrooms with hand-washing facilities were more common in higher-income households, but in both higher-and lower-income households there was adequate access to soap and detergent most of the time. Less time was spent showering in this study in lower-income households, but individuals in these households were showering more frequently, so water usage may have been similar for showering. While laundry practices did not vary greatly between lower-and higher-income households, there were higher levels of car ownership and consequently car washing which will have affected water use in higher-income households. Water availability to indigenous communities in Malaysia has been the subject of a long debate. Wook discussed the case of Orang Asli plaintiffs from a fishing village in Southern Johor, wanting exclusive land and water rights in their settlements where they had lived for more than 50 years. Land reclamation and development had removed resources that communities had previously depended on meaning that livelihoods were being threatened along with water provision. Unfortunately, the High Court ruled that Orang Asli had non-exclusive rights to this land and water through common law. As such, there would not necessarily be any legal protection from these resources being further removed in the future. From this study, it is clear that there are differences in the perception of risk between the two community types. As such, public health education programmes would need to be tailored to the community in question. Future public health education programmes for the indigenous communities should also be directed towards educating communities about the importance of improving sanitation and hygiene. Both communities had some awareness of bacterial contamination of their water supplies but did not fully understand the consequences. Simple hand-washing hygiene and water preparation information targeting various age groups in the communities are the next step in trying to improve WASH facilities and practices in the Johor River Basin for indigenous communities. In modernised communities there is also work to be done explaining the risks to health with water contamination. While WASH facilities are generally good in this community, knowledge of health risks is variable so public health education in these areas will be better directed to the health consequences of water contamination. Changing behaviours on water treatment and usage is difficult when many of these behaviours have been lifelong and may be cultural or learned from previous generations. Further study into why water is used and treated or not treated will allow investigators to work with communities to modernise some behaviours to improve sanitation and hygiene in vulnerable communities. --- CONCLUSIONS This study confirms the statement by WHO/UNICEF that in Malaysia, those living in marginalised communities and stateless individuals, indigenous or otherwise may not have access to basic drinking water and sanitation. Significant differences exist between indigenous and modernised communities in their water access and sanitation facilities. Further study is required not only to understand behaviours but also to educate populations on relevant potential health risks from water contamination in the Johor River Basin. --- DATA AVAILABILITY STATEMENT All relevant data are included in the paper or its Supplementary Information. --- CONFLICT OF INTEREST The authors declare there is no conflict.

Water access, sanitation and hygiene (WASH) data for Malaysia suggest that almost 100% of the population have access to basic sanitation and basic drinking water, but this data may not include marginalised communities and stateless individuals, indigenous or otherwise. The aim of this study was to evaluate WASH provision for residents of the Johor River Basin and evaluate the disparity in facilities between indigenous Orang Asli and more modernised communities. Questionnaires were distributed to eight communities. In total, 899 questionnaires were completed including 100 from indigenous communities and 799 from more modernised communities. Significant differences existed between communities with regard to education levels (p , 0.001), occupation (p , 0.001), household income (p , 0.001), type of toilet, sewage and sanitation facilities (p , 0.001) and perception of health risks and concerns (p , 0.001). There is a significant difference in access to water and sanitation facilities between indigenous and modernised communities. Further study is now required to understand behaviours and educate river-based communities on relevant potential health risks from water contamination in the Johor River Basin.

INTRODUCTION In 2011, at the height of the euro crisis, the European Union imposed strong austerity programs on Portugal, as well as on other European countries . In Portugal, specifically, the measures designed by the Troika have profoundly affected citizens' lives. The GDP fell significantly between 2010 and 2014, unemployment also significantly increased, and many people emigrated . In addition to the poverty rate rise, taxes increased, wages decreased, and the investment in health care and education was greatly reduced. The measures imposed by the Troika have brought intense suffering, increased social inequalities, and have been an issue of intense political and economic debate, nationally and internationally . How did the Portuguese citizens react to this economic crisis? Did they consider themselves responsible for their social and economic misfortune? Research on the psychosocial variables affecting the reaction of populations during the last global economic crisis has been scarce [Christandl and Papastamou et al. are exceptions], especially those associated with ingroup blame for its own suffering. This paper intends to fill this gap by investigating how belief in a just world and national identity predict Portuguese citizens' ingroup blame. Previous research has shown that when confronted with a victim of injustice, individuals need to preserve their perception that the world is just , so that they can maintain their confidence in the future and guarantee their mental health . The preservation of the BJW when facing injustice can be done through various ways, such as the engagement in actions perceived as effective in re-establishing justice , or through "secondary" victimization, i.e., blaming or derogation of the victims, whether the victims are other people or the actual individual . This process of cognitive restoration of justice only happens when the suffering is ongoing and it is not possible to alleviate that suffering . Importantly, recent studies have shown that the more people believe in a just world and the more identified with the victim's group they are, the higher their need to reestablish the perception of justice when threatened by ingroup victimization. Indeed, those individuals showed higher secondary victimization of an ingroup victim , or of many members of the ingroup, and possibly they themselves . Nevertheless, research has not investigated whether this pattern occurs when individuals themselves are victims simply due to belonging to a given group and when the victimization takes place in an intergroup international context. Based on a national probabilistic sample, this study intends to test whether the BJW and national identification of Portuguese citizens jointly predict the victims' reactions to the suffering inflicted by the economic measures imposed by the Troika. --- NATIONAL IDENTIFICATION, BELIEF IN A JUST WORLD, AND VICTIMIZATION OF INGROUP MEMBERS According to social identity theory , when people categorize themselves as members of social groups they define themselves more in terms of their group rather than their personal characteristics. Therefore, sharing a common identity with a victim of injustice is a potential cause of threat to one's BJW , especially when individuals strongly identify with their own group . As previously assumed by the social identity approach , "the degree of internalization of or the identification of a category with an ingroup-outgroup membership [. . .] is a major determinant of accessibility" of a category . This happens because there is a convergence between the belief that good things happen to good people while bad things happen to bad people , and the motivation for positive distinctiveness arising from the categorization between us, the "good ones", and them, the "bad ones" . A non-threatening situation occurs when bad things happen to the outgroup or when good things happen to the ingroup. On the other hand, a threatening event occurs when bad things occur to good people, i.e., when the ingroup is victimized. In such a situation, individuals are motivated to solve the threatening incongruence by restructuring the situation in order to perceive it as just and legitimate. Furthermore, within the framework of the system justification theory research has shown that the need for system justification can lead individuals of disadvantaged groups to blame themselves and their group for their own disadvantage. Although apparently paradoxical, the costs of internalization of inequality at a personal and group level are compensated by the benefits at the system level that one's outcomes are predictable and controllable , which reduces the threat caused by the ingroup misfortune. Indeed, after results such as those of Novak and Lerner , where victims who were perceived as being more similar to the observer were subject to greater avoidance, Correia et al. showed that an innocent ingroup victim is more of a threat to the BJW than an innocent outgroup victim. One other study , additionally showed that the ingroup victim was also more secondarily victimized in a non-obtrusive, or implicit derogation measure, than an ingroup non-victim. However, these previous studies did not differentiate between participants who strongly and weakly endorsed the BJW, nor between participants who strongly and weakly identified with the group. The introduction of these measures allowed for findings on explicit derogation measures. It was found that when the identity of the victim and the victimization situation are not necessarily related , the positive relationships between BJW and victims' derogation, and between BJW and psychological distancing, were significant for strongly identified participants but not for weakly identified participants . Furthermore, the same result was found when there is an intrinsic relation between being an ingroup member and being a victim . In the latter case, the measure of reaction toward victims was the legitimation of wife abuse. Therefore, both when the identity of the victim and the victimization situation were and were not related, there was an association between BJW and secondary victimization for strongly identified participants but not for weakly identified participants. This means that the relationship between BJW and secondary victimization of a specific target perceived as an ingroup member is moderated by the extent to which the perceiver identifies with this ingroup. These previous studies analyzed the victimization of particular individuals in a group but not the victimization of the group as a whole. The current paper goes further by proposing that victim blaming is a more general phenomenon affecting the entire ingroup when it is under suffering. Specifically, we test whether BJW and identification also interact to predict secondary victimization when the group as a whole is a target of misfortune, in this particular case, provoked by the economic austerity measures imposed by the Troika. We may then predict a two-way interaction between BJW and ingroup identification on ingroup blaming, so that the impact of BJW should be stronger in more identified individuals when the ingroup is victimized. Because only negative events occurring to the ingroup are threatening to BJW, when the ingroup suffering is lower, more identified individuals will no longer be motivated to blame the ingroup because their ingroup is no longer being victimized. In such a situation, ingroup identification should not moderate the impact of BJW on ingroup blame. Accordingly, it is likely that the interaction between BJW and ingroup identification should occur when the ingroup is a target of a misfortune, but not when the ingroup is no longer victimized. We may then predict a threeway interaction between BJW, ingroup identification, and the victimization context. If this is the case, this paper represents an important contribution for the literature about justice motivation in terms of intergroup relations. For the first time, secondary victimization produced by a threat to BJW will be shown not to be specific to individuals who suffer life misfortunes, but a wider phenomenon that also has a group-based identity function. According to the BJW theory, this happens because blaming of the ingroup when facing victimization is a protective mechanism for people to continue to believe that they, as ingroup members, are protected from injustices, so that they can continue to delay gratification and to invest in the future, hoping that they will be fairly rewarded. --- OVERVIEW OF STUDIES Using representative probabilistic samples of Portuguese citizens, we carried out two studies aiming to address, how national identification and BJW jointly predict secondary victimization of an ingroup as a whole when there is a threat to BJW caused by externally imposed austerity measures, and when this threat is lower because those austerity measures have finished. We conducted Study 1 in 2014, at the height of the Portuguese financial crisis during the intervention by the Troika. Study 2 was conducted 3 years later, when the Troika had already left Portugal. As we already mentioned, this external intervention was accompanied by a profound deterioration of economic activity, with extremely negative consequences for the lives of the population. Indeed, there was the deep economic recession resulting from the Troika's financial intervention which produced an environment of continued social and psychological suffering that affected almost the entire Portuguese population. This scenario, at the time of Study 1, provided us with a unique opportunity to analyze secondary victimization in a realistic context. When the measures finished, at the time of Study 2 there was a period of some social enthusiasm due to returning economic growth, allowing us to see the social environment in which the study was carried out as one of less suffering compared to that of Study 1. Together, these two studies allowed us to test the hypothesis that BJW is positively associated with ingroup blaming for its own suffering and that this association is moderated by national identification and by threat produced by ingroup suffering. Specifically, we predicted that, because an environment of ingroup suffering is more threatening of the BJW of more ingroup identified individuals, BJW would be positively associated with ingroup blame in highly identified Portuguese participants, i.e., individuals' degree of national identification should moderate the effect of BJW on secondary victimization . Additionally, we predicted a different pattern of results when the suffering caused by social environment decreased. When external intervention was concluded and the country's socio-economic situation improved, ingroup suffering should be less salient for national identified individuals and, so, the association between BJW and secondary victimization should not be moderated by individuals' national identification . --- STUDY 1 In this study, we aimed to address the articulation between national identity and BJW on ingroup blame for economic suffering during externally imposed austerity measures. More specifically, as regards to ingroup blame, we predicted that only for highly identified Portuguese participants, BJW would be positively associated with ingroup blame because the BJW motivates the reestablishment of justice in the world, when the victim shares a common identity with the perceiver. Additionally, in order to better test our hypotheses several control variables were introduced in the regression models. These variables have shown to be correlated with BJW in previous studies [see Correia for a revision] and, consequently, may contribute to explain the dependent variable ingroup blame. This is even more probable if we take into account that the study is cross-sectional and the sample is representative of a countries' population. We also predict that European identification may foster ingroup blame. Therefore, it should be controlled so that a stronger test of our hypothesis that BJW and national identification predict ingroup blame over and above those control variables can be done. --- Materials and Methods --- Participants and Procedure A national representative probabilistic sample was used . For the present study, we only considered data from participants who were Portuguese citizens . Of these participants, 779 matched all measurements and therefore constitute the final sample of the present study . Data were collected between September 2014 and January 2015, as part of the Portuguese module of the International Social Survey Program . These data were collected by trained interviewers. The interviews were face to face and carried out in the participant's home. Participants' consent was obtained prior to the beginning of the study, in accordance with the Declaration of Helsinki. The protocol and questionnaire were approved by the ISSP General Assembly according to their Ethics Statement, except the item that measured ingroup blame and the items that measured Belief in a Just World, that were part of the Portuguese module of the ISSP. The data and further information about documentation and data collection can be found at http://www.issp.org, and at https://www.ics.ulisboa.pt/docs/issp/Study_1_ISSP_database _ Portugal.sav . --- Measures Religiousness We measured this construct with one item asking people "Without counting special occasions such as weddings, funerals, and baptisms, how frequently do you participate in religious services?" in an eight point scale from 1 "Several times a week" to 8 "Never." The answers to the items were recoded so that higher scores indicate stronger endorsement of the construct. --- Subjective social status We measured this construct with one item asking people "In a general way, some people are at the top of our society and others are at the bottom. This scale represents the top and the bottom. At which point of the scale do you think you are at this time of your life?" in a 10-point scale from 1 "Bottom" to 10 "Top." --- Belief in a just world We measured this construct with three-items taken from the General Belief in a Just World Scale , ranging from 1 to 5 . The answers to the items were recoded so that higher scores indicate stronger endorsement of the construct. We computed a global score for this scale by averaging across items. --- Ingroup identification We used two items to measure ingroup identification in a four-point scales ranging from 1 to 4 . The answers were recoded so that higher scores indicate stronger endorsement of the construct. We computed a global score for this scale by averaging across items. --- European identification We used one item to measure identification with Europe in a four-point scales ranging from 1 to 4 . The answers to the item were recoded so that higher scores indicate stronger endorsement of the construct. --- Ingroup blaming We measured this construct with one item "Regarding the impact of the measures imposed by the Troika in Portugal, Portuguese people are partly to blame for the suffering they are going through" with five-point scales ranging from 1 to 5 . The answers were recoded so that higher scores indicate stronger endorsement of the construct. Sixty percent of the participants said they agreed or totally agreed with that sentence; only 26% disagreed or strongly disagreed. --- Results and Discussion --- Preliminary Analysis Table 1 presents descriptive statistics and zero-order correlations between all variables. Some results are important for a better characterization of the context in which the study was carried out, besides serving as baseline for comparisons with Study 2. Both national and European identification were strongly higher than the midpoint of the response scale , and , respectively. Mean scores of BJW were slightly below the midpoint of the scale . In turn, ingroup blaming was substantial, being scored significantly above the midpoint of the scale . Concerning the correlations, BJW and national identification were both positively correlated with ingroup blame. Additionally, ingroup blame was positively and significantly correlated with identification with Europe and years of schooling, and negatively correlated with age. --- Main Analysis We then tested whether national identification moderated the relationship between BJW and ingroup blame , while controlling for the effects of European identification. As age, years of schooling, social status, and religiousness correlated significantly with the main predictor variables , as well as with the criterion variable , they were also introduced in the regression. We thus conducted a multiple regression analysis. In a first block, we entered the socio-demographic and the control variable . In a second block, we entered BJW and national identification. In a third block, we entered the product between BJW and social identification. In the current and in the subsequent study, all the predictor variables were centered before analyses . The results are shown in Table 2. In the final model, ingroup blame was explained by years of schooling, European identification, national identification, and BJW. All these associations were positive. Furthermore, a significant two-way interaction between BJW and social identification significantly predicted ingroup blame. This significant effect obtained in the third model was over and above the effects of other variables included in the model estimated in Block 1 and Block 2. In accordance with our hypothesis, simple slope analyses showed that for Portuguese citizens higher in national b, unstandardized coefficients. For all measures, scores were computed by averaging across items, with higher scores indicating stronger endorsement of the construct. For sex: 0 = "male"; 1 = "female". * p < 0.05; * * p < 0.01; * * * p < 0.001. identification , BJW was positively associated with ingroup blame, b = 0.32, t = 4.00, p = 0.001 . Also as we predicted, for Portuguese citizens lower in national identification , BJW was not significantly associated with ingroup blame, b = 0.06, t = 0.74, p = 0.461. The pattern of results we found is the first evidence for the key role played by national identification in understanding the association between BJW and secondary victimization of an ingroup as a whole, especially in a social environment in which the national ingroup is under ongoing suffering imposed by an external outgroup. According to our rationale, this occurred because the more identified participants are, the more they are sensitive to social and psychological consequences of the economic austerity measures, which may have threatened their BJW. Indeed, a bad thing was happening with good people, i.e., with their own beloved and valued ingroup. Our rationale also assumes that the social environment plays a key role in victimization. Specifically, if the impact of national identification depends on the social environment where the victimization occurs, we can predict that a change in the social context that led to victimization should also impact the association between BJW and ingroup victimization of more national identified individuals. Specifically, if the social environment is less threatening to the ingroup, the need to restore justice should not be so prominent among the most identified individuals, which may mitigate the role of identification in the relationship between BJW and victimization. This possibility will be tested in Study 2. --- STUDY 2 This study aimed to analyze the moderating role of national identification on the relationship between BJW and ingroup blame in a social context where externally imposed austerity measures were not present anymore. Study 2 was conducted in 2017 when the Troika intervention program had already finished and the Portuguese social environment was regaining some enthusiasm due to returning economic growth. Therefore, the study was conducted in a social context of less victimization compared to that of Study 1. Because of the decreased victimization, it is possible that threat to ingroup had been removed and therefore national identification no longer played a role in the relationship between BJW and ingroup blame. Thus, we predict that national identification should not moderate the BJW effect. Moreover, Study 2 allows us to overcome some important limitation of the first study. The results we obtained in Study 1 were based on a measure of the dependent variable accessed with only one item, which weakens the accuracy of the estimated parameters and limits the power of inference on the studied phenomenon. The current study addresses this aspect by considering more items to measure ingroup blame, as well as by using different forms of accessing it. The study also tested the proposed hypothesis by taking into account the role played by relevant controlling variables in cross-sectional representative surveys. --- Materials and Methods --- Participants and Procedure We used the national Portuguese database from the European Social Survey Round 8 . The sample is composed of 1270 individuals who are representative of the Portuguese population. Of them, 1140 indicated they were born in Portugal, have Portuguese nationality, and are over 18 years of age, and so we considered them eligible for the current study. Because we had the possibility to carry out the study with a large and diverse sample, it was possible to extend the test of our hypothesis by using two different versions of the ingroup victimization measure, which allowed us to increase the scope of generality of the proposed effects. Therefore, when the Portuguese specific items of the ESS8 were applied, half of respondents answered a version of victimization items ; while the other half responded to a different set of victimization items . Subsample A is composed of 551 participants aged between 18 and 90 years old , being 224 male and 327 female . Subsample B is formed by 589 participants . The participants were randomly allocated either in Subsample A or in Subsample B at the moment they were answering the ingroup victimization items. The two different scales of ingroup blame are presented below. Participants' consent was obtained prior to the beginning of the study in accordance with the Declaration of Helsinki and the protocol and questionnaire were approved by the ESS Research Ethics Committee. The data and further information about documentation and data collection can be found at http: //www.europeansocialsurvey.org and at http://asp.ics.ul.pt . --- Measures --- Belief in a Just World We asked the participants to answer the same three-items we used in Study 1 to measure BJW . The scores were recoded and averaged so that higher values indicate stronger endorsement of the BJW . --- Ingroup Identification We also used the same two items of Study 1 for measuring national identification . We computed a global identification score by averaging across items that vary from 1 to 4 . --- Ingroup Blaming As we indicated above, participants were randomly located into two subsamples, according to the set of items we used to measure ingroup blaming. The participants in Subsample A indicated the extent to which they agreed with the following two items by using a five-point answer scale : "Regarding the impact of the measures imposed by the Troika in Portugal, Portuguese people are partly to blame for the suffering they went through" and "Regarding the impact of the measures imposed by the Troika in Portugal, Portuguese people are partly responsible for the suffering they went through". We recoded the answers so that higher scores indicate stronger ingroup blaming. The participants in Subsample B used a four-point answer scale to indicate their agreement with the following two items: "Regarding the impact of the measures imposed by the Troika in Portugal, how much do you think the Portuguese people are to blame for the suffering they went through?"; "Regarding the impact of the measures imposed by the Troika in Portugal, how much do you think the Portuguese people are responsible for the suffering they went through?". We also recoded the answers so that higher scores indicate stronger ingroup blaming. In both versions, each set of items showed have strong internal consistence: Subsample A ; Subsample B . --- Controlling Variables Besides some relevant participants' sociodemographic characteristics, we also included three controlling variables: Religiousness ; subjective income ; left-right political positioning, varying from 0 to 10 . --- European Identification "How close to or identified do you feel with Europe?, " coded from 1 = not at all identified to 4 = very much identified. --- Results and Discussion --- Preliminary Analysis Table 3 shows descriptive statistics and bivariate correlations between all variables. The mean scores of our key variables are substantially different from those we obtained in Study 1, which denote a less threatening social environment. For example, in both samples of the current study, the national and European Identifications were higher than in Study 1 . Similarly, BJW in both Study 2 Subsamples was stronger than in Study 1: t = 5.10, p < 0.001, d = 0.28 and t = 5.60, p < 0.001, d = 0.27, respectively. Importantly, ingroup blaming was significantly lower in Subsample A of Study 2 than in Study 1, t = -6.29, p < 0.001, d = -0.35 .1 Regarding the correlations, in each subsample, BJW correlated positively with ingroup blame. The correlation was substantially stronger in Subsample A. In this sample, only BJW and European identification are associated with ingroup blame. In Subsample B, besides the association with BJW, ingroup blame was positively correlated with participants' years of schooling, subjective income, and identification with Europe, and negatively with age. National identification did not correlate with ingroup blame in any sample, which points in the direction of our hypothesis, according to which ingroup identification plays a less important role in a social context where the victimization is little salient. Despite these preliminary results indicating weak associations between ingroup blame and the controlling variables, we included them in the regression analysis when testing our hypotheses. --- Main Analysis Table 2 presents the estimated parameters for the regression analysis we used to test our prediction in each subsample. The results indicate very consistent results across samples. The more the participants' BJW, the more they blamed Portuguese people for the Troika intervention. Importantly, this main effect of BJW was not moderated by national identification. This means that the association between BJW and ingroup blame occurred not only over and above individuals' ingroup identification, but it is equally positive both in more and less identified participants. Moreover, the BJW remained a significant predictor, even taking identification with Europe into account, which was a controlling variable associated with more ingroup blame. The pattern of results we found in the current study is in accordance with our prediction that the association between BJW and secondary victimization is not moderated by individuals' national identification in a social environment where ingroup suffering is not salient, as was the case when the study was conducted. 2 This was at the time the Troika intervention was completed and the country's socio-economic situation started to get better. In sum, the results are in accordance with our prediction that BJW is positively associated with ingroup blaming for its own suffering, and that this association is moderated by national identification and by the environmental social context where the ingroup blaming means between Study 1 and 2 by using only the common item across the two studies. Results demonstrate that, effectively, ingroup blaming was significantly lower in Study 2 than in Study 1 , t = -6.39, p < 0.001, d = -0.4. Moreover, ingroup blaming does not reach the midpoint of the scale in Study 2 , while it was significantly above this midpoint in Study 1 . Additionally, the reduction of ingroup blaming from Study 1 to Study 2 is more evident when we take into account the percentage of participants who agreed with the ingroup blaming indicator. While in Study 1, about 60% of them scored above the midpoint of the scale, in Study 2 this percentage decreases to only 46%. 2 Because in Study 1 we had not an indicator of left-right political placement, the non-significant interaction in Study 2 could be due to control for this variable. In order to address this possibility we re-estimate the regression model without left-right as a controlling variable. Results showed very similar effect to those presented on Table 2. In fact, the interaction effect was not significant in Subsample A , nor in Subsample B . Thus, the non-moderating effect of national identification in Study 2 cannot be explained by controlling for individuals' left-right political placement. secondary victimization occurs. That is, the moderating effect of national identification should, in fact, occur in Study 1, but not in Study 2. In order to carry out a more rigorous test of this hypothesis, we conducted a new analysis in which we assembled the databases of the two studies by focusing on the measures that fully matched between the two time points. We then estimated a regression model taking ingroup blame as the dependent variable, the year when data were collected , BJW, national identification , and interaction terms as predictors. Results showed a reliable main effect of the year of study, confirming that ingroup blaming was lower in 2017 than in 2014 . As expected, we found a reliable main effect of BJW and a marginal effect of national identification . Importantly, we obtained a three-way interaction between the year of study, BJW, and national identification . As we predicted and verified before in each study, the decomposition of this interaction indicated a reliable two way interaction between BJW and national identification in 2014 , but not in 2017 . The pattern of interaction follows those already depicted in Figure 1. These results represent strong evidence for our hypothesis that the moderating role played by national identification in the relationship between BJW and ingroup blame depends on the social environment where the victimization occurs. 3 --- GENERAL DISCUSSION This study addressed, for the first time, the relation between national identity and BJW on ingroup blame for externally imposed economic austerity measures by the Troika, that lead to suffering of the population and was perceived as a victimization imposed by an outgroup. Using probabilistic representative samples of Portuguese citizens, we found a consistent pattern of results. Across the two studies, the more participants endorse BJW, the more they blame the ingroup as a whole for their suffering. Importantly, in a social environment characterized by ongoing suffering caused by an outgroup intervention , the association of BJW with ingroup blame was moderated by national identification. This result is in accordance with our prediction that BJW is positively associated with ingroup blame only for highly identified Portuguese participants in a social context of victimization by an outgroup. Importantly, 3 years later, when the victimization was less prominent, national identification did not play a role in ingroup blaming . In sum, the results were in accordance with our proposal that, in terms of intergroup relations, the moderating role of ingroup identification in the relationship between BJW and secondary victimization depends on the existence of a threatening social context where the ingroup is victimized. --- Theoretical Implications Results we found provide new insight into the role played by national identification on the relationship between BJW and secondary victimization, establishing a new frontier for understanding the conditions under which ingroup identification favors the relationship between BJW and ingroup blaming. From a theoretical point of view, the results support the generalizability of the relation between the degree of endorsement of BJW and social identification in the reaction to ingroup victims. Either the ingroup victim is an isolated victim and there is no relation between the nature of the victim's group and the victimization that happened ; or there is an intrinsic relation between being an ingroup member and being a victim ; or, as in the present study, when people are victimized just because they belong to a given group, the same result was found. It is also important to stress that these effects have already been obtained with different forms of secondary victimization: victim derogation and psychological distancing from the victims and legitimization of the victimization ). The present research advances prior research on the psychological effects of victimization, since the moderating role played by ingroup identification occurs when the group as a whole is in continuous suffering , but not when the act of victimization by the outgroup was removed . Beyond advancing the literature on secondary victimization, the present paper also contributes to the understanding of the social consequences of intervention imposed by a powerful outgroup, and therefore studies the phenomenon at an intergroup relations level of analysis . Our results suggest that the blaming of the ingroup is a way to deal with BJW threat and, consequently, to maintain confidence in the future. Indeed, to believe that the misfortunes occurring with the ingroup are not random and are, to some extent, deserved as a consequence of its own "misbehavior, " may be psychologically and socially functional. In other words, it can contribute to maintaining the fundamental illusion that the events occurring to us are predictable, stable, and controllable . This possibility is in line with theorizing and research about the socio-psychological consequences of the legitimation of social inequality [see Costa-Lopes et al. for a review]. From a social identity perspective , individuals are motivated to value their ingroup by differentiating it from outgroups in order to maintain positive self-esteem. Individuals who are members of minority groups have their self-esteem threatened when their ingroup is under victimization imposed by a high status outgroup. One possible way to maintain selfesteem is by perceiving victimization as illegitimate and ingroup boundaries as impermeable, which motivates them to engage in collective actions. For instance, when members of minority groups can attribute their misfortune to prejudice, they increase identification with the minority group, which leads to enhanced well-being ; especially those who already have higher ingroup identification . Furthermore, highly identified members may deviate from the ingroup members internalization of the disadvantage, willing to improve the ingroup situation . A different reaction can occur when individuals view victimization as legitimate and group boundaries as permeable. In this case, it motivates them to disidentify with the ingroup, which leads to the outgroup favoritism effect that can have pervasive harmful consequences for the individuals' own ingroup . The current research shows that individuals can follow a third way in solving the ingroup-victimization problem: they can actively tend to legitimize their situation through ingroup blaming, when their ingroup identity is under threat. Indeed, the self-protective role of national identity motivating a coping process when facing a threat of injustice by an outgroup perpetrator has never been studied, and this paper constitutes a first step in that direction. That possibility is in accordance with the system justification theory that predicts a justice motive to legitimize the existing social order whose function is to reduce dissonance, especially in disadvantaged groups . Accordingly, the results of the present research not only extend previous research within the framework of BJW literature but also contribute to illuminate the functionality of BJW in legitimizing the suffering observed in the social system as a whole. It is also in line with recent research that showed at an interpersonal level, that random and uncontrollable bad outcomes increase beliefs about deserving bad outcomes . Our research contributes to this literature by showing that legitimization also depends on the existence of threats resulting from the macro social environment. --- Limitations and Further Directions The fact that the constructs were assessed with few items represents a weakness. However, in Study 2 we found the same results with two different measures of ingroup blame. Nevertheless, the results obtained are according to the theoretical predictions, which lessens this issue's potential impact. Moreover, the size and representativeness of the present study sample allows the hypotheses to be tested on individuals who are very diverse in terms of age, gender, economic status, etc. We must also not forget that the correlational design of this study limits the nature of the conclusions that can be drawn about the causal and sequential relations among BJW, national identification, and ingroup blame. Future studies should experimentally manipulate the motivation to reestablish the BJW and the strength of national identification, to check their joint impact on ingroup blame. Future studies should also include measures related with the perception of efficacy to change the ingroup situation or of support of collective action, so that it is possible to compare high and low identifiers on their perceived efficacy to change the ingroup disadvantaged situation . The reliability of BJW in Study 2 was low. The measures of BJW have been mostly used with adult participants with a medium to a high level of education. In our representative sample we have participants with a comparatively lower education level than in most samples. Furthermore, we only have a three-item scale. All these reasons may explain the lower reliability of the BJW scale. Even so, the findings were according to the theoretical predictions. Methodologically, the main strength of this paper is the analysis of the same population over time, where it is possible to study the impact of threats resulting from the macro social environment on the relation between BJW, national identity, and ingroup blame. Future studies could also measure the impact of ingroup blame on well-being. In fact, if ingroup blame is used to reduce threat to BJW, it is expected that its use can have positive consequences for the well-being of the individuals. On the downside, it also legitimizes the status quo and contributes to its passive acceptance, and therefore to social injustice. --- --- Conflict of Interest Statement: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Using representative probabilistic samples of Portuguese citizens and framed by an intergroup perspective, we carried out two studies aiming to address how national identification and belief in a just world (BJW) jointly predict secondary victimization of an ingroup as a whole (specifically ingroup blame). We conducted Study 1 (N = 779) in 2014, at the height of the European austerity policies imposed on Portugal by an institutional outgroup, specifically the Troika (the European Union, the European Central Bank, and the International Monetary Fund). Study 2 (N = 1140) was conducted after the Troika intervention. An environment of ongoing ingroup suffering caused by an outgroup is more threatening for the BJW of individuals who are more identified with the ingroup. We therefore predicted and found that BJW was positively associated with ingroup blame in participants higher in national identification when the victimization provoked by an institutional outgroup was higher (Study 1). However, when the suffering caused by the outgroup decreased, the association between BJW and secondary victimization was not moderated by individuals' national identification (Study 2). Indeed, a three-way interaction was found between BJW, national identification, and social context (high vs. low victimization). These results are an important contribution for the literature about justice motivation in terms of intergroup relations, because they show that secondary victimization produced by a threat to BJW has a group-based identity function.

Introduction Breast cancer is the second leading cause of cancer-related death among women, with notable differences by race/ethnicity in breast cancer burden [1,2]. For example, compared with White women, women of color are more likely to be diagnosed with metastatic breast cancer and die from the disease [3]. Such inequities in the distribution of metastatic disease are concerning, as they have negative financial implications for women whose treatment regimens may be more complex and costly due to indefinite treatment duration. Financial toxicity, or the financial burden and distress that cancer patients experience, is now considered a significant adverse effect of cancer care [4], affecting more than 30% of cancer patients [5]. Financial toxicity has been linked to lower health-related quality of life and higher mortality among cancer patients [6,7]. Moreover, patients reporting cancer-related financial burden are more likely to engage in cost-management behaviors, such as delaying/discontinuing treatment, forgoing medical care, and filing for bankruptcy [5,[8][9][10]. Although racial/ethnic disparities in financial barriers to care are well-documented [11], research on racial/ethnic differences in financial burden has been limited. One recent prospective cohort study of Black and White women with breast cancer found that compared with Whites, Black women were more likely to report income loss, health care-related financial barriers, health care-related transportation barriers, job loss, and loss of health insurance [12]. However, no study, to our knowledge has examined racial/ethnic differences in employment status and financial coping among women with incurable metastatic disease. Moreover, little is known regarding the extent of financial coping in less studied racially/ ethnically diverse populations, including Hispanics/Latinas, Asians/Pacific Islanders, and American Indians/Alaskan Natives. Such understanding can help inform the development of future interventions aimed at addressing financial toxicity, with a bend towards equity. Using data from a national survey of diverse patients with metastatic breast cancer, we examined racial/ethnic patterns in employment changes and financial coping due to cancer. Specifically, we assessed racial/ethnic differences in cancer-related changes in work for pay and cost-management behaviors among non-Hispanic Whites, non-Hispanic Blacks, Hispanics/Latinas, Asian/Pacific Islanders, and American Indians/Alaskan Natives. --- Methods --- --- Outcomes --- Changes in Work for Pay.-To assess changes in work, we combined survey items from several prior studies that assessed changes in work status among cancer patients and survivors [9,[12][13][14]. Specifically, participants were asked, "Since being told you have metastatic or stage IV breast cancer, which changes, if any, have you made in your work for pay? ." Participants could select multiple responses in eight dimensions including stopping work completely, reducing hours, taking paid leave, taking unpaid leave, retiring early, or changing jobs as a result of their cancer. Financial Coping/Cost-Management Behaviors.-We define our financial coping measures according to the framework developed by Altice and colleagues, where cancer financial coping behaviors are defined as those behaviors that "patients adopt to manage their medical care while experiencing increased household expenses during/following cancer care" [15]. Consistent with the Altice and colleagues definition, we use the terms "financial coping" and "cost-management behaviors" interchangeably throughout this paper. To assess cost-management behaviors, we combined survey items from several prior studies that assessed financial coping behaviors among cancer patients and survivors [5,13,16,17]. Specifically, we asked, "Which of the following have you done to manage the cost of your cancer? ." Cost-management behaviors included discontinuing care due to cost, skipping vacations or other activities, withdrawing money from savings, filing for disability, avoiding treatment for other medical problems, skipping payment of nonmedical bills, and applying for or receiving financial assistance. --- Covariates The primary variable of interest was race/ethnicity, as defined by self-report. Individuals could select more than one racial category but nearly all individuals identified as only one race. All those who identified as more than one race identified as White and another race and were categorized into the non-White group. Individuals who identified as having Hispanic ethnicity are classified as "Hispanic" regardless of race-the majority of these individuals are White Hispanics . The sample size was sufficient to report on non-Hispanic White, non-Hispanic Black, Hispanic, Asian/Pacific Islander/Native Hawaiian, and American Indian/Alaskan Native participants. Control variables were divided into clinical characteristics and socioeconomic characteristics. Clinical variables included age at the time of the survey and years living with metastatic disease. Socioeconomic variables included insurance coverage , marital status, whether any dependents are present in the household, total household income, educational attainment , and whether women were employed at the time of the survey. --- Statistical Analysis First, we evaluated racial/ethnic differences in participant sociodemographic and clinical characteristics using chi-squared tests comparing each racial/ethnic group to non-Hispanic Whites. Next, we calculated unadjusted prevalence rates of each outcome by race, using chisquared tests to report statistically significant differences between each racial/ethnic group and non-Hispanic Whites. Lastly, we estimated modified Poisson regressions predicting each outcome as a function of race/ethnicity , adjusting for patient clinical and sociodemographic characteristics. Differences are presented as risk ratios and each group is compared to non-Hispanic Whites using a Wald test. Statistical tests were two-sided with significance assessed using an alpha value of .05. All analyses were performed using Stata 15 . --- Results --- Participant Characteristics Survey participant characteristics are displayed in Table 1. The study sample included 66.0% non-Hispanic Whites, 9.0% non-Hispanic Blacks, 6.6% Hispanics, 10.1% Asians/Pacific Islanders/Native Hawaiians, and 8.3% American Indians/Alaskan Natives. Mean age for the sample was 42.3 years. Compared with all other racial/ethnic groups, non-Hispanic Whites were more likely to report living with metastatic breast cancer for less than a year, possessing insurance, and being married or living with a partner. Most participants reported having dependents and education . Non-Hispanic Blacks were most likely to be currently employed . --- Unadjusted Comparisons Figures 1 and 2 display unadjusted comparisons of outcomes by race/ethnicity, with non-Hispanic Whites as the reference group for chi-squared comparison tests. Regarding changes in work for pay , stopping work completely was the most commonly reported change in work for pay across all racial/ethnic groups , with participants of color reporting higher rates of work discontinuation relative to non-Hispanic Whites. Retiring early and changing jobs were least commonly reported across the entire sample , but relatively more common among participants of color than non-Hispanic Whites. With respect to cost-management behaviors , stopping or refusing treatment was the most commonly reported cost-management behavior for non-Hispanic Blacks , Asians/Pacific Islanders/Native Hawaiians , and American Indians/Alaskan Natives , while borrowing money from friends was most commonly reported for Hispanics , and skipping a vacation was the most commonly reported cost-management behavior for non-Hispanic Whites . Of note, very few participants applied for and received financial assistance for their cancer care , with no statistically significant differences by race/ethnicity. --- Adjusted Comparisons Results from the adjusted modified Poisson regression analyses are reported in Figures 3 and4. In adjusted analyses comparing non-Hispanic Whites with non-Hispanic Blacks on changes in work for pay , Blacks were more likely to report taking unpaid leave . Of note, non-Hispanic Blacks exhibited the highest prevalence of unpaid leave in the entire sample . Hispanics were more likely than Whites to report reducing work hours , taking paid leave ; highest prevalence group, 68.6%), and changing jobs . Asians/Pacific Islanders/ Native Hawaiians were also more likely than non-Hispanic Whites to report stopping work and taking paid leave . Moreover, compared with non-Hispanic Whites, American Indians/Alaskan Natives were more likely to report stopping work completely and reducing work hours . Racial/ethnic differences in cost-management behaviors were also observed in adjusted analyses . Specifically, non-Hispanic Blacks were more likely than non-Hispanic Whites to report stopping or refusing treatment . Hispanics were more likely than Whites to report borrowing money from friends and filing for disability , but were less likely to report skipping a vacation , and using savings . Asians/Pacific Islanders/Native Hawaiians were more likely than non-Hispanic Whites to report stopping or refusing treatment and skipping other medical bills , but less likely than non-Hispanic Whites to report borrowing money from friends and using savings . Finally, American Indians/Alaskan Natives were more likely than non-Hispanic Whites to report stopping or refusing treatment , skipping a vacation , and skipping non-medical bills and skipping other medical bills to cope with cancer care costs. --- Discussion Women with metastatic breast cancer experience a range of changes in work for pay and engage in a wide variety of cost-management strategies to cope with the costs of their cancer care. We observed racial/ethnic differences in the prevalence and types of work changes and cost-related coping behaviors reported by participants in our study. Specifically, women of color were more likely than their non-Hispanic White counterparts to report adverse changes in their employment status due to the burden of their cancer care . Furthermore, stopping/refusing treatment was the most commonly reported cost-management behavior among patients of color, while using savings and skipping a vacation were the most common financial coping practices reported among non-Hispanic Whites. These findings highlight the need for an equity prioritization lens in efforts aimed at addressing financial burden among cancer patients. Higher prevalence of adverse changes in work for pay among women of color likely reflects racial/ethnic differences in the types of jobs held by persons of color relative to their White counterparts. National data indicate that, on average, Blacks and Hispanics are more likely than Whites to be employed in service, transportation, and manual labor positions, but less likely to hold management, professional, and related positions [18]. As such, racial/ethnic differences in employment categories have implications for racial variations in changes in work for pay, as individuals in service, transportation, and manual labor positions generally have less flexibility and autonomy in determining their work roles and schedules, as well as less job security, relative to persons employed in management/professional positions [19,20]. Furthermore, given the persistent physical side effects of metastatic cancer treatment and the physical demands of many service, transportation, and manual labor positions, individuals in these positions may face additional barriers in performing their job duties that can affect job retention. More research is needed to further elucidate associations between race/ethnicity, job type, and changes in work for pay among cancer patients, as well as identify strategies for addressing the disproportionate burden of work discontinuation and other adverse effects of cancer treatment on employment among persons of color. Indeed, past research suggests that increasing employer support for employees with cancer, including accommodating alternative work schedules and responsibilities, is critical to work continuation and return [21]. Such practices are also consistent with employment-related non-discrimination policies, such as the American Disabilities Act, which requires employers to provide reasonable accommodations to employees or job applicants with a disability [22]. Additionally, ensuring equitable access to physical and occupational therapy may help mitigate the abovementioned barriers to job performance and retention in patients of color. Similarly, early identification of individuals at high-risk of adverse work changes and creating systems of support for these individuals , can help offset the negative impact of cancer care on work status. Racial/ethnic disparities in cancer patient survival are well-documented and partly attributable to racial/ethnic differences in treatment completion [23,24]. In this study, treatment refusal/discontinuation was the most commonly reported cost-management behavior among patients of color, suggesting that financial burden, over and above socioeconomic status, is a potential key driver of racial/ethnic inequities in survival among metastatic breast cancer patients. As such, supportive cancer care services that address financial burden, particularly among patients of color, hold much promise for helping to mitigate racial/ethnic inequities in cancer care outcomes. Interestingly, very few patients in our study reported that they applied for and received financial assistance for their cancer treatment costs. In a recent study of oncology navigators' perceptions of financial burden and financial assistance resources, our team identified several barriers to patients obtaining financial assistance, including lack of financial assistance resources at hospitals, limited knowledge about available resources, and complex/duplicative application processes [25]. Thus, to improve equitable access to financial assistance services, it will be important to establish systems within cancer hospitals that enhance transparency regarding available financial resources and coordination for patients seeking these resources. It is also worth noting that the cost-management strategies most commonly reported among non-Hispanic Whites included using savings and skipping a vacation. Yet, most of the patients of color in this study were more likely to report other cost-management behaviors such as stopping/refusing treatment, borrowing money from friends, and skipping payments on non-medical bills. These racial/ethnic differences in the types of coping behaviors employed likely reflects broader national trends in wealth and access to economic reserves. For example, prior research has shown that for every dollar of wealth that Whites possess, Blacks have 6 cents and Latinos have 7 cents [26,27]. These longstanding wealth inequalities need to be taken into account in broader discussions related to addressing financial toxicity, particularly among patients with metastatic disease who are more likely to face prolonged financial strain due to their ongoing need for cancer treatment. There are limitations to this study that are worth noting. First, this study cohort is a convenience sample of patients with metastatic breast cancer who were members of a metastatic breast cancer support network and willing to complete an online survey. Thus, participants in this study may be a more engaged patient population and may differ from the broader population of patients with metastatic breast cancer in ways that are meaningful to our study outcomes. Consistent with this notion, we found that participants in this study were relatively younger than the general population of women living with metastatic breast cancer in the US [28]. Prior research suggests that younger and working-age cancer survivors are at great risk for financial burden [10,29]. Thus, additional research is needed to assess racial/ethnic variations in financial coping across age subgroups of patients with metastatic breast cancer. Moreover, given our focus on metastatic breast cancer, findings from this study may not generalize to other cancer types or disease stages. Despite these limitations, this study has several strengths that make it a novel and important contribution to the literature, such as our large and racially/ ethnically diverse sample that included understudied groups of patients of color . Additionally, our intentional focus on patients with metastatic disease provides insight into the distinct financial challenges faced by a group of patients with indefinite treatment trajectories. --- Conclusion Women with metastatic breast cancer experience substantial financial burden as a result of their cancer treatment. Importantly, our study suggests that patients of color experience more adverse changes in work for pay and financial coping than their White counterparts. Given the negative impact of financial strain on patient well-being and treatment decision-making, as well as longstanding disparities in cancer outcomes, equity must be a guiding principle in strategies aimed at addressing financial toxicity in cancer patients. --- Supplementary Material Refer to Web version on PubMed Central for supplementary material. Bars represent 95% confidence intervals; Analysis: Adjusted relative risk of each behavior relative to non-Hispanic Whites after adjusting for clinical characteristics and socioeconomic characteristics . Significance assessed using a Wald test. *includes only those who applied for financial assistance Analysis: Adjusted relative risk of each behavior relative to non-Hispanic Whites after adjusting for clinical characteristics and socioeconomic characteristics . Significance assessed using a Wald test.

Ms. Sellers reports payment as a consultant with Pfizer which was unrelated to the submitted work. None of the other study authors have any conflicts of interest to disclose, beyond receiving independent grant funding from Pfizer.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.The experiments conducted in this study comply with the current laws of the country in which they were performed.Informed consent was obtained from all individual participants included in the study.

Background Modern family planning methods have become more broadly accepted and used as a replacement for traditional methods and as one of the interventions to most empower women. Women empowerment, as an important goal for achieving national development goals, needs to be strengthened and sustained to ensure that women exercise their responsibilities and enjoy their human rights [1][2][3]. Women status and empowerment have been found to be associated with longer birth interval, lower rate of unintended pregnancy, and lower fertility rate [3]. Through FP programs, women have been given access to modern contraceptives, allowing them to better meet their fertility preferences and to avoid unwanted pregnancies and their potential complications [4][5][6][7]. Nonetheless, even in highly developed countries such as the U.S., unintended pregnancies remain high [8] and constitute a health and socioeconomic burden for women and their partners [9,10]. An obvious explanation is that there remain sociocultural barriers and perceived health risks associated with the use of new FP methods [11][12][13]. Previous research has shown that the main challenges facing women and preventing them from using modern contraceptive methods include the social pressure on women to prove their fertility immediately after marriage and the fear of side effects and negative consequences of modern FP methods [14][15][16]. In a recent qualitative study involving 42 focus group discussions with Jordanian and Syrian young couples, there was a strong belief among participants that most modern FP methods can have serious side effects that could harm women's health, including bleeding, hypertension, diabetes, foetal abnormalities, and cancer [17]. These concerns often drive married couples to use less effective but safer methods, such as withdrawal and condoms. Women's personal experiences, knowledge, and perceptions of how a FP method might impact their quality of life can influence FP decisions among women. While different FP methods may have varying degrees of impact on women's health-related quality of life [18], there yet remains no consensus on the relationship between modern FP methods and the QoL of women. Most of the previous research has focused on either single or limited types of contraceptives and on only one or two QoL domains [19][20][21][22][23][24][25]. For instance, it has been found that combined oral pills statistically decreased general well-being among healthy women and reduced three of the six dimensions of the Psychological General Well-Being Index , namely positive well-being, self-control, and vitality [19]. The authors concluded that even a modest reduction in general wellbeing could be of importance and could explain the high incompliance rate and irregular use of oral contraceptives [19]. Similarly, Sadatmahalleh et al. observed lower sexual function and QoL in women who had undergone tubal ligation than in women who had not, hence concluding that tubal ligation is not a safe FP method [26]. In contrast, intrauterine contraception has been shown to significantly improve HRQoL [20]. On the other hand, a recent systematic review by Worly et al. revealed that the available studies do not support a clear general association between progestin hormonal contraceptives and depression levels or incidence of depression diagnosis [25]. --- Modern FP use among Jordanian women Although the Total Fertility Rate in Jordan has declined steadily in recent decades to reach 3.5 in 2014, it has not changed significantly during the last few years [27]. Jordan has made some progress in meeting FP needs, such that the use of modern contraceptives increased by 15% from 1990 to 2012 [28]. However, the use of both modern and traditional FP methods has declined from 42 to 37%, and from 19 to 14% between 2012 and 2017/2018, respectively. Among currently married women adopt a modern method of FP, the most commonly used method is the Intra Uterine Devices , followed by the pill , and the male condom [28,29]. The majority of modern contraceptive methods are accessible to women through the primary and comprehensive healthcare centers of the Ministry of Health. Oral contraceptives, Etonogestrel implants, Depo Provera contraceptive injections, male condoms, and IUDs are offered free of charge, and there are some facilities for female sterilization. The process of choosing FP methods in Jordan is primarily influenced by the husband's decision and preference. About 85% of women currently using contraceptives report that the decision to use any FP method was a shared decision with the husband. Additionally, two thirds of those who report not using any method say that the decision not to use was also a mutual decision with the husband, regardless of the education level. Women reported that they first discussed FP and the likelihood of using contraception with husbands, doctors and midwives, and friends. Oral contraceptives and IUDs were the two most common methods suggested by those advisers. When women decide to start using contraception, physicians were the most sought person to give advice as they are highly trusted by women [29,30]. However, a lack of comprehensive understanding of the impact of modern FP methods continues to exist among Jordanian couples. To date, research addressing the impact of different modern FP methods on women's QoL remains limited [31][32][33][34]. A study found that women who had undergone tubal ligation and those who used injectable contraceptive were less likely to have average or better physical HRQoL than women who used combined hormonal contraceptives and that women who used injectable contraceptive were also less likely to have average or better mental-HRQoL [18]. Another study showed that women who had undergone tubal ligation had significantly worse "physical functioning" but better "general health perceptions" than women whose partners used condoms [32]. To this end, the primary aim of this study was to examine the relationship between the use of common modern FP methods and QoL among Jordanian women. Also, identifying main predictors of QoL was another aim of the study. --- Methods --- Study design and setting A cross-sectional household survey in two cities in Jordan was conducted from April to December 2017. Each city was stratified into 5 sectors based on geographical location and density of population. Housewives from each sector were visited in their houses, and working women who were unavailable during the morning were visited in the afternoon. An initial screening was first conducted to ensure that each woman was eligible and that she consented to participation in the study. The screening questions included information on age, health status, medical history, and whether the participant was pregnant. If the woman was eligible, the female interviewers explained to her the objectives of the study and assured her of the confidentiality of the interview before commencing with the interview itself. Talking about family planning methods is a socio-cultural sensitive issue in Jordan, especially among young women. Many Jordanian women usually feel embarrassed to discuss family planning methods, and this led to a low response rate of around 15% of the household survey. For this reason, non-pregnant women who visited the obstetrics and gynecology clinic of King Abdullah University Hospital for contraceptive advice and follow-up consultations were also included. KAUH is a teaching referral hospital that provides a wide range of services. Ethical approval was sought and obtained from the Institutional Research Committee of Jordan University of Science and Technology. After full clarification of the study aims and ethical considerations, any woman who showed interest in participating and gave consent was included. Since contraception is a culturally sensitive issue in Jordan, willingness to participate voluntarily was a main inclusion criterion, and thus, a convenience sampling method was applied. --- Data collection and measures According to the latest national survey, about 30% of Jordanian women discontinued using the method within 12 months. The most common reason for discontinuations was the desire to become pregnant , followed by complaints that the method was inconvenient to use [29]. Consequently, non-pregnant women of child bearing age who had been using a modern contraceptive method for the past year were interviewed through face-to-face structured interviews. Three female researchers were trained to conduct the interviews, where each one was responsible for conducting the interviews in a particular geographical location/area. A structured interview questionnaire guide composed of four main sections was used for data collection. The socio-demographic data form included questions about the woman's age, number of living children, age at marriage, and religion. The first section also included statements on socioeconomic status, including educational attainment, employment class, monthly income, housing tenure, and the number of dependents. The second section included questions on birth spacing and on the type, duration of use, and previous information of the modern FP methods used, as well as previous knowledge of their side effects. Another questionnaire, namely the Arabic version of World Health Organization Quality of Life-BREF , was used as the measuring instrument for QoL in the current study. The WHOQOL-BREF is a cross cultural, well validated, generic questionnaire that has been employed in various clinical conditions in different countries around the globe [31,[35][36][37]. According to the WHO report [38], the WHOQOL-BREF serves as an adequate alternative instrument to the evaluation of domain profiles using WHOQOL-100. With a total of 26 questions, the instrument contains four domains, namely physical health, psychological, social relationships, and environment. These questions use a five point Likert response scale. There are also two questions in the WHOQOL-BREF that are evaluated separately; the first question asks about the participant's overall perception of their QoL and the second about the participant's overall perception of their health [39]. While the WHOQOL-BREF examines respondents' perceived QoL and can thus provide an overview of the participant's perceived effects of disease and health interventions, it is not supposed to act as an objective tool for measuring symptoms and disability. Therefore, the WHOQOL is "an assessment of a multi-dimensional concept incorporating the individual's perception of health status, psycho-social status, and other aspects of life." [38]. As per the WHO guidelines, the mean score of questions within each domain is used to calculate the score of the domain; means are multiplied by 4 and subsequently transformed into a 0 to 100 scale [38]. The domain scores are comparable with the scores used in the WHOQOL-100, and the mean score in each domain reflects women's perceptions of and satisfaction with each aspect of their quality of life. The higher the score, the better the response. A permission to use the WHOQOL-BREF was obtained from the Information, Evidence, and Research Department / The World Health Organization, Geneva. The last section of the interview guide contained questions about side effects of modern FP methods and bleeding patterns. At the end of each interview, the participating woman was asked to read and check the filled data for accuracy, and then she was voluntarily asked to sign the filled questionnaire. Each interview lasted about 20 min. --- Data analysis Data was analyzed using R Statistical Computing Software version 3.4.3 . Descriptive statistics including means, standard deviations, and percentages for collected data are presented. QoL scores for the four domains were calculated individually for each participating woman, and then the total scores for each domain were summarized. Finally, predictors of quality of life scores were identified through multiple linear regression and stepwise selection. A 5% significance level was assumed throughout the analysis. --- Results Five hundred forty-eight women aged between 18 and 49 participated in the study. The participating women had been using a FP method for an average of 5.17 years, discontinuously. The results show that the average time from marriage to first pregnancy was 3.31 months, and the average number of children per family was 3.79 . The mean duration of spacing between births was 2.78 years. Detailed information on the participants is provided in Table 1. Around one third of the participants had a graduate or post-graduate academic degree, around 33% had a family income less than 400 JDs, and 58.5% resided in rented accommodation. In Jordan, there is no clear official definition of the poverty line. However, when taking into consideration the latest available data and reports, an estimated family income of per month can be considered as the poverty line [40,41]. In accordance with the national figures, about 9.5% of the participants were smokers [42], and only 11.86% were employed [43]. The results also show that about 9.52% of the participating women used a FP method without a doctor's prescription. Unfortunately, about 80.66% of the women had no previous knowledge of the possible side effects of using FP methods, and only 46.72% of them had had enough information about FP methods before starting to use them. As for the types of contraceptive methods used, 41.61% of the participants used IUDs, 23.18% used oral contraceptives, 14.78% used implant and injectable hormonal contraceptives, 6.2% used sterilization, and 14.23% reported that their husbands used condoms as a FP method. Only about 50% rated their QoL as being good or very good and about 40.88% were satisfied with their health status. Women's responses to QoL related questions of the WHOQOL-BREF tool are summarized in Table 2. Based on these responses, scores for the four QoL domains, namely physical health, psychological, social relationships, and environment, were calculated for each woman. A summary of these domain scores, along with the FP method used, is shown in Table 3. From highest to lowest, average scores for the social relationships, psychological, physical health, and environmental domains were 13.32, 12.97, 12.94, and 12.81, respectively, on a scale of 4-20. Women who used IUDs had the highest QoL average score for the physical health domain, while those whose husbands used condoms had a much higher average QoL scores for the psychological, social relationships, and environment domains than other women's groups. Multiple linear regression in combination with the stepwise selection method was used to identify the significant predictors of the domain scores and to identify the effect of FP methods on the QoL of the participating women. As the effect of the FP method used might be confounded with other variables such as the socioeconomic status and age, all collected variables were used in the regression model to adjust for the effects of the FP methods. Significant predictors along with the model coefficients for the four domains are shown in Table 4. Multicollinearity among used predictors was assessed through variance inflation factors . Values for VIF were all less than 10 indicating no multicollinearity issues. Significant predictors of physical health scores were level of education, income, residency, employment status, birth spacing, side effects, type of contraception, quality of life rating, and satisfaction with health. In comparison to women who used OCs, women who used IUDs for family planning had the highest probability of good physical health scores , followed by women who use implants and injectable hormonal contraceptives , whereas those who used sterilizations were more likely to score low in the physical health score . Level of education, number of children, birth spacing, side effects, contraceptive method, and QoL rating were the significant predictors of the psychological domain scores. Similar to the physical health scores, a negative effect was observed for sterilization , while positive effects were observed for IUDs and male condoms . For the social relationships domain, age, income, occupation, birth spacing, contraceptive method, and satisfaction with health status were identified as the significant predictors. In comparison to women who used OCs, women who used IUDs or implants and injectable hormonal contraceptives and those whose husbands used condoms were more likely to have better scores, while those who used sterilization were more likely to score low in the social relationship . Finally, age, income, smoking, occupation, period of contraceptive use, birth spacing, contraceptive method, quality of life rating, and satisfaction with health status were the significant predictors of the environmental domain scores. For the environmental domain, women who used IUDs and those whose husbands used condoms as FP methods reported higher scores than women who used OCs. However, women who had received permanent sterilization had the worst environmental scores among all of the family planning methods . To further investigate the effect of FP methods on QoL, multinomial logistic regression was used to identify significant predictors of side effects frequency, bleeding frequency, QoL rating perceptions, and satisfaction with health status rating. Identified significant predictors are shown in Table 5. Results indicate that the type of contraceptive method used was a key predictor of side effects, bleeding, QoL perception, and health satisfaction. Table 5 shows that women who had undergone sterilization reported the highest probability of frequent side effects while those whose husbands used condoms had a high probability of experiencing rare or no side effects. Women who used implant and injectable hormonal contraceptives had a very low probability of never experiencing side effects. Similarly, women who had undergone sterilization and those who used IUDs had the highest probability of bleeding. Results also show that women who used IUDs had the highest probability of good/very good quality of life perceptions while sterilized women had the lowest probability of good/very good perceptions. Women who used IUDs or implant and injectable hormonal contraceptives and women whose husbands used condoms had the highest level of health satisfaction, while women who used oral pills and sterilization had the lowest health satisfaction. --- Discussion From social, psychological, and health-related viewpoints, FP methods are of great importance in women's lives [44,45]. This study investigated the relationship between the use of common modern FP methods and QoL domains among Jordanian women. In line with the latest Jordanian national survey 2017/2018 [29], our findings observed that the most commonly used modern FP method is the IUDs, followed by OCs. The findings also revealed that about a tenth of Jordanian women of reproductive age had previously used a modern FP method without medical prescriptions or advice. Furthermore, more than half of the participating women did not have enough previous information about modem FP methods. It has been found recently that the percentage of Jordanian women who were not informed about side effects of modern FP methods ranged between 20 to 39% among various methods including pills, female sterilization, IUD, implants and injectables [29]. Nevertheless, women who intend to use modern FP methods have the right to know the potential side effects and negative consequences of these methods, including emotional, psychological, physiological, and sexual consequences. Most women in developing countries, including Jordan, prefer to get pregnant immediately after marriage [46][47][48][49], and hence an average time from marriage till first pregnancy of only 3.31 months was observed among the participating women. Often, this short waiting period is a result of social pressure and reflects the tendency among young women to prove their fertility immediately after marriage, regardless of whether they are physically and emotionally prepared [50][51][52]. It has also been argued that, in some cases, Jordanian women may use their ability to get pregnant soon after marriage as a way to raise their status and power among their in-laws. This provides insight on why FP methods are usually only considered after the first child has been born [53,54]. Based on the WHOQOL-BREF scale, the overall mean scores of the four domains were found to be average, with the social relationships mean score being slightly higher than the other domains and the environmental domain being slightly lower. Our results also revealed that women who used IUDs and women whose husbands used condoms as FP methods had better QoL in the four domains than women who used OCs. In line with our findings, a recent prospective observational multicenter study conducted in Spain found that the Levonorgestrel intrauterine system has a positive impact in terms of health related QoL. The results were obtained through conducting a SEC-QoL questionnaire at baseline and 12 months afterwards. The study demonstrated improved scores in all domains of the SEC-QoL, including the social, menstrual symptoms, breast symptoms, psychological, and sexual domains. Beside its efficacy as a FP method, LNG-IUS provided women with additional non-contraceptive benefits [21]. Similar results were reported by Singh from India [55]. Though IUDs may cause mild side effects which may interfere with a woman's QoL, such as irregular bleeding, amenorrhea, and hormonal disturbances [56,57], women who used IUDs and those whose husbands used condoms were nonetheless more satisfied than women who used OCs and sterilization. The use of female condoms is uncommon among Jordanian women, and 14.23% of the participating women in our study reported that their husbands used male condoms. Loss of sexual function and pleasure is reported as being the most devastating side effect of using condoms [58,59]. In consistence with our results, a recent randomized, double-blind, placebo-controlled trial which assessed the influence of a first-choice combined oral contraceptive on general well-being and depressive symptoms found that contraceptive pills are associated with reduced general well-being, self-control, and vitality among healthy women [19]. Also, in Japan, it has been reported that OCs can worsen QoL if used for contraceptive purpose only [60]. On the other hand, other studies have reported that OCs have no negative impact on QoL, especially among first time users [61]. Zhao et al. conducted a prospective cohort study on rural women who used OCs and IUDs in a Chinese province; the study found that oral pills and IUDs could significantly improve overall QoL [62]. The mechanism behind reduction in well-being by the use of OCs among healthy women is yet to be discovered. However, the decrease in free testosterone level induced by OCs use and the direct progestin-induced central nervous system effect may be the underlying causes behind reduced well-being [19]. Our results observed that women who had been using implant and injectable hormonal contraceptives have better QoL in terms of the physical health and social relationships domains. Di Carlo et al. studied the impact of contraceptive implants on QoL and sexual function among Italian women. Their results showed that general QoL and physical role status of the women improved significantly after use of the implant and that the implant had some positive effect on sexual function [63]. In a review of evidence on implant contraindications, satisfaction, and rate of continuation, Amico et al. found that whilst irregular bleeding was the most common reason for discontinuation of the implant, most of the participating women reported an overall reduction in bleeding. Additionally, complications related to its use, insertion, and removal were rarely reported [64]. Consistently, the Short Form-36 QoL questionnaire was employed to evaluate the HRQoL changes associated with the use of the depot medroxyprogesterone acetate injection. Along with its contraceptive efficacy, DMPA was linked with improvement in perceived physical health and with no adverse effects on mental health and sexual function [65]. To identify predictors of QoL for women using FP methods, multiple linear regression models were fitted to the scores of the four QoL domains. Common QoL predictors such as education level, family income, employment status and place of living were also identified as predictors of QoL for women using FP methods. Significant method specific predictors were also identified including birth spacing, experiencing side effects, and type of modern FP method. Regression results indicated that the more frequent side effects, the lower physical health. Women who used IUD as their FP method had higher probability of better physical QoL scores compared to women who used other methods. Those whose husbands used male condoms have shown higher probability of better QoL scores for the psychological, social relationships and environmental domains. The multiple linear regression analysis confirmed that, in comparison with women who used oral pills, women who had chosen permanent sterilization as their contraceptive method had the lowest QoL scores in all of the four domains. This is not surprising given the adverse effects and negative consequences that tubal ligation can have on women's overall wellbeing including psychological wellbeing and sense of productivity [66]. Similarly, Bahrami et al. adopted the to compare the effects of different contraceptive methods on women's QoL and found that women who had used sterilization or injectable contraceptive had the lowest level of QoL [67]. The logistic regression analysis extended our findings and showed that women who had undergone permanent sterilization were more likely to experience side effects and vaginal bleeding than women who used OCs. On the other hand, women who had been using other types of modern FP methods had less likelihood of experiencing side effects and bleeding. A study conducted on women who performed tubal ligation method found that one third of women perceived tubal ligation as a risky procedure that should not be performed, whereas the majority of women indicated that they will not advise women to undergo this procedure [68]. Another study revealed that depression significantly increased after tubal ligation due to several factors including changes in self-image, fear of negative perceptions of other people, and most importantly the husband's negative attitude towards the procedure [69]. Because female sterilization or tubal ligation is a permanent contraceptive method which requires a one-time effort, some women still consider it to be the most convenient and effective FP method. In an Iranian study, many of the participating women stated that their main reason for choosing sterilization was to avoid the side effects of other contraceptive methods. However, the study results showed that the mean total scores of the SF-12 and sexual function were significantly lower in the female sterilization group than in the non-sterilization group. 20% of the women in the sterilization group regretted their decision [26]. The main reason why these women had chosen permanent sterilization was that they felt fully satisfied with their family size [26]. However, the most widely known biological change after terminating fertility by tubal ligation is the post-sterilization syndrome, which comprises symptoms such as hormonal disturbance, menstrual irregularities, and vaginal bleeding [70][71][72]. This could explain why an increasing number of women are opting for reversible long-acting FP contraceptive methods rather than permanent tubal ligation [73]. Our multinomial logistic regression analysis showed that women who used IUDs and those who had undergone sterilization had a higher probability of experiencing vaginal bleeding than women who used OCs, yet women who used IUDs had the highest QoL . It has been argued that dissatisfaction due to bleeding profile is the most common reason for the discontinuation of a FP method [74]. Previous studies confirm that women who use IUDs report higher levels of satisfaction than users of other FP methods [75,76]. Our analysis also demonstrated that women who used OCs and permanent sterilization were less satisfied with their health status than women who used other modern FP methods. --- Strengths and limitations The current study has some limitations that need to be acknowledged. First, the sample collected through a cross-sectional household design from only two cities in Jordan; in which all eligible women were chosen based on a convenience frame. The convenience selectivity of the sample limits the generalizability of the findings as there is a possibility that women who agreed to participate in this study differed from those who refused to do so. For example, women who declined participation could have been unwilling to talk about their experiences with using modern FP methods or share their perceptions for several reasons that could directly impact QoL. Regardless, the authors tried to increase representativeness of the sample by stratifying each city into 5 sectors based on geographical location and density of population. Future research need to conduct a national survey using a randomization process to increase representativeness of the findings to a wider population. Second, QoL was self-reported, and this might have been associated with false reporting. As with all selfreporting surveys, there is always a chance with inaccurate answers that over-estimate patients' responses due to many reasons including courtesy bias [77], recall bias, and/or social desirability bias [77,78]. However, the WHOQOL-BREF is a cross cultural, well validated, generic questionnaire that has been employed in various clinical conditions, including contraceptive use, in different countries worldwide [31,[35][36][37]67]. Future studies need to use more objective measures to assess the impact of modern FP methods on women's QoL, preferably using a longitudinal design to draw causal inferences. Additionally, Further research need to design and/or use more relevant questionnaires that truly reflect and measure the real perceptions of QoL among users of modern FP methods taking into considerations medical history and overall health status of women. Nonetheless, the authors tried to cover some of these aspects in this study by asking women specific questions related to FP methods and QoL such as birth spacing, the type of method used, duration of use, and previous information of the modern FP methods used, as well as previous knowledge of their side effects. Finally, although we faced several difficulties in recruiting participants and in data collection, this study can be considered the first study that attempted to explore the association between modern FP methods and women's QoL in Jordan. --- Implications The current study revealed that the overall average scores of the four domains of QoL were relatively low among women who were using modern FP methods. This raises an important question about whether Jordanian women who are not using modern FP methods have the same low level of QoL. A national household survey in Jordan found that females reported poorer HRQoL in comparison with their counterpart males [79]. Thus, more attention to this segment of the population need to be provided to improve all aspects of QoL associated with reproductive health, not merely those related to FP issues. Similarly, more research need to be undertaken to compare QoL levels among Jordanian women who use either modern or traditional FP methods versus those who do not in order to establish a baseline for overall HRQoL among Jordanian women in general. Simple QoL questions could be used by health care professionals as a screening tool for overall health at every medical contact. Our findings also call for establishing programs to assess QoL among women in Jordan and other Arab countries focusing on the potential impact of modern FP use on overall QoL. These programs should be widely available for women who need it the most across the country. However, women's decisions about the best FP options are highly affected by the method's efficacy, medical conditions, personal subjective experience with side effects or negative consequences, and the method's impact on QoL [16,[80][81][82]. Jordanian women have some misconceptions in regards to the use and side effects of modern FP methods. Even worse, lack of trust between women and healthcare providers donates to the high percentages of discontinuation and/or reluctance to seek alternatives [53]. Hence, women who intend to use modern FP methods have the right to know the potential side effects and negative consequences of these methods, including emotional, psychological, physiological, and sexual consequences. Health care professionals, especially trained midwives, need to be willing to spend enough time with women, especially at maternal and child health medical centers, to increase their awareness about the realistic benefits and side effects of each of the modern FP methods in order to change some women's misperceptions in this regard and ultimately increase their adoption of effective methods. This is of paramount importance in light of the findings of a recent national survey , which found that more than 60% of Jordanian women of childbearing age do not use any modern FP methods [29]. Further, the results of this study shed light on the importance of providing effective counselling and education on FP methods to women of reproductive age in Jordan, and underlines a need to provide couples with premarital counselling on FP and potential risks associated with early pregnancy, particularly in rural areas with high fertility rates. Importantly, clinicians need to use a patient-centred approach when providing counselling about all FP methods and support women's reproductive autonomy [64,83]. This can be achieved by providing and securing various alternatives for women in regards to modern FP methods especially those that are perceived as well tolerated, highly effective in controlling blood loss, such as IUD and definitely a better alternative to hysterectomy for women with heavy menstrual bleeding [55]. The current study also found that women who used IUDs and women whose husbands used condoms were nonetheless more satisfied and had better QoL than women who used OCs and sterilization. Studies show that women who encounter complications while using a certain contraception method tend to have a lower QoL. Similarly, women who experienced side effects reported lower QoL scores than those who did not [84]. In the case of condom use, it is less likely that women experience side effects thus they tend to be more satisfied. Indicating a need for designing and implementing specific interventions, as a part of counseling practice, that teach women ways to cope with side effects and/or complications with various modern FP methods and evaluating the impact of these methods on both QoL and sexual life [84]. The relatively higher QoL scores observed among women whose husbands used condoms raising the issue of male participation in the use of contraception. A study conducted on male Muslims in a Ghanaian municipality concluded that condom is the most preferred and used modern contraceptive, suggesting that male Muslims need to be motivated to discuss FP with friends and wives, as well as programs should be developed to focus on involving men in the decision of FP with women [85]. This is very important given the fact that sociocultural factors could play a vital role in male involvement in FP. Therefore, social support, adequate information, and shared responsibility can all motivate men to have a more vital role in FP and use of certain contraceptive methods. Additionally, increasing literacy of reproductive health among men to improve their attitude and change their perceptions to better participate in reproductive health services is needed [86,87]. Male participation in FP, in turn, enhances the status of women. A qualitative study on Iranian Muslim women revealed that participants felt more empowered when shared FP decisions were made with their male spouses based on agreement and support [88]. Consequently, more attention is needed to underpin strategies to encourage gender equity, shared decision making, shared responsibility and actual participation of men, empowering women, and to optimize worth of male participation [89]. --- Conclusion Overall, participating women reported relatively poor quality of life particularly those using oral contraceptive bills in comparison to those who use IUDs and male condoms. When comparing QoL across different methods of modern contraceptives, we found that women who used oral contraceptives and those who had undergone permanent tubal sterilization were likely to have a lower level of QoL than users of IUDs and implant and injectable hormones and women whose husbands used condoms. Also, women who used oral contraceptives and women who had undergone tubal sterilization were less likely to be satisfied and had the highest probability of frequent bleeding. Being able to decide freely whether and when to have children is regarded as a fundamental reproductive health right and is strongly linked to women's health and quality of life. QOL: Spanish Society of Contraception Quality-Of-Life; SF-12: Short Form Health Survey for evaluating QoL; TFR: Total Fertility Rate; WHO: World Health Organization; WHOQOL-BREF: World Health Organization Quality of Life-BREF --- --- Abbreviations DMPA: Depot medroxyprogesterone acetate; FP: Family planning; FR: Fertility rate; HRQoL: Health-related quality of life; IER: Information, Evidence, and Research; IUDs: Intra Uterine Devices; JD: Jordanian Dinar; KAUH: King Abdullah University Hospital; LNG-IUS: Levonorgestrel intrauterine system; OCPs: Oral contraceptive pills; OCs: Oral contraceptives; PGWBI: Psychological General Well-Being Index; QoL: Quality of life; SD: Standard deviation; SEC-Authors' contributions MSA and HHH conceived the ideas of this study, participated in the study design, analysis and interpretation, as well as drafted and amended for the manuscripts. HAA and NAA carried out the statistical analysis and wrote the first draft of the results, they also contributed in data interpretation. DA, SM, SQ, and SD contributed in study design, data collection and interpretation of the results. Professor YSK critically revised the manuscript, he also had a significant contribution to analysis and interpretation of data. All co-authors read and approved the final draft. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Although Jordan has made progress in meeting Family Planning (FP) needs in last decades, recently the use of FP methods has declined significantly. Women's personal experiences, knowledge, and perceptions of how a FP method might impact their quality of life (QoL) can influence FP decisions. However, a lack of comprehensive understanding of the impact of modern FP methods on women's QoL continues to exist among Jordanian couples. Therefore, this study aimed to investigate the relationship between the use of common modern FP methods and QoL among Jordanian women. Methods: Using the WHOQOL-BREF questionnaire along with other questions, non-pregnant women of reproductive age were interviewed at their homes through face-to-face structured interviews. Women who visited the obstetrics and gynecology clinic of King Abdullah University Hospital for contraceptive advice and follow-up consultations were also included. Results: A total of 548 women aged between 18 and 49 participated in the study. Based on the WHOQOL-BREF scale, the overall mean (SD) scores of the four domains were found to be average. Our findings show that women who used Intra Uterine Devices (IUDs) and women whose husbands used condoms had better QoL in the four domains (physical health, psychological health, social relationships, and environment) than those who used Oral Contraceptives (OCs). Women who used implant and injectable hormonal contraceptives had better QoL in terms of the physical health and social relationships domains. In contrast, women who had undergone permanent sterilization had lower QoL scores in all of the four domains. Further analysis revealed that women who had undergone tubal sterilization were less satisfied overall and more likely to experience side effects than women who used OCs.The choice to use contraceptives and decide freely whether and when to have children is regarded as a fundamental reproductive health right and is strongly linked to women's health and QoL. Women who use OCs and women who have undergone permanent sterilization are likely to have lower QoL than women who use IUDs or implant and injectable hormones and those whose husbands use condoms.

Introduction Entry into the labor market is an important part of adolescents' transitions to adulthood . Success or discontinuities in school-to-work transitions strongly affect occupational careers and behavior later in life . From a developmental perspective, transitions to work are influenced by both "young people's active efforts to shape their biographies and the structured set of opportunities and limitations that define pathways into adulthood" . Quite a number of studies have shown that, over and above educational attainment, young people's cognitive and noncognitive skills, as well as their family resources, influence both their continuation of education and occupational career . Moreover, high aspirations have been shown to increase success in labor market entry, even for early school leavers . Existing studies predominantly focused on the US and UK-both characterized by comprehensive school systems and general upper secondary education systems . Their findings may not apply to countries like Germany or Switzerland, because qualifications are known to be a stronger signal in labor markets in tracked school systems, which sort students early by cognitive skills and social origin , and apprenticeship systems or occupational labor markets . Moreover, existing research mainly looked at between-group differences and did not pay particular attention to individuals with similar school attainment. Furthermore, they looked at entry into jobs as a dependent variable but did not differentiate between adolescents' agency, that is, their application behavior, and employer selection as constraints. Thus, the interplay between agentic resources, structural constraints, and later outcomes is not well understood . We therefore investigate the role of agentic resources, application efforts , and structural constraints on low-achieving school leavers' success in the period of school-to-work transitions. We thereby examine whether positive characteristics and active efforts can create new opportunities for them in this transition period -supporting the integration of lowachieving school leavers into the labor market-or whether they face persistent disadvantage because of their low qualifications. Low-achieving adolescents are quite heterogeneous in terms of their personal and parental resources . These withingroup differences may be associated with differences in adolescents' application effort. On the other hand, we know that low-achieving school leavers face great difficulties in their school-to-work transitions . Thus, agency may not matter for them because, for example, their early school experiences as "low-achievers" may result in generally low aspirations, despite differences in cognitive or noncognitive characteristics, and thereby in less active application efforts. Moreover, the label of "having low qualifications" may strongly restrict the success of adolescents' job application efforts owing to employers' screening of applicants based on school certificates . As a consequence, low-achieving adolescents may have only few or no opportunities to demonstrate their productive cognitive or noncognitive potential in job interviews . We study Germany and look at entry into regular training positions. Our German study enables us to investigate how heterogeneous the group of low-achieving school leavers is in a highly tracked school system. At the same time, the German vocational educational and training system offers valuable opportunities for adolescents to continue their education and to learn an occupation below the level of higher education. In this respect, the German education system seems to be rather inclusive for low-achieving school leavers . However, the German training market is highly competitive and serves as entry into the labor market . Hence, low-achieving adolescents who failed to enroll in apprenticeships bear a higher risk of being marginalized not only at the beginning but also throughout their entire work-life . --- The German Vocational Education System The German school system is highly stratified. Students are tracked into different school types as early as age 10-12. In addition, the vast majority of students with disabilities attend special-needs schools . The German school system is also stratified in terms of the school-leaving certificates that students can obtain at the end of lower secondary education : the lower secondary certificate, the extended lower secondary certificate, and the intermediate certificate. Students may also leave the general school system without a secondary school qualification . These school-leaving certificates do not correspond precisely to the school types but can be formally obtained at all secondary school types. In Germany, the group of low-achieving school leavers is therefore defined by school-leaving certificates: those who leave the general school system without or with only a lower or extended lower secondary school certificate. According to this definition, about 25% of the school leavers were classified as low-achieving school leavers in 2012 . 1 After leaving the general school system, low-achieving school leavers are legally eligible to enroll in vocational education and training programs, though they are not entitled to enroll in higher education. They may enter: regular firm-based training programs combined with school-based education , regular school-based programs, or prevocational training programs . Only apprenticeship and regular school-based training programs lead to nationally recognized, occupation-specific certificates , whereas the various prevocational programs do not . Low-achieving adolescents are free to apply to regular training programs. Firms and vocational schools , however, are likewise free to select candidates for their training places. School leavers unable to find a regular training place usually contact the Federal Employment Agency and are channeled into prevocational training programs. Seeking regular employment instead of training is usually not an option for them, because vocational education is compulsory until at least the age of 18 in all German states. In 2012, 27% of the students enrolling in the training system entered prevocational programs; the majority of them were low-achieving school leavers . --- Theoretical Considerations on Agency and Constraints Studies for Germany provided inconsistent findings on the impact of low-achieving adolescents' cognitive and noncognitive skills on their chances to enter regular training positions: Protsch and Dieckhoff found that for adolescents with lower secondary school certificates, only differences in school grades but not in noncognitive skills influenced their likelihood of entering regular training, whereas for adolescents with intermediate secondary school certificates, conscientiousness but not grades produced within-group variability. In contrast, Solga and Kohlrausch observed that, beyond school grades, it was conscientiousness and teachers' reports on students' work behavior that influenced the training opportunities of low-achieving school leavers. Both studies found that differences in cognitive abilities did not matter, in contrast to a Swiss study by Mueller and Wolter . They found that below-average math test scores reduced the chances of getting an apprenticeship, whereas above-average scores did not matter, that is, they did not increase these chances. These studies did not however differentiate between the impact of these agentic resources on adolescents' application behavior and the recruitment decisions of employers or vocational schools . Yet, both sides together influence the chances to enter regular training programs. In this section, we will therefore provide theoretical considerations on why adolescents' efforts may vary by agentic resources, how this variation may matter for low-achieving adolescents' success in their transitions into vocational training, and why their low qualification may constrain the success of such effort. --- Adolescents' agency Search and application activities depend on applicants' initiative in terms of where to apply, how many times to apply, for what occupation to apply-all are based on adolescents' abilities to make such decisions. Thus, application efforts of low-achieving adolescents may differ by their decision-making abilities and resources-such as cognitive and noncognitive skills, aspirations, and parental support. A substantial number of these school leavers are underachievers-that is, they underperform in terms of grades and school-leaving certificates compared to their cognitive abilities . This learning potential may become advantageous during the transition period. Research has demonstrated that higher levels of competence and noncognitive skills are predictors of lower risks of educational dropout and higher early occupational attainment . Thus, underachievers among those with low school attainment may experience new opportunities for using their cognitive potential in the job search and in subsequent training/work. Moreover, career aspirations and plans have been shown to promote more successful transitions -probably because of more frequent application efforts and more effective application decisions. Furthermore, network resources are known to influence individuals' job search behavior . Supply networks provide information on vacant apprenticeship positions and give second-hand accounts of experiences with job requirements. The group of low-achieving adolescents is not random but socially selective. Their family members and friends are more likely to be less educated, non-employed, or only employed in low-skilled jobs, compared to their higher-educated peers . As a result, many low-achieving adolescents know less about "where, when, and how to apply" . Besides this informational dimension of networks, poor parental resources may be associated with a lack of parental guidance, engagement, support, and monitoring , which may result in fewer application efforts. At the same time, however, those low-achieving adolescents who do possess better network and parental resources may be more active and systematic in their job search. Network resources may not only support adolescents' search for training positions but also the success of their efforts . Networks help improve their reputation if network members are employed in firms with vacant job or training positions . Such recruitment networks would be particularly important for low-achieving adolescents, because network members could testify to these applicants' actual cognitive abilities, practical skills, or motivational potential irrespective of missing credentials or poor school attainment. Correspondingly, a study by Seyfried revealed that recommendations by family members, neighbors, and friends play a major role for German firms when hiring low-skilled persons. Thus, adolescents' application effort and its success may vary by their network resources. But agency may be less developed among low-achieving school leavers in general, regardless of their decisionmaking abilities and resources. Stigmatization owing to their mostly negative school experiences and biographies may reduce low-achieving adolescents' application effort. They may have learned about their "inferior status" in society-their stigma of having "low education" . This may lead to dis-identification with educational goals and a voluntary withdrawal from the apprenticeship market to avoid possible humiliation and negative reactions from others . Lowachieving adolescents may not permanently but only temporarily withdraw from training markets and choose to first attend prevocational programs as an educational investment to increase their future training opportunities . No matter whether that withdrawal is permanent or temporary, stigmatization would result in the phenomenon that a substantial part of low-achieving adolescents select themselves out of the applicant pooleven those who possess higher cognitive and noncognitive skills and parental resources. --- Constraints for adolescents' agency The success of low-achieving adolescents' application efforts may be constrained, however, by the selection practices of employers and vocational schools. One important source of restriction is competition. According to human capital theory , signaling theory , and job competition theories , educational attainment is viewed as an observable proxy for adolescents' trainability and therefore serves as an important selection criterion in recruitment processes. School type, certificates, and grades can be observed from school reports. Given that applicants successfully pass the first selection stage and are invited for tests and interviews, competences and noncognitive skills can be observed by employers and vocational schools . Based on these theories, applicants with lower educational attainment and skills may be placed at lower ranks in the applicant queue-leading to lower probabilities of being selected for a vacant regular training position. Moreover, the study by Seibert and colleagues has shown that low-achieving adolescents' ranks in the applicant queue vary by regional differences in the supply of, and demand for, training places-because competition is stronger in more constrained training markets. 2 However, in a study conducted in the German state of Lower Saxony, Solga and Kohlrausch found that the training opportunities of school leavers from lower secondary schools did not vary by regional economic conditions. Moreover, the cohort studies by Kleinert and Jacob and Solga demonstrated that, regardless of the respective supply-demand relationship, low-achieving adolescents in younger cohorts had lower chances to access regular training programs than their counterparts in older cohorts. This suggests that lowachieving applicants may not only be ranked lower in applicant queues but that employers exclude them from the applicant pool altogether . Employers and vocational schools may view low-achieving adolescents as not capable of successfully completing training programs. Several studies demonstrated that employers increasingly complain about low-achieving school leavers' low or even non-employability . In Germany, this view of low-achieving adolescents has been evident in the discussion on "training maturity" over the last two decades . Today, employers and vocational schools are less willing to choose lowachieving adolescents for their training places-even if there is a shortage of higher-achieving applicants . This phenomenon of sorting individuals with low formal qualifications out of the applicant pool because of their supposed "incapability" is called the discrediting mechanism . It is an extreme form of statistical discrimination by school-leaving certificate. In sum, students' resources acquired in school and at home may enhance their application behaviour and success of their school to work transition. At the same time, the usefulness of these resources and the success of adolescents' efforts may be constrained by gatekeepers' recruitment decisions. --- The Current Study The main goal of this study is to better understand the interplay between agency and constraints in the school-towork transition period of low-achieving school leavers. In Germany, entry into regular training programs is an important step in this transition not only in terms of continuing with upper secondary education but also in terms of entering the labor market. Most previous research compared educational groups by looking at "entry to jobs or training" as the dependent variable without differentiating between adolescents' application efforts and employers' recruitment preferences. Moreover, existing research has paid only little attention to within-group differences in agentic resources and adolescents' activities. Hence, the group of low-achieving adolescents has mostly been viewed as a homogenous group. In contrast, we focus on the variability in school-to-work transitions within the low-achieving group. From a developmental perspective, we explicitly investigate both the impact of agentic resources acquired during schooling and at home on their application efforts and the constraints that may limit the success of their agency in the transitions to work. The sample size of the data we use-the German National Education Panel Study-enables us to explore the impact of within-group heterogeneity. This data set also provides rich information on adolescents' school attainment , cognitive and noncognitive competencies, educational aspirations and vocational orientation, and family background. Moreover, information on local differences in youth unemployment allows for exploring the influence of economic conditions on their success in entering regular training. Based on the theoretical considerations presented in the previous section, we derive the following hypotheses about why low-achieving adolescents' agency during the transition period may open up new opportunities despite their low qualification: First, we expect that low-achieving school leavers with advantageous decision-making abilities and resources are more likely to apply for regular training places than those with poor abilities and resources . Higher decision-making abilities and resources are defined as higher levels of cognitive and noncognitive skills, higher career aspirations and better vocational orientation, and better network resources. Second, we expect that better network resources also directly improve adolescents' chances to access regular training programs, controlled for application behavior . That is, school leavers may enter regular firmbased training programs through informal contacts or prior internships. In this case, they may not report having formally applied, because they were not selected through a formal recruitment procedure. We also developed some theoretical explanations of the factors limiting the success of their application efforts and hence causing them to experience persistent disadvantages because of their low school attainment. Low-achieving school leavers may withdraw from the training market because they feel stigmatized owing to their prior school experience. We therefore expect that low-achieving adolescents with especially inferior prior school experiences apply less often for training places than low-achieving school leavers with a lower or extended lower secondary school certificate . Moreover, the success of their application efforts is highly dependent on gatekeepers' selection . Whether or not low-achieving adolescents actually apply may not matter for their training opportunities, because they may simply not be selected by firms and vocational schools. One reason might be competition: Applicants are ranked in applicant queues during the screening process based on their educational attainment and cognitive and noncognitive skills. The ranking place may also depend on regional training market conditions: Low-achieving applicants may be ranked lower in more competitive contexts than in less competitive contexts. We therefore expect to find that the lower the school attainment and the lower the competences and noncognitive skills, the lower their chances of entering regular training programs . We also expect that low-achieving adolescents are less likely to enter regular training in regions with more competition . In contrast to competition, the discrediting mechanism states that low-achieving adolescents are not only ranked lower in applicant queues but also excluded from applicant queues because they are viewed as "not being trainable." This mechanism is supported if low-achieving adolescents' training chances do not vary by their application efforts and regional training market conditions . Additional support is provided if their training chances do not vary by cognitive and noncognitive skills-indicating that lowachieving applicants are not invited to job interviews, in which they could demonstrate their skills. --- Methods --- Data and Sample We use data from the so-called starting cohort 4 of the German National Educational Panel Study . In this cohort, all respondents attended grade 9 at German secondary schools in fall 2010 . The sample design followed a stratified two-stage sampling strategy, sampling first schools and then classes within schools . The students were surveyed once or twice each year. As long as they were still in the general school system, they were interviewed in the classroom context via paper-and-pencil interviews . Afterwards, they were surveyed individually with computer-assisted-telephone interviews or computer-assisted-personal interviews . We use the Scientific Use File SUF SC4 7.0.0 , which includes the first seven waves for this cohort . 3 The total sample of students who agreed to participate in the study consists of 16,425 students ; 16,379 of these students participated in at least one wave. 23% of the respondents attended lower secondary schools , 20% intermediate secondary schools , 18% comprehensive schools or schools with multiple tracks, 32% university-preparatory schools , and about 7% special-needs schools for learning disabilities. This distribution is not the actual distribution of 9th graders in 2010, because students from three school types were oversampled: students from lower secondary schools and from special-needs schools and students from comprehensive schools . In our descriptive analyses, we account for this oversampling design by using corresponding design weights that adjust for both the sampling design and panel attrition . The incorporation and oversampling of students from specialneeds schools makes the NEPS one of the very few data sets that includes a large group of students with learning disabilities. 4 This is particularly important for our study, as these students constitute a substantial part of school leavers without a school certificate. Among the respondents were 31% low-achieving school leavers , 32% respondents who left school also after grade 9 or 10 but with a higher certificate , and 37% respondents who stayed in the general school system after grade 10 . For our study, we only used the subsample of low-achieving school leavers, that is, those who left school with less than an intermediate school certificate after grade 9 and 10. We restricted this sub-sample to those for whom we have valid information on their status in October after they left school . These restrictions left us with a sample size of 3417 low-achieving school leavers, with a slightly lower share of females than in the total sample -in line with the literature, because boys are often found to be overrepresented among low-achievers. Our respondents were on average 16.7 years old at the time they left general school. This corresponds to official statistics . Panel attrition was quite low in the first seven waves: A total of 1289 students from the original sample dropped out of the panel permanently . It is not possible to state how many of the dropouts belong to the group of low-achieving adolescents because being classified as low-achieving school leavers requires that we can observe respondents until they leave school in order to know about their school-leaving certificate. By definition, this is not the case for those who dropped out of the NEPS earlier. Taking the school types they attended in grade 9 as a proxy, attrition analyses found that students who attended lower secondary schools and special-needs schools had a significantly higher propensity of panel attrition than students from higher school types . This selective panel attrition is another reason why we use nonresponse-adjusted design weights in our descriptive analyses . --- Dependent Variables In our analyses, we used two dependent variables: whether low-achieving adolescents applied for regular training places and whether they were able to directly enter regular training programs, controlled for their application effort . --- Application to regular training programs Students were asked whether they applied for a training position in the first wave after they left school . 59% of our sample applied. We have no indication of potential underreporting by students who applied unsuccessfully because the percentage of respondents with applications is much higher than the percentage of those who entered regular training programs . --- Entry into a regular training position Our second dependent variable is defined as entry into regular training programs or not in fall directly after leaving school. We classified respondents in two groups, as follows: In each wave of the NEPS, respondents were asked to report all episodes of school, regular training, and prevocational program attendance, and other kinds of activities until the interview. As many prevocational programs and some regular training programs are schoolbased, respondents sometimes had difficulties differentiating between school, prevocational, and training episodes when reporting their activities. We therefore inspected and edited the reported school episodes in the following way: First, we prioritized vocational and prevocational programs over school episodes if they were reported concurrently. Second, we defined school episodes at vocational schools as regular training programs when students reported pursuing a vocational certificate, and as a route to obtaining the Abitur when students reported seeking a university entrance qualification. 5 If students reported neither of these two options, school episodes at vocational schools were classified as prevocational programs. Some students reported an internship or being on parental leave, working, or unemployed. These activities are classified as "others." In our sample, 39% of the respondents started a regular training program and 51% a prevocational program; only 10% belonged to the "other" category. The latter group is small because most of our students were under age 18 when leaving general school and thus had to remain in education . For the sake of simplicity and because of the small numbers, we grouped prevocational participation and the "other" category together for our multivariate analyses. In many characteristics, the subgroup "others" resembles those who started prevocational programs . We also re-estimated all models with entry into training instead of prevocational participation , excluding the "other" group. The results were very similar and substantially the same as reported in the article. Among those who started a regular training program, 72% entered firm-based training programs and 28% school-based programs. In our analyses, we did not differentiate between the two types because of the rather small number of observations for the latter. The robustness check, in which we re-estimated our models only including those with apprenticeships, showed that the results were robust. --- Independent Variables In the following, we provide information on the independent variables of our analyses. Distributions and descriptive statistics of our independent and control variables are presented in Table 1. --- School-leaving certificates The school-leaving certificate was reported by the respondents in the first wave after leaving school. In vertical order, we differentiated between extended lower secondary , lower secondary certificate , and no school-leaving certificate . --- School types We differentiated between lower secondary schools , special-needs schools , and other types of schools at the time of leaving school. This information is available from the sampling plan for respondents who did not change school after grade 9 ; otherwise it was reported by the respondents in the first wave after leaving school. The share of those who attended lower secondary schools in our study is very similar to the 52% reported in official statistics . However, the share of those 6 These lower shares in our sample at least partly result from the fact that the NEPS only includes students at special-needs schools for learning disabilities, whereas official statistics include students at all types of special-needs schools. Thus, our shares may be representative of this subgroup. --- Grades The final grades and grade point average on students' school-leaving certificate were reported by respondents . We used the GPA, on a scale from 1 equal to failed) to 6 . If the final GPA is missing, the average of the grades in mathematics and German on earlier report cards was used instead resulting in a very low item-nonresponse of less than 2%. The mean GPA is 4.0 and understandably lower than the mean GPA of those who left school with an intermediate certificate . The differences within the low-achieving group are also plausible: it is lowest for those without a certificate and highest for those with an extended lower secondary certificate . --- Cognitive competences The NEPS administered competence tests in starting cohort 4, except for special-needs school students. The NEPS consortium has developed competence tests for different domains, scaled by using models of Item Response Theory . The competence tests used four different response formats: simple multiple choice, complex multiple choice, matching items, and short-constructed responses. The NEPS provides the weighted maximum likelihood estimator , which is a typical point estimate expressing the most likely competence score for each single person given the item responses of that person . We used the tests administered in grade nine. In our analyses, we employed the average of the z-standardized mathematics and reading WLE scores. We zstandardized this average with a mean of zero and a standard deviation of one. On average, the competences of low-achieving adolescents were quite low, as one would expect: nearly one standard deviation lower than the competence mean of the entire sample of the NEPS starting cohort 4. School leavers with an intermediate certificate, by comparison, scored near the mean. However, variation within the low-achieving group is quite remarkable. --- Noncognitive characteristics We used a measurement of conscientiousness, one dimension of the common five factor model of personality, which also includes extraversion, agreeableness, neuroticism, and openness . The NEPS used a 10-item short version of the well-known Big Five inventory , developed by Rammstedt and John . As we need many independent variables for testing our hypotheses, we decided not to use all five dimensions but only conscientiousness. Our choice was driven by the idea that this dimension is "closest" to what is needed for successful job search and application behavior . We also tested this empirically and found the correlation between conscientiousness and our dependent variables to be higher than for the other four dimensions. Conscientiousness was measured by two items in grade 9 on a scale of 1 to 5 . Students had to assess the extent to which the following statements apply to them: "I am easy-going and tend to be a bit lazy" and "I am thorough." Given the two-item measurement, the Cronbach's α of 0.53 is low in conventional terms . Lacking an alternative better measure of personality traits, we still used it although we may not best capture conscientiousness. We also included students' global self-esteem. Here, the NEPS uses a revised version of the German adaptation of Rosenberg's self-esteem scale, consisting of 10 items and using a scale of 1 to 5 . The Cronbach's α is 0.85 for our sample . For example, students had to assess the extent to which the following statements apply to them: "I have found a positive attitude towards myself" or "I can do many things just as well as most other people." For both measures we used z-standardized measures in our multivariate analyses. A limitation is that neither conscientiousness nor self-esteem were assessed for specialneeds school students. --- Network resources We could not study the quality of network resources directly. 7 We know that parents play an important role in their children's search for training . We therefore used parents' employment status, highest socio-economic status, and education as proxies for respondents' potential network resources, also in view of whom they know in their broader radius, like relatives and friends. To define parental employment, we used students' reports in grade 9 on whether their parents were working , looking for a job, or inactive at the time of survey. We distinguished between no employed parent , one employed parent , or two employed parents -by comparison, about 77% of adolescents with an intermediate certificate had two employed parents. As students had to apply to regular training programs one year in advance in order to enter training programs directly after leaving school , the information in grade 9 is still reasonably valid for our analysis. The occupational status of parents was measured by the International Socio-Economic Index of Occupational Status . The ISEI is based on an optimal scaling procedure, assigning scores to occupations "in such a way as to maximize the role of occupation as an intervening variable between education and income" . The ISEI-08 scale ranges from 11 to 89. The information on occupations, collected in grade 9, is based on parents' reports when available and on students' reports otherwise . If both parents were employed, we used the higher ISEI of the two jobs. The mean parental ISEI of low-achieving adolescents' parents was 39.5-almost 8 ISEI points lower than the mean for adolescents with intermediate certificates. Variation within the group of low-achieving adolescents is quite considerable, as indicated by a standard deviation of about 18 ISEI points. We used information on highest parental education based on parents' reports if available and based on students' reports otherwise . We used the level of education of the higher educated parent and differentiated between no school-leaving certificate , lower secondary certificate , intermediate certificate, including completed regular vocational training , university-entrance qualification , and tertiary certificate . In our sample, the highest correlation between the three parental background variables is .45 for the detailed parental education and parental ISEI, which is very reasonable for the German labor market. The correlations between parental education and employment and between employment and ISEI are only .15 and .16, respectively. For our multivariate analysis, we therefore used a less detailed education scale, only differentiating between the highest educated parent holding at least an intermediate certificate and less than an intermediate certificate -with a correlation of only .34 with parental ISEI. --- Career plans As a first indicator of adolescents' occupational orientation, we looked at whether students were able to report a desired occupation. In grades 9 and 10, students were asked: "Considering everything you know right now, what occupation will you most likely pursue in the future?" We coded 1 if students reported a desired occupation and 0 if students did not report one in the last wave before leaving school . On average, 74% of the low-achieving school leavers were able to report a desired occupation-ranging from only 68% of those who left school without a school certificate to 79% of those holding an extended lower secondary certificate. The desired occupations seem to be quite realistic, as the mean ISEI of the reported occupations is only 37 on average-ranging from only 32 for those without a certificate to 40 for those with an extended lower secondary certificate-and thus in the lower half of the ISEI scale, as well as considerably lower than the mean ISEI for school leavers with an intermediate certificate . Our second indicator is adolescents' training aspirations. We used the information on whether respondents originally planned to do vocational training right after school, collected in the first wave after leaving school. One could argue that this retrospective response might be biased by the success of adolescents' applications. The high proportion of 75% who reported such a plan compared to only 39 % who entered regular training programs suggests that, if such a bias existed, it should be very small. NEPS also provides a prospective measure with a different wording and thereby associated with a slightly different meaning. Here, students were asked what they expected to do after leaving school, not what they wanted to do. The retrospective question is more suitable for capturing students' aspirations for doing a regular training program -indicated by the fact that 70% of those who prospectively expected to enter prevocational education did not "aspire" to it, as their response to the question was that they planned to pursue regular training after leaving school. --- Local training market situation The provision of firm-based training places correlates with the local economic situation . We therefore used the local youth unemployment rate among young people under 20 years old as a proxy for the local apprenticeship market situation. We linked the NEPS data to this unemployment rate at the municipality level based on respondents' residential address. The information was provided by the Institute for Employment Research . We used data for the year of leaving school; that is, for the 3rd quarter of 2011 and 2012, respectively. The local unemployment rates ranged from zero to 21.8%. For our multivariate analyses, we used z-standardized rates . --- Reasons for participation in prevocational programs To better assess why low-achieving adolescents did not enter regular training programs , we used the following information in our descriptive analyses: Respondents who entered prevocational programs were asked about their reasons and provided with the following response options: I wanted a better qualification; --- Control Variables We included gender, migration background, and German state as control variables. Gender was taken from school records in grade 9 . Based on students' self-reports, we defined students as having a migration background if they themselves or both parents were born outside Germany . In addition, we included dummies for the 16 German states in which a student attended school. This way, we accounted for differences between states and took the sampling design into account. We are not allowed to report the estimates of the states' dummies owing to NEPS regulations. In the analyses of adolescents' application effort, we used the local youth unemployment rate as a further control variable. --- Plan of Analyses To test our hypotheses regarding the impact of agentic resources on low-achieving school leavers' application efforts and their eventual success in entering regular training programs, we estimated a series of logistic regressions, first, on their application efforts and, second, on the odds of entering regular training programs instead of prevocational programs or other activities, controlling for whether they applied or not . For methodological reasons and for easier interpretation, we will report average marginal effects, so-called AMEs . The AMEs display the percentage-point change in the probability of the dependent variable for a oneunit change in the respective independent variable. In contrast to odds ratios , AMEs are comparable across different model specifications. Continuous variables were z-standardized based on our subsample of low-achieving respondents to provide meaningful comparisons of the sizes of the AMEs . Because of the sampling design, we estimated survey logit models and included dummies for the German states. We used nonresponse-adjusted design weights in our descriptive but not in our multivariate analyses, as suggested by Steinhauer and Zinn . We dealt with item nonresponse by imputing the data using the MICE algorithm in Stata 14. School-leaving certificates, school types, GPA, competences, and noncognitive skills were expected to have an effect on both dependent variables . The same applies to the parental background variables . By including information on whether school leavers applied for training places into the regression on the odds of entering regular training, we assume to control for the influence of adolescents' application efforts and thus to observe the influence of these independent variables on the employer/vocational school selection side. We faced some restrictions in our analyses. First, competences and noncognitive characteristics were not assessed for special-needs-school respondents. Thus, the test of our hypotheses is limited for these respondents. We therefore estimated the final regression models twice-with the full set of independent variables for the sample without special-needs-school students and with the limited set of variables including these respondents. Second, we could not test directly the discrediting mechanism. This would require an experimental design , controlling for all other potential sources of disadvantage on the applicant's side and at the local level. We therefore argue that it is fair to assume their applications were not considered if we find that respondents' training opportunities are not higher when they applied and if they do not vary by cognitive and noncognitive skills and the local market situation. This interpretation presumes that all other mechanisms that might be at work here have been considered and measured in a way that accounts for the entire variance, besides potential measurement errors. Although we certainly cannot rule out these potential error sources, we would like to point out that we did much more than most other studies by allowing not only one but multiple individual characteristics to affect the training opportunities and by including competition at a fine-graded local level. We conducted several robustness checks with different specifications of variables, models, and subsamples . Overall, the results proved to be robust. --- Results --- Descriptive Results Only 39 % of the low-achieving school leavers were able to enter regular training programs directly after school. Figure 1 shows that the training opportunities differ strongly by school-leaving certificate-ranging from 55 % of the school leavers holding an extended lower secondary certificate to only 10% of those without a school-leaving certificate. 8 Correspondingly, the proportion of those who enrolled in prevocational programs ranged from 30 to 77%, and is much higher than the proportion among school leavers with an intermediate certificate , who in turn more often continued with general education to pursue a university entrance qualification, which low-achieving adolescents cannot do directly. Their application rates were much higher than their rates of successful entry on average and for all subgroups: 59% of low-achieving school leavers applied, ranging from 67 to 36% (see Table 1 --- above). Figure 2 displays the distributions of combined mathematics and reading competences. Although the distributions differ by school-leaving certificate in the expected way, we see a considerable variation within each subgroup as well as substantial overlaps in the competence distributions of low-achieving adolescents and school leavers with an intermediate certificate. These overlaps indicate that quite a substantial share of school leavers with low formal qualifications are underachievers-that is, they left school with lower qualifications compared to their relatively high levels of competences. Table 2 presents first descriptive findings on the importance of differences in agentic resources for low-achieving adolescents' training opportunities. We differentiated between low-achieving adolescents who entered regular training programs , who started prevocational programs , or who pursued other activities. We focus on the comparison of the first two groups. Trainees had considerably higher educational attainment in terms of level of school-leaving certificate and school type attended than prevocational participants. They also more often had two employed parents. In contrast, the differences between the two groups in terms of grades , mean levels of math and reading competences and of noncognitive skills, and parental occupational status were very small. The subgroups did not even differ in parental education. We see that those who entered regular training applied much more often than prevocational participants . Yet we also observe that about 24% of trainees did not report that they applied for training; most probably they got their training places by referrals or after internships. The application difference between trainees and prevocational participants does not mirror differences in their aspirations: The proportion of prevocational participants who planned to do a regular training program is high and not much lower than the proportion among the trainees . The same is true for career orientation: The proportion of prevocational participants who reported a desired training occupation is only slightly lower than the one of trainees . Compared to trainees, prevocational participants reported occupations with lower occupational status, expressed as the mean ISEI score, indicating that their occupational aspirations were not unrealistically high. The mean local youth unemployment rate was higher in the regions of those who started a prevocational program compared to those who entered regular training programs -though the mean unemployment rate was quite low for both groups. Finally, prevocational participants reported the following reasons for starting a prevocational program : 52 % wanted but did not get a regular training position. The majority of prevocational participants hoped to improve their educational qualification and thereby their future training opportunities. But 41 % of prevocational participants lacked career guidance, reporting they did not know which training program to choose. --- Application Efforts Table 3 reports the average marginal effects based on a logistic regression analysis on the odds of applying to regular training programs. Adolescents' application efforts differed strongly by school-leaving certificate: Those without a school-leaving certificate were about 20 to 25 percentage points less likely to apply than those with lower secondary certificates, while those with an extended lower secondary certificate were 4 to 5 percentage points more likely to apply . These differences are independent of the GPA on the school-leaving certificate. The effect of GPA is close to zero and not significant. In contrast, the school type attended had an additional and substantial impact on adolescents' application effort: School-leavers from special-needs schools were 16 percentage points less likely to apply than those who attended a lower secondary school , even when they had the same school-leaving certificate, GPA, career orientation, and parental resources . Given that the majority of them left school without a certificate , the typical special-needs-school student had a 36 percentage-point lower application rate than the typical school leaver from a lower secondary school. Interestingly, school leavers from other school types showed a 5 to 7 percentage-point lower application rate than those from lower secondary schools . This higher likelihood is partly explained by the fact that school leavers with higher math and reading competences were less likely to apply . This result indicates that some of the better performing low-achieving students decided more often to attend a prevocational program; most probably to improve their educational attainment before entering regular training. Concerning the noncognitive characteristics, more conscientious school leavers applied significantly more often -controlled for parental background, the effect is not significant . In general, the effect size is rather small: An increase of one standard deviation in conscientiousness increased the application rate by only 2 percentage points. The effect for self-esteem was not significant . Career orientation had a strong influence on adolescents' application activities : Those who planned to do regular training applied substantially more often-indicated by an increase in the application rate of 31 to 32 percentage points, net of other potential factors. This is the largest effect on application behavior . In addition, those who reported a desired occupation were 5 to 6 percentage points more likely to apply. Finally, parental resources played a minor role for adolescents' application efforts : Parental education and employment were not significant; for the ISEI of the highest parental occupation, we observe a significant and very small effect. Similar to higher competence levels, the effect is negative: an increase of one standard deviation in parental ISEI decreased the likelihood to apply by 2 percentage points. --- Entry into Regular Training Positions Table 4 reports the results of a logistic regression on the odds of entering regular training positions . School leavers who applied were 16 to 20 percentage points more likely to enter regular training programs than those who did not apply . Net of application, the ability to report a desired occupation increased the training chances additionally by 7 to 11 percentage points . Net of application effort, adolescents' school-leaving certificate strongly affected the likelihood of entering regular training programs: school leavers with an extended lower secondary certificate were 7 to 8 percentage points more likely to enter regular training than those with a lower secondary certificate ; in contrast, adolescents with no certificate were about 21 to 22 percentage points less likely than those with a lower secondary certificate . The inclusion of respondents from special-needs schools reduced this effect size only a little bit . Figure 3 reports the interaction between application effort and school-leaving certificate. Applying is associated with higher training chances for all three groups, but the effect sizes differ remarkably between the groups. That is, applying paid off more for school leavers with a lower secondary certificate than for adolescents without a certificate: for the former, their application effort increased their training chances by about 30 percentage points; for the latter, that increase was only about 14 percentage points. Training chances did not differ by regular school type ; however low-achieving adolescents from GPA significantly affected training chances, even when controlled for school-leaving certificate and other variables: an increase of one grade was related to a 9 to 10 percentage-point higher probability of entering regular training . In contrast, Models 2-4 show that the effect size of competences, conscientiousness, and self-esteem were small and not significant-though low-achieving school leavers differed quite remarkably in these characteristics . We tested whether the effects of competences were already taken up by school-leaving certificate, school type, or GPA by re-estimating Model 2 adding only math and reading competences: Again, the effect size was zero . 9 Labor market conditions positively influenced training opportunities: One standard deviation of increase in the local youth unemployment rate reduced the odds to enter regular training by 4 to 5 percentage points, net of other characteristics . Parental education and occupational status did not affect low-achieving adolescents' training chances , whereas parental employment did: Those with no employed parent were 13 percentage points less likely to enter regular training . When including school leavers from special-needs schools , the effect size decreased to 7 percentage points and lost its significance. We re-estimated Model 5 separately for school leavers from special-needs schools and for those from regular schools . For the latter, we found a negative effect of "no parent employed" as in Model 4 , while the effect for those from special-needs schools was 0.01 . In other words, parental employment only mattered for low-achieving adolescents from regular schools. In sum, career plans and vocational orientation as decision-making resources influenced adolescents' application efforts; however, skills and parental resources did not . A positive association between parental resources and entry into training was only found for low-achieving adolescents from regular schools but not for those from special-needs schools . Moreover, the results provide strong empirical support for withdrawal because of stigmatization, on the one hand , and for job competition restricting the success of application efforts owing to gatekeepers' selection, on the other . We observed, however, considerable differences in the impact of application on training chances by school-leaving certificate-ranging from "only" 14 percentage points for those without a certificate to 30 to 31 percentage points for those with a lower secondary certificate. --- Robustness Checks Besides the robustness checks reported above , we reestimated several other model specifications, variable definitions, and subsamples . The results for application efforts and odds to enter training were robust for all robustness checks conducted. We only compared respondents who entered apprenticeships to those who started prevocational education or other activities. The results were also robust when excluding respondents with "other activities" after leaving school. We included parental education in a more differentiated way. We also tested a nonlinear relationship between application effort and conscientiousness and self-esteem, respectively, by including also quadratic terms for the two latter variables-because moderate levels of these two personality characteristics may be better than the two extreme points . The quadratic terms were not significant and the main effects did not change. We did the same for the odds of entry into regular vocational training; the results were the same. We tested alternative indicators for the local labor market situation . We also included school-leaving age . In all these specifications, the results reported in 3 and4 proved to be robust. We additionally re-estimated Model 3 of Table 4 by including an interaction term of the local unemployment rate with respondents' school-leaving certificate. In doing so, we explored whether the influence of the local unemployment rate on the odds of entry into regular training programs differed by school-leaving certificate. The coefficients of the interaction term were not significant. --- Discussion In this article, we investigated whether the school-to-work transition period provided low-achieving school leavers with new opportunities or whether they still faced persistent disadvantage owing to their low qualification, regardless of their agentic resources and efforts. Existing research has demonstrated that cognitive and noncognitive skills, aspirations, and parental resources shape individuals' continuing enrollment in education as well as their early occupational career and later work life . In our study, we investigated whether adolescents' efforts and initiatives to search and to apply for a regular training position were influenced by these decision-making abilities and resources. We also looked at the success of their application efforts, given that employers use educational certificates in their first screening of applicants. We studied the entry of low-achieving adolescents into regular vocational training in Germany, which can be regarded as the equivalent to entering the labor market . The results of our analyses show that low-achieving adolescents with better decision-making abilities made stronger application efforts. However, only higher aspirations, career plans, and vocational orientation predicted a higher likelihood to apply for training places. In contrast to existing population studies , we found that neither cognitive and noncognitive skills nor parental resources had an effect on adolescents' application efforts and the success of these applications. The reason for these findings is not that low-achieving adolescents' competence levels and noncognitive skills are too low-after all, there is considerable overlap in their competence distributions with those of school leavers with intermediate certificates and quite similar mean levels of noncognitive characteristics. The findings rather indicate that the existing underachievers had little opportunity that employers discovered their learning potential-because of employers' screening of applications based on school attainment. School-leaving certificate and school type had the strongest impact on low-achieving adolescents' application effort and the success of this effort: The most vulnerable low-achieving school leavers among them-those who left school without a certificate and/or attended a special-needs school-applied much less frequently compared to their better performing peers, and submitting applications improved their chances to enter regular training programs only to a small extent. In contrast, applications of those with a lower secondary school certificate strongly increased their training chances. Thus, the success of low-achieving school leavers' application efforts seems to be strongly restricted by competition; and those with the lowest attainment even seem to suffer from discrediting processes. In terms of parental resources, only parental employment status-but not parental education and occupational status -proved to be a somewhat valuable resource for access to regular training, albeit only for school leavers from regular schools. Thus, it is not just that low-achieving adolescents usually lack better parental resourceseven when they do have access to better resources, these resources do not seem to have the power to compensate for disadvantages resulting from the negative signal of low school achievement. Taken together, our results indicate that the transition period gives adolescents with better career orientation and relatively higher educational attainment new opportunities to enter regular training. They have better capacities and resources to actively search for jobs or training positions and, if there is less job competition, the opportunity to achieve successful school-to-work transitions. But even for that group, not all agentic resources are related to more agency and success. In contrast, low-achieving adolescents with the lowest educational attainment and/or those labeled as "learning disabled"-because they come from special-needs schools experience persistent disadvantage. To account for the persistent disadvantage in the transition period for this most vulnerable subgroup, we found some indication of both lack of agency owing to stigmatization and a high extent of unsuccessful applications owing to discrediting processes by gatekeepers. These differences in the timing and chances to enter the labor market have been shown to have long-lasting effects on later labor market attainments -and this might be even more the case in Germany, where the "normal" life course requires completion of vocational education and training or higher education before starting to work . Moreover, although our study showed that career guidance at German lowertrack schools seems to be quite effective in terms of helping low-achieving adolescents develop career aspirations and plans, those who are forced to continue with prevocational programs may see these unfulfilled expectations translate into frustration, possibly leading to higher risks of educational cooling-out processes and less agency later on . Our study contributes to the existing literature in several ways: Ours is one of the few studies capable of differentiating the respective impact of adolescents' agency and structural constraints on the success/failure in transitions into work-still a largely underresearched area . We extended existing research by not only relying on school-leaving certificates as a proxy for adolescents' skills but also considering grades, cognitive competences, and noncognitive characteristics. Moreover, family background was measured in a comprehensive manner by including three dimensions . We addressed structural constraints of low-achieving adolescents' training chances by including fine-graded regional differences in youth unemployment. We thereby added new insights into whether the "low qualification" label per se results in lower training chances, irrespective of differences in individual resources. Finally, this is one of the very few German studies to include school leavers from special-needs schools. This is important because most students classified as disabled are still not integrated into mainstream schools, and the vast majority of them leave school without a certificate or a lower secondary certificate. Including these students makes our study useful at the international level as well, because studies for countries with inclusive school settings for special-needs students may not adequately cover the population of disabled adolescents when relying on voluntary survey participation . Our study has some limitations. The discrediting mechanism could only be studied indirectly . Experimental designs would be required to validate and strengthen our findings in this respect. Moreover, stigmatization was examined via observed application behavior but not directly as an identity construct. Further studies should try to measure stigmatization more directly. The NEPS data do not provide measures of competences and noncognitive characteristics for respondents from special-needs schools, meaning we do not know whether their lower application rates and training chances are owing to very low skills. This may not be the case, however, because competences and noncognitive characteristics were not related to the differences in training chances of low-achieving adolescents from mainstream schools. Moreover, the NEPS data do not allow for reliably detecting integrated students with learning disabilities. We were therefore not able to study the extent to which the very low training chances of respondents from schools for learning disabilities are caused by their classification as being "learning disabled" and the fact that they attended special schools. Once data are available, future research should intend to disentangle the impact of these different dimensions of "labeling." Moreover, to fully cover the group of low-achieving adolescents, including students with other types of disability would be preferable as well. Finally, our study addressed the difficulties of low-achieving adolescents in a country with a strong vocational education and training system and a highly stratified education system-associated with the fact that educational credentials are very important in both training and labor markets . Given that low educational attainment is associated with very different levels of competences across countries as well as different meanings , research for countries with different institutional configurations should replicate our study to broaden further our understanding of the impact of educational credentials and agentic resources on new opportunities or persistent disadvantages of low-achieving adolescents in the school-to-work transition period. --- Conclusion Educational attainment and skills are known to be important for successful school-to-work transitions in particular and transitions to adulthood in general . Hence, preventing students from dropping out of education before achieving the recognized level of educational attainment is an important societal task. In this respect, vocational education and training are perceived as a means to reduce educational dropout. Research has shown, however, that low-achieving school leavers have a high risk of not entering or dropping out of vocational training as well . Many reasons have been proposed for this-ranging from employer discrimination, lack of competences and skills to withdrawal because of stigmatization. In our study, we investigated to which extent transitions to work are influenced by both low-achieving adolescents' application efforts and the success of their efforts . Agentic resources-like competences, noncognitive characteristics and parental resources-did not, or only to a very limited extent, influence adolescents' application efforts and the recruitment decisions of firms and vocational schools, despite the fact that low-achieving school leavers vary considerably in these resources. We demonstrated that the main disadvantage of low-achieving adolescents in Germany's training markets-which serve as entry labor markets-is their low school attainment . Career aspirations and a good occupational orientation developed during school, however, opened up new opportunities in the transition period: They increased adolescents' application efforts, which in turn promoted entry into regular training. However, for those who left school without a certificate and those from special schools for learning disabilities, the label of "having low qualifications" is the major obstacle to leveraging agency in this transition period. They are exposed to persistent disadvantages in the transition period and most likely throughout their work life. The findings of our study also have important policy implications for promoting apprenticeships as a means to prevent early educational dropout among low-achieving adolescents . Steedman stated that apprenticeships are "not a sufficient solution to improving the labour market situation of young people with poor school achievements or other disadvantages." She argues that many of these young people "have failed to find places. Employers now discriminate much more than in the past in favor of apprentices with good or very good school achievements." Low-achieving school leavers are, therefore, forced to enroll in remedial, or prevocational, education programs after compulsory general education . Our results support her considerations. We found that a major source of low-achieving adolescents' disadvantage in access to regular training is competition. Policies should therefore aim at providing a sufficient number of training places corresponding to the size of the applicant pool. Second, policies should also aim to improve employers' opportunities for detecting the competences and skills these young people possess despite their low school-leaving certificate. Doing internships prior to application, for example, might be beneficial for enhancing their training opportunities . Finally, prevocational programs should be evaluated in terms of how effectively they improve low-achieving adolescents' training and labor market entry chances-an area where we still lack research. --- Author Contributions A.C.H. performed the data editing and statistical analyses, participated in the design of the study and the interpretation of the data. L.M. participated in the data editing and statistical analyses. H.S. conceived the study, drafted the manuscript, and participated in statistical guidance. All authors participated in improving the manuscript, revisions and approved the final version. --- Compliance with Ethical Standards This study uses data conducted by the NEPS consortium. The data collected followed the ethical regulations of the German states and was approved by their data protection officers. --- Conflict of Interest The authors declare that they have no competing interests. Informed Consent Informed consent was obtained from all individual students and parents included in this study.

School leavers with low educational attainment face great difficulties in their school-to-work transitions. They are, however, quite heterogeneous in terms of their personal and social resources. These within-group differences may influence who shows initiative during the school-to-work transition period and thereby helps employers recognize their learning potential at labor market entry. Yet this recognition also depends on the ways employers select applicants, which may prevent them from discovering such within-group differences. We therefore investigate the interplay between agency and its constraints, that is, whether higher cognitive and noncognitive skills and more parental resources provide low-achieving school leavers with new opportunities in the school-to-work transition period or whether their low school attainment causes the persistency of their disadvantages. We use panel data from the German National Educational Panel Study (NEPS), which started in grade 9. The NEPS also includes school leavers from special-needs schools. Our sample consists of 3417 low-achieving adolescents (42% female), defined as adolescents who leave school with no or only a lower secondary school-leaving certificate. Their average school-leaving age is 16 to 17 years. Our key findings are that the transition period opens up new opportunities only for those low-achieving adolescents with better vocational orientation and higher career aspirations, leading them to make stronger application efforts. The success of youth's initiative varies considerably by school-leaving certificate and school type but not by competences, noncognitive characteristics, and parental background. Thus, the label of "having low qualifications" is a major obstacle in this transition period -especially for the least educated subgroup. Their poor school attainment strongly disadvantages them when accessing the required training to become economically independent and hence in their general transition to adulthood. Our results are also of interest internationally, because participation in firm-based training programs functions as the entry labor market in Germany. Thus, similar explanations may apply to low-achieving adolescents' difficulties in finding a job.

Introduction Operational deployments are a routine part of military life which most personnel cope well with. However, for those who experience numerous stressors associated with both home and military life, there is a risk of developing adverse mental health outcomes [1]. The mental health impact of deployment-related trauma has been widely researched [2,3]; however, service personnel's anxieties about home life, such as the potential impact of separation on relationships, and the impact of absence from the family may also have deleterious psychological effects. Military personnel can be concerned that aspects of their service might have a negative impact on their families, and among the various apprehensions arising during deployment, worries related to the family at home are a key concern [4]. Over half of a representative sample of 3198 UK military personnel with children believed that their military career had negatively impacted their children [4]. A study of US Navy personnel showed that concerns about children and spouses were substantially greater during deployment and following return than before deployment [5]. Military deployments and operational trauma can adversely affect the quality of relationships between military personnel and their spouses or partners and their children. UK military reservists that deployed to Iraq were more likely than their regular counterparts to report actual or serious consideration of permanent separation from their partners [6]. Most military studies tend to focus on combat and operational events while research examining the effects of deployments on families is less frequent, and is usually conducted retrospectively . With the exception of one study reporting on the impact of home front stressors [1], no studies relating to the impact of deployment on intimate relationships and children have been conducted among military personnel while they are deployed. In 2009, the UK Armed Forces first deployed a mental health research team to evaluate the mental health of deployed personnel. The project, known as the Operational Mental Health Needs Evaluation , was subsequently repeated on three further occasions. The data collected included measurements of mental health symptoms, help-seeking and combat events, participants' perceptions of how their current deployment impacted their intimate relationships and the potential effect on their children. --- Methods Data were collected during operations in Iraq in 2009 [7] and Afghanistan in 2010, 2011 and 2014. We sought to survey the bulk of personnel from the middle to the end of their deployment. With the exception of special forces personnel , participants were eligible to take part in the studies if they were members of any of the three UK armed Services and were deployed during the study period. Purposive sampling was conducted to ensure that the study sample was representative of the deployed force at the time of the survey. The OMHNE surveys were as follows: Iraq 2009 , Afghanistan 2010 , Afghanistan 2011 and Afghanistan 2014 . For OMHNE I, the survey team collected data primarily in the main operating base and satellite locations [7]. OMHNE A1 took place during intense combat operations; A2 during a steady state period where it was possible to focus the survey effort on more austere and dangerous locations, while A3 took place during the drawdown phase in Afghanistan while preparations to end the mission were underway. All surveys used a similar procedure where the visiting team undertook data collection in the participants' deployed location; however, OMHNE A3 data collection was carried out by a mental health practitioner following the delivery of a psychoeducational stress briefing which may or may not have influenced participant responses. Secondary data analysis was undertaken following the team's return to the UK. Ethical approval was granted by the Ministry of Defence Research Ethics Committee . Data were collected using a self-report questionnaire, which included questions about socio-demographic and military characteristics, deployment experiences, psychological distress, symptoms of post-traumatic stress disorder and self-rated health. Psychological distress was assessed using the 12-item General Health Questionnaire [8]; for the current study, those endorsing four or more symptoms on the GHQ-12 were classified as 'cases'. Symptoms of PTSD were measured with the 17-item National Centre for PTSD Checklist [9]; for the current study, a screening score of 30 or more was used to indicate the presence of traumatic stress symptoms. Combat exposure was assessed with a 17-item measure that asked about the frequency of exposure to combat events; scores were summed and tertiles were generated to facilitate a comparison of low, medium and high levels of exposure. Homefront stressors were measured by seven questions asking about, 'injury or death of a loved one', 'spouse separating from the deployed person', 'financial problems', 'the birth of a child', 'problems with children at home', 'facing other major problems at home while deployed' and 'having been concerned I might lose my civilian job'; the latter was answered by reservists only. Perceived support for the family during deployment was measured by a question asking: 'Has the military provided any reassurance or support to your spouse/partner/family while you have been on this deployment? . Participants selected one of the following responses to this questions, 'Yes, it is sufficient; yes, but it is not sufficient; no, or not applicable'. The primary outcomes in this study were the perceived impact of deployment on intimate relationships which was measured by a question asking: 'So far, what impact do you think this deployment has had on your marriage or relationship?', and the perceived impact of the current deployment on children which was measured by a single question asking: 'So far, what impact do you think this deployment has had on your children?'. Participants selected one of the following responses: 'no impact, positive impact, negative impact, or not applicable'. Participants were further asked if they were, 'currently planning divorce or separation?' or if their 'spouse or long term partner was planning divorce or separation?' Multinomial odds ratios and 95% confidence intervals were calculated using univariate and multivariate multinomial logistic regression. The associations between covariates and the primary outcomes were explored in unadjusted multinomial logistic regression models. Covariates showing significant associations with primary outcomes were included in adjusted multinomial logistic regression models. The analyses for perceived effect of deployment on intimate relationship were restricted to those who reported that they were in a long-term relationship, and the analyses for perceived impact of deployment on children were limited to those who reported having dependent children. All analyses were performed using the statistical software package Stata . --- Results The Ninety-one per cent of the overall sample was male, 39% were under the age of 25, 72% were junior personnel , 84% of the sample was in the Army/Royal Marines, 56% served in a support rather than a combat role and 94% were regulars. 2788 participants reported they were in a longterm relationship and 1464 reported having dependent children. Around a third to a half of those surveyed perceived deployment to have a negative effect on their intimate relationships , and around a half to two thirds perceived that deployment had a negative effect upon their children . Univariate analyses of the socio-demographic variables showing significant associations with the outcome variables were then included as potential confounding variables in adjusted multinomial logistic regression models. Planned separation either by deployed military personnel or by their partner at home was significantly associated with the deployed person reporting four or more symptoms of psychological distress [, ]. Similarly, planned separation was significantly associated with the deployed person reporting one or more home front stressors [, ]. Military personnel on deployment were also more likely to report considering separation from the partner at home when they perceived support for their family at home to be insufficient . Compared with regular personnel, reservists were significantly more likely to report a positive impact of deployment upon their intimate relationships . Personnel reporting four or more symptoms of psychological distress perceived deployment to have a negative impact on their intimate relationships , as did those reporting traumatic stress symptoms . Participants who reported being in danger of being injured or killed on one or more occasions were more likely to report that deployment has negatively affected their relationships . Reservists were less likely to report a negative impact of deployment on their children compared with regular personnel. Junior ranking personnel were also less likely to report that they perceived deployment to affect their relationships negatively . Personnel reporting symptoms of traumatic stress perceived that deployment had a negative impact on their children. Personnel reporting symptoms of psychological distress, PTSD, and those holding junior ranks were more likely to perceive that the support available to their families was insufficient. Those deployed in a combat role were less likely to perceive family support provided by the Ministry of Defence to be insufficient. --- Discussion Combined estimates from four mental health surveys conducted in Iraq and Afghanistan over a 5-year period suggested that overall, 41% of those surveyed thought that the deployment had had a negative effect on their intimate relationships while 55% perceived that their children had been negatively affected. These percentages were almost identical over the course of individual deployments . The highest rates of perceived negative impact, on both intimate relationships and on children, were reported during the Iraq deployment in 2009 and the Afghanistan deployment in 2010, while the lowest rates of negative impact were reported during the 2014 Afghanistan deployment. The earlier deployments to Afghanistan were characterized by more intense periods of fighting, sustaining casualties, combat deaths and engaging the enemy. It is highly likely that personnel felt that they were at heightened risk of experiencing injury or death during earlier deployments. The Iraq survey took place when UK forces were confined to the main operating base and feelings of boredom and nervousness were high, as many personnel had deployed to previous Iraq operation in which they had experienced indirect and direct rocket fire in their base locations, and may well have perceived a heightened threat to life [10]. In comparison, the 2014 deployment to Afghanistan coincided with the drawdown phase of current operations with an accompanying lower risk of exposure to dangerous or life threatening events. The perceived negative effect of deployment was related to a number of factors among deployed personnel including symptoms of psychological distress and traumatic stress symptoms, and stressful events occurring at home during the deployment. Our findings are in keeping with research which shows that negative outcomes for families increase with the amount of exposure 8) 55 111 74 106 Rank Officer 525 74 168 145 138 Senior 655 104 212 180 159 Junior n, number; %, percentage. service personnel have to traumatic or life-changing experiences, and to deployment stress. US military studies conducted during the Iraq and Afghanistan conflicts have shown that separation from the family is one of the primary deployment worries service personnel reported and for those with mental health problems concerns for their family was the most influential risk factor of all those measured [11]. As such, military service in general and deployments where combat and operational tempo is low do not appear to significantly increase the probability of negative outcomes for military families [12]. However, reporting symptoms of poor mental health can be associated with negative outcomes [13] and separation from one's family can in itself be a cause of loneliness and strain. In the US military, deployment in the past year was related to higher levels of PTSD symptoms for military husbands, and the husbands' current PTSD symptoms were associated with lower marital satisfaction, confidence in the relationship, positive bonding between the partners, parenting alliance and dedication to the relationship for both military husbands and their wives [14]. Our results showed that home front stress was associated with planned separation by both military personnel and their partners. Interviews conducted with mental healthcare providers reveal that home front stress, such as relationship difficulties, or financial problems, is the major reason for which US service personnel sought help while they were deployed [15]. Inevitably, knowing that one's family is experiencing difficulty at home and not being there to support them could give rise to negative perceptions about the effect of deployment on families [16]. Research has shown that support from a supervisor can reduce role stress which in turn was associated with reduced family conflict and improved family cohesion in a population of policewomen [17]. Our study extends these findings by demonstrating that support for families is also an essential factor associated with the health of deployed military personnel. Contrary to previous findings from the UK [6], our findings show that while deployed, reservists were less likely to report a negative effect of deployment on their children, and more likely to report a positive effect of deployment on their intimate relationship. In a study of families of US military reservists, most family members reported deployment had increased family closeness along with a combination of patriotism, pride and civic responsibility [18]. Furthermore, reservists and their spouses also saw the financial benefits of deployment as a positive outcome [18] which may have some relevance to UK reservists. Findings from a recent study of regular US service personnel show that they reported better family life while they were on deployment [19]. The authors postulate that this may be because personnel were removed from the daily stresses associated with family life or possibly because they appreciated their family more while they were separated from them [19]. It is possible that openly discussing the benefits and potential detriments of deployment to the family system while deployed allows reservists to view their deployment in a more positive light, compared with regulars. In this study, the data are cross-sectional and therefore it is not possible to comment on causality. These data were gathered by survey, which limits the richness of the data and only allows for forced choice responses. However, this study is unique in offering a during deployment perspective of how military personnel think about the ways in which their deployment might affect their families and the key variables associated with negative outcomes. In conclusion, a significant number of deployed UK military personnel perceived their deployments to have a negative effect on their intimate relationships and on their children. These findings are consistent with existing research showing links between deployment experiences and poor family outcomes. Research from the UK has already shown a lack of support for military families to be associated with relationship difficulties. There is scope for improving the reach of pre-deployment preparedness briefings for military families and for workshops that involve military personnel, their spouses and children. Future research should focus on gathering data from all family members during the deployment cycle. Ultimately, military families do well when they have adequate support, as such welfare support programmes should actively target families that experience problems on the home front. --- Key points • During deployment, perceiving that deployment had a negative impact on families was associated with psychological distress, traumatic stress symptoms and being in danger of being injured or killed. • Reservists were less likely to report negative effects of deployment on their children compared with regulars. • Perceived insufficient support from the Ministry of Defence was associated with poor mental health during deployment and holding a junior rank. --- Conflicts of interest None declared.

In the UK, little is known about the perceived effects of deployment, on military families, from military personnel in theatre.To investigate military personnel's perceptions of the impact of deployment on intimate relationships and children.Deployed service personnel who were in a relationship, and who had children, completed a survey while deployed on combat operations. Data were taken from four mental health surveys carried out in Iraq in 2009 and Afghanistan in 2010, 2011 and 2014.Among 4265 participants, after adjusting for military and social-demographic covariates, perceiving that deployment had a negative impact on intimate relationships and children was associated with psychological distress, and traumatic stress symptoms. Military personnel who reported being in danger of being injured or killed during deployment, were more likely to report a perceived negative effect of deployment on their intimate relationships. Reservists were less likely to report a perceived negative impact of deployment on their children compared with regulars. Military personnel who themselves planned to separate from their partner were more likely to report psychological distress, and stressors at home. Perceived insufficient support from the Ministry of Defence was associated with poor mental health, and holding a junior rank. Conclusions Deployed UK military personnel with symptoms of psychological distress, who experienced stressors at home, were especially likely to perceive that their family were inadequately supported by the military. Those planning to separate from their partner were at increased risk of suffering with mental health problems while deployed.

Problemas de saúde mental são comuns na atenção primária e são geralmente relacionados à ansiedade e à depressão. Este estudo tem o objetivo de avaliar a taxa de transtornos mentais comuns e suas associações com características sociodemográficas em unidades de saúde da família. É um estudo multicêntrico, transversal, com os usuários da atenção primária do Rio de Janeiro, São Paulo, Fortaleza e Porto Alegre , Brasil. Utilizou-se o General Health Questionnaire e o Hospital Anxiety and Depression Scale . A taxa de transtornos mentais nos usuários do Rio de Janeiro, São Paulo, Fortaleza e Porto Alegre foram, respectivamente, 51,9%, 53,3%, 64,3% e 57,7%, com diferenças significativas entre Porto Alegre e Fortaleza comparando-se ao Rio de Janeiro. Problemas de saúde mental foram especialmente altos em mulheres, desempregados, em pessoas com baixa escolaridade e com baixa renda. Dadas as iniciativas do governo brasileiro para o desenvolvimento os cuidados primários e para reorganização da política pública de saúde mental, é importante considerar os transtornos mentais comuns como uma prioridade tal como outras morbidades crônicas. Cad. Saúde Pública, Rio de Janeiro, 30:623-632, mar, 2014 --- Introduction Common mental disorders are associated with disability 1,2,3 , poor prognosis of comorbid diseases 4,5 and impacts on health care costs and economic productivity 6,7,8 . A significant proportion of the global health burden is attributable to mental health 9 . Severe mental health problems account for 21.5% of all disability-adjusted life years in Brazil 10,11 . Recent epidemiological research among adults in the megacity of São Paulo showed a one-year prevalence of 19.9% for anxiety disorders, 11% for mood disorders, 4.3% for impulse-control disorders and 3.6% for substance abuse. These represented some of the highest prevalence estimates among cities around the world 12 . In order to improve health conditions, the Brazilian government has been promoting significant changes in the health system, investing and remodelling primary care and mental health services 13 . It is proposed that the substantial burden of mental disorders can be reduced by integrating mental health into primary care, particularly in places with high levels of inequality and socioeconomic deprivation 14 . The Family Health Strategy is the cornerstone of this integration, involving the introduction of 30,000 family health teams covering 95% of Brazil's municipalities and more than 50% of the population. Each team comprises one doctor and one nurse, two nurse assistants and six community health workers . There are few studies of prevalence estimates of mental disorders in family health units in Brazil, and most of these were done in cities with no more than 650,000 people 15,16,17 . Some studies have taken place in large cities, but in traditional primary health centers 15,18,19,20,21 . In Petrópolis 22 and Santa Cruz do Sul 16 a range of between 51 and 56 common mental disorders were found among people in family health units. Azevedo-Marques & Zuardi 17 found 36.7% of any DSM-IV disorders in family health units in Ribeirão Preto . Considering São Paulo or other big cities, the prevalence of psychiatric morbidity among patients in traditional primary health centers varies from 46% and 47% in São Paulo and Rio de Janeiro 15,19 to 56% in Porto Alegre 18 . Considering the breadth of responsibilities of the FHS -which include a major role in mental health -it is important to investigate further the epidemiology of common mental disorders in the context of the FHS in Brazil. The aims of the current paper are: to estimate the prevalence proportions of common mental disorders among patients in the FHS in four cities: São Paulo, Rio de Janeiro, Porto Alegre and Fortaleza; to study the association between sociodemographic factors and common mental disorders. --- Methods --- Research design and population The study was based on surveys conducted during 2009 and 2010 in four state capitals , which represent different regions of Brazil with considerable geographic and cultural differences. Porto Alegre is located in the Southern region of Brazil and has a population composed mainly of descendants of European immigrants, with an economy based on agro-industrial activities and one of the best Human Development Indices in the country. Fortaleza is the 5th most populous city in Brazil, located in the Northeast region, with a high prevalence of illiteracy and a lower HDI. Its economy is based on business, commerce and tourism and its population is composed mainly of Portuguese and Native American descendants. São Paulo and Rio de Janeiro are located in the Southeast, the most industrialized, urbanized and wealthiest region of the country. São Paulo is the biggest city in South America and has a population based mainly on immigrants from Europe and Asia and migrants from the Northeast region of Brazil. Rio de Janeiro is the second largest city in the country. Its population is originally European and Afro-Brazilian with a strong presence of Northeastern migrants. The study was originally designed to evaluate an intervention for training primary care and mental health workers in shared care , which is published elsewhere 23 . The population of interest was composed of patients from 20 urban health family primary care centers with 27 family health teams from these four cities. These units were those chosen by the Health Secretaries from the four cities where training in mental health in primary care was considered a priority. The number of teams evaluated in each city was proportional to the number of professionals trained in each one: there were 3 teams in Porto Alegre, 3 in Fortaleza, 6 in São Paulo and 12 in Rio. All patients aged 18 to 65, and attending nurses and doctors were invited to take part in the study. Pregnant women and patients with impaired cognitive functioning were not in-Cad. Saúde Pública, Rio de Janeiro, 30:623-632, mar, 2014 cluded. The original study was conceived as two cross-sectional surveys in a quasi-experimental pre-post design. The first cross-sectional survey was carried out from September to November 2009 and the second survey from June to August 2010. No patient who participated in the first survey was allowed to participate in the second. For this study, the entire sample was gathered and analysed together. For local logistical reasons, there was no sample from Fortaleza in the second phase. The research protocol was approved by the Ethics Research Committee of the São Paulo Federal University, Rio de Janeiro State University and all four municipalities allowed the research to take place in their primary care health centers. --- Measures A researcher -who was based in the waiting room -obtained written consent from patients and applied the Portuguese version of the General Health Questionnaire , Hospital Anxiety and Depression Scale and a sociodemographic questionnaire. These instruments were applied as interviews due to the high illiteracy prevalence proportions within this population 15,19,20 . The GHQ-12 was used to identify "probable common mental disorders" among patients. This instrument has been validated against a semi structured psychiatric interview 24,25 and the Brazilian version at the cut-off point of 2/3 has demonstrated a sensitivity of 91% and specificity of 71% for the presence of common mental disorders in a population with no more than four years of schooling 22,26 . To evaluate "probable depression" and "probable anxiety", the HAD scale was used with a cut-off of 8/9 as previously validated in Brazil 27 . These scores are associated with mood and anxiety distress, which is related with functional impairment and higher risk of developing mental disorders 28 . Common mental disorders were used to highlight the psychiatric morbidity on emotional distress, as described by Goldberg & Huxley 29 . It is different than probable depression and/or anxiety disorders analyzed by specific scales that were used to point out more severe cases and also to allow comparison between wider data among other studies. Sociodemographic data included gender, age, self-reported ethnicity, marital status, education , employment status, income and ethnicity. Continuous variables were coded into dichotomous values. We divided ethnicity, income and education variables as: white or non-white, income higher or lower than half the minimum monthly wage per person per family , and more or less than four years education . --- Data analyses The scores from GHQ-12 and HAD were dichotomized and taken as the dependent variables. Patients scoring at least 3 points on the GHQ were considered cases of "probable common mental disorders" and with 9 or more points in HAD for both subscales were cases of "probable depression" and "probable anxiety". We present descriptive statistics on the prevalence proportions of "probable common mental disorders", "probable depression" and "probable anxiety". The chi square test was used to determine differences in prevalence proportions between sites. We used logistic regression to examine variation between cities in prevalence proportions of common mental disorders while adjusting for gender, age, education level, ethnicity, employment, and marital status. Odds ratios with 95% confidence intervals were calculated to estimate the association between sociodemographic variables and the presence of common mental disorders, depression and anxiety. Statistical analyses were performed using the IBM SPSS version 19.0 . --- Results A total of 1,857 patients completed the screening questionnaires during the period of the surveys, 1,260 in the first phase and 597 in the second. 909 were from Rio de Janeiro, 557 from São Paulo, 171 from Fortaleza and 220 from Porto Alegre. Only income and employment status were significantly different between the samples from the two phases . Patients were mainly women over 35 years in age with more than four years of education. The majority were married or living with a partner and self reported their ethnicity as nonwhite. About one-third of patients come from a deprived background with family income lower than half the minimum wage at the time. Table 2 depicts sociodemographic characteristics between health centre patients among cities. The prevalence proportion of common mental disorders, anxiety and depression are presented in Table 3. There were no significant differences between patients in these cities for common mental disorders, depression and anxiety, with two exceptions. Among Fortaleza's patients the prevalence proportion of common mental disorders was significantly higher than in Rio de Janeiro's even when adjusting for gender, income, employment status, race, marital condition and education level . Patients in Porto Alegre also presented significantly more common mental disorders than those in Rio de Janeiro after controlling for these sociodemographic factors . Table 4 shows the associations between common mental disorders, depression and anxiety cases and sociodemographic factors. The bivariate analysis revealed that common mental disorders and depression were statistically and positively associated with gender, educational level and income. There were minor changes after controlling for all sociodemographic factors. Employment status was no longer related to common mental disorders and depression and educational level no longer showed significant associations with depression after adjusting for confounders. --- Discussion This paper reports the first multicentre study in Brazil examining the prevalence proportion of common mental disorders in primary care attendees and its association with patient sociodemographic factors. We found high prevalence proportions of common mental disorders, anxiety and depression in all cities. Patients attending primary care in Fortaleza and Porto Alegre presented significantly more common mental disorders than in Rio de Janeiro even after adjustment for confounding variables. There were no significant differences between patients from the health centers of these cities when we ana-lysed depression and anxiety disorders separately. Psychiatric morbidity among primary care patients was higher for females, those unemployed, those with less education, and those with lower income. After adjusting for the joint effects of sociodemographic factors on common mental disorders and anxiety, only employment status failed to show a significant association with disorder prevalence proportions. There was no association of depression with education level after adjustment for other variables. The prevalence of mental health problems in primary health care is high, especially common mental disorders in all low and middle income countries, with particularly high prevalence proportions in Brazil. In Chile 30 and Nicaragua 31 it is 53% and 47%, respectively, similar to India 32,33,34 that is 50%. Even in European countries, there is a high prevalence of psychiatric morbidity. Depression is present in 37% of patients in the UK 35 , 32.7% in Portugal 35 , 35% in the Netherlands 35 and 34.4% in Spain and Bosnia 36,37 . There are ICD-10-PC diagnoses in 49.7% of primary health care patients in Denmark 38 . It is clear that there is a high prevalence of common mental disorders in primary care regardless of the average levels of income. The present study found the highest prevalence proportions of "probable anxiety" which is consistent with a recent epidemiological study that found a community prevalence of 19.9% in São Paulo -the highest compared with 23 other countries studied in the same survey 12 . There are many reasons which might explain the high prevalence proportions of anxiety disorders in Brazil, such as widespread urban violence and adverse socioeconomic conditions. It is known that one of the main sources of mortality and morbidity in Brazil is violence 39 . Furthermore, pollution, high noise levels and lack of recreational areas in Brazilian cities might be related with anxiety levels. Cad. Saúde Pública, Rio de Janeiro, 30:623-632, mar, 2014 In accordance with other studies 19,33,34,38 we found associations between prevalence proportions of disorders, indicators of poverty and female gender. However, this profile of association changes among countries. In India 32,33,34 a low income is most strongly associated with common mental disorders, which was not observed in Chile 30 . In the present study this was the second most relevant variable, while gender was the most important factor. In contrast, being female in Chile is strongly associated with common mental disorders while in India there is no association. Patel & Kleinman 40 pointed out in a review of 11 community studies in six low and middle income countries that the most consistent factor is low levels of education. We also found low education to be an important factor. After adjustment, education was not associated with depression. This could reflect an inverse correlation with social disadvantage, education level and prevalence of common mental disorders. In Chile 41 --- social class and education Non-white 71.5 1.0 71.1 1.0 75.2 1.0 OR: odds ratio; 95%CI: 95% confidence interval. demonstrated a reduced strength of association after adjustment in a community survey. Similar results were found in Brazil 42 where the relationship between education and common mental disorders was significant only when the income was not extremely low. Extreme poverty reduced the strength of this association, probably because both factors are related and used to happen together in low and middle income countries. The sample size for the surveys was calculated in order to assess changes in recognition of common mental disorders over time and not for a prevalence study. The number of patients who refused to participate was not assessed and, therefore, could not be included in the analysis. Consequently it was not possible to estimate the true prevalence among all patients and the results cannot be rigorously extrapolated for the population of each city. However, this sample should be comparable to the primary practice routine of other urban areas in Brazil. It is not possible to generalise to smaller urban areas and rural populations, although 85% of the Brazilian population is estimated to live in urban areas. The samples were from two cross-sectional surveys conducted at different times but were considered homogeneous enough for pooled analysis. The screening questionnaires measure psychiatric symptoms and do not provide a formal diagnosis. However, in practice, emotional distress is related with disability and poor social functioning 28 . Individuals with sub-threshold depression and anxiety are frequently seen in primary care 43 and some researchers suggest that these conditions are important contributors to overall impairment and high service utilization 44 . It is very important to measure and identify probable cases at risk of developing formal psychiatric disorders. It is justifiable to use the concept of common mental disorders, which encompasses emotional distress with vulnerability and recovery 29 , and does not exclusively focus on categorical classification such as depression and anxiety. Discussing the possible implications of the results of this study to the delivery of care to the Brazilian population is one of the most important consequences of the results we have found. With over half of all adults attending primary care being classified as having probable common mental disorders, health policies must be developed to address this public health problem, which differ substantially to the patients usually attending specialized units that have been the emphasis of mental health planning in recent years in Brazil. First of all, it is important not to see common mental disorders as only categorical diagnoses, but as possible risk factors for the development of more severe disorders 46 . Despite some possible biases about high common mental disorders prevalence proportions as over reporting or diagnosing self limited cases, family health teams must be aware of the extent of psychosocial problems in order to take an integrated care approach. Studies have demonstrated evidences of cost-effectiveness and efficacy of psychosocial interventions for common mental disorders in low and middle income countries 45 , but implementing these interventions and developing confidence and skills in primary care professionals is challenging. Training and education programs for primary care professions need to be introduced together with structured pathways and network support services 42 . Education strategies must involve additional competencies other than simply diagnosing and managing medication in common mental health disorders 46 . The strong association of emotional distress with psychosocial variables suggest that psychosocial interventions may help in supporting these patients. Involving other primary care professionals may help teams identify cases 17 . Supporting professionals should be available in order to help primary care professionals manage common mental disorders and more severe problems. Recent evidence demonstrated the effectiveness of primary care-specialist collaboration 47 . In Brazil, matrix support introduced this collaborative model, but the support of specialists must be made accessible to all primary care teams and shared care coordinated by appropriate management 48 . Finally, policy-makers must make efforts to reduce economic inequities and implement educational and public safety policies to overcome the vicious circle of poverty, urban violence and mental disorders, acting directly for promoting human wellbeing. --- Conclusion This study reports high levels of probable mental health problems among four state capitals and identifies associations between sociodemographic characteristics and mental health problems in primary health care. Considering the moves the Brazilian government is making towards the development of primary care and the reform of its mental health policies, it is very relevant to consider common mental disorders as a priority alongside other chronic health conditions. Establishing comprehensive care at primary care level and integrating health services are relevant steps to achieving equity in the Brazilian national health system. Cad. Saúde Pública, Rio de Janeiro, 30:623-632, mar, 2014 --- Resumen Los problemas de salud mental son comunes en la atención primaria y están relacionados con la ansiedad y la depresión. Este estudio tiene como objetivo evaluar las tasas de trastornos mentales comunes y sus asociaciones con las características sociodemográficas de los usuarios de la atención primaria. Se trata de un estudio multicéntrico, transversal, con usuarios de Río de Janeiro, São Paulo, Fortaleza y Porto Alegre, Brasil. Se utilizó el General Health Questionnaire y el Hospital Anxiety and Depression Scale . La tasa de trastornos mentales en pacientes de Río de Janeiro, São Paulo, Fortaleza y Porto Alegre fueron, respectivamente, 51,9%, 53,3%, 64,3% y 57,7%, con diferencias significativas entre Porto Alegre y Fortaleza. Los problemas de salud mental fueron especialmente altos en las mujeres, desempleados, personas con bajo nivel educativo y quienes tienen bajos ingresos. Teniendo en cuenta los esfuerzos del gobierno brasileño para el desarrollo de la atención primaria y las políticas para la reorganización de la salud mental es importante considerar los trastornos mentales como una prioridad junto a otras afecciones crónicas. Trastornos Mentales; Salud Mental; Atención Primaria de Salud Contributors D. A. Gonçalves contributed to the methodological design, statistical analysis and writing of the paper. J. J. Mari contributed to the methodological design and writing and revision of the paper. P. Bower, L. Gask and C. Dowrick contributed to the methodological design and writing of the paper. L. F. Tófoli contributed to the methodological design, data collection and writing of the paper. F. B. Portugal contributed to the data analysis and writing of the paper. D. Ballester contributed to the study design, data collection and revision of the paper. M. Campos contributed to the methodological and study design, data interpretation, statistical analysis and revision of the paper. S. Fortes contributed to the study design, data collection and revision of the paper.

Mental health problems are common in primary health care, particularly anxiety and depression. This study aims to estimate the prevalence of common mental disorders and their associations with socio-demographic characteristics in primary care in Brazil (Family Health Strategy). It involved a multicenter cross-sectional study with patients from Rio de Janeiro, São Paulo, Fortaleza (Ceará State) and Porto Alegre (Rio Grande do Sul State), assessed using the General Health Questionnaire (GHQ-12) and the Hospital Anxiety and Depression Scale (HAD). The rate of mental disorders in patients from Rio de Janeiro, São Paulo, Fortaleza and Porto Alegre were found to be, respectively, 51.9%, 53.3%, 64.3% and 57.7% with significant differences between Porto Alegre and Fortaleza compared to Rio de Janeiro after adjusting for confounders. Prevalence proportions of mental problems were especially common for females, the unemployed, those with less education and those with lower incomes. In the context of the Brazilian government's moves towards developing primary health care and reorganizing mental health policies it is relevant to consider common mental disorders as a priority alongside other chronic health conditions.

Introduction Occupations are defined as valued daily activities, performed with a specific purpose and meaning, that are impacted by one's culture and factors internal and external to the person [1]. It is common for individuals to overlook the significance of participation in everyday occupations until the ability to do these activities is lost or altered. Individuals who have faced any type of challenge in their lives, including physical, may not be able to independently engage in desired occupations [2]. When individuals have deficits in completing day-to-day occupations, assistive technology is a tool that may be utilized to aid individuals in engagement [3]. According to the Technology-Related Assistance for Individuals with Disabilities Act of 1988 [4], AT is "any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. AT service is directly assisting an individual with a disability in the selection, acquisition, or use of an assistive technology device." The use of AT devices and services can help individuals to regain independence and function in various aspects of life [3,5,6]. Service dogs perform a variety of tasks that can maintain or improve functional capabilities of the individuals with whom they work. Service dogs can be trained to help individuals with mobility impairments engage in occupations such as assisting to propel wheelchairs, opening doors, retrieving dropped items, providing balance, and conserving energy. Camp [7] reports that service dogs are used to enhance independence in occupational performance areas and to contribute to improvements in psychosocial functioning; "given these benefits, service dogs could be used as a form of assistive technology under the Technology Act in that they also are 'used to increase, maintain, or improve functional capabilities of individuals with disabilities'" . Similarly, Shintani et al. [8] found positive effects of service dogs on various aspects of health-related quality of life, as measured by the Medical Outcomes Study 36 Item Short-Form Health Survey Version 2.0 . The researchers concluded that they " . . . hope that this research will encourage more therapists to acknowledge service dogs as a new assistive technology, and to consider the recommendation of service dogs, under the right circumstances, for the people with physical disabilities they work with" . It is clear that service dogs can assist persons with mobility impairments to engage more fully in valued daily occupations [8][9][10][11][12][13]. Prior research has verified the positive impact of service dog ownership on various aspects of health, quality of life, and social participation. For example, a study by Hall, MacMichael, Turner, and Mills [14] found that, when compared to persons on a wait-list for a service dog, persons partnered with a service dog had significantly higher scores on an assessment of quality of life. In particular, the researchers reported that those with service dogs had higher scores on areas related to socialization and engagement in educational, volunteer, and work activities. Similarly, the results of a randomized controlled trial by Allen and Blascovich [15] concluded that among persons with severe disabilities affecting ambulation, service dog partnership resulted in improved psychological, social, and educational/vocational functioning, as well as a decrease in the number of hours of paid/unpaid assistance required. Furthermore, the results of research by Lane, McNicholas, and Collis [16] suggested that service dog partnership is associated with increased social interaction and improved self-perceptions of health. A longitudinal study by Guest,Collis,and McNicholas [17], focused specifically on persons who were deaf or hard-of-hearing, found that partnership with a hearing dog had positive impacts on psychological well-being , as well as social interaction. While prior research has demonstrated the positive impacts of service dogs on social interaction, psychological well-being, and self-perceived health, there is a limited body of qualitative research specifically examining how service dogs impact engagement in occupation among individuals with mobility impairments. Studies conducted by Camp [7] and Fairman and Huebner [13] provided preliminary research supporting the idea that service dogs can assist with performance of occupations. However, Camp indicated that there was a need for further research regarding how assistance dogs compare to an individual's prior form or forms of AT. In a literature review conducted by Winkle, Crowe, and Hendrix [11], it was concluded that additional qualitative studies should be conducted to examine the meaningfulness of service dog use, and provide comparison of previous AT with current service dog use. Furthermore, as stated by Shintani et al. [8], additional research is needed to assist rehabilitation professionals in understanding the impacts of service dogs on the daily performance of those with disabilities, and grasping the potential role of rehabilitation professionals in working with persons who may benefit from service dog partnership. The purpose of this qualitative descriptive study was to learn how service dogs impact engagement in occupation among persons with mobility impairments that affect gait or balance, as well as their experiences utilizing a service dog as a form of AT. This study built upon previous research by exploring, from the owners' perspectives, how their service dogs influenced their engagement in occupations inside the home and throughout the community, and how their service dog compared to AT used in the past. --- Materials and Methods This study utilized a qualitative descriptive research design involving interviews with four participants. This approach allowed the researchers to learn about each participant's engagement in occupation while partnered with a service dog, and how their experiences with their service dog differed from their experiences with various types of AT. All subjects gave their informed consent for inclusion prior to participation in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Saginaw Valley State University Institutional Review Board . Participants were obtained through convenience sampling and snowball sampling. Recruitment flyers containing information about the research study were distributed to clients of one organization that trains service dogs. A total of four persons who met the inclusion criteria volunteered to participate in the study. The population for this study consisted of English-speaking adults over 18 years of age with a mobility impairment. Participants were required to have been partnered for at least one year with a service dog trained by the organization ). The service dog had to assist them with completion of activities of daily living ; and instrumental activities of daily living . Data was collected through in-depth, semi-structured phone interviews which lasted for approximately one hour. A structured interview schedule, consisting of three core questions was used to guide each interview. Questions were developed based upon the main areas of focus of the research study, which included the impact of service dog partnership on individuals' engagement in occupation; comfort level going into the community with their service dog; and their feelings regarding working with a service dog as a form of AT. All participants were allowed to speak for as long as they felt necessary to fully respond to the presented questions. All interviews were transcribed for data analysis, which was completed through a process of open, axial, and selective coding, as described by Patten [18]. Open coding was used to identify common ideas expressed by all participants in interviews; these shared ideas were given a descriptive label . Axial coding was used to condense the number of categories identified during the open coding process, by combining categories sharing similar ideas. Finally, selective coding was used to further condense the number of categories identified during the axial coding process, and identify core overarching ideas identified by participants. Triangulation of researchers, member checking, and peer examination, as described by Krefting [19], were utilized during the research process to enhance trustworthiness of reported results. --- Results A total of four females volunteered to be interviewed for this qualitative descriptive study. Following analysis and coding of the data, four broad themes appeared. All participants expressed that their service dogs had made significant impacts on their daily lives and their abilities to independently perform everyday occupations, and had characteristics that made them unique from prior forms of AT used in the past. --- Value of Service Dogs as a Form of AT The first broad theme expressed by the participants was that service dogs provide valuable assistance in the completion of everyday activities within the home and community. The support that service dogs provide, as a form of AT, allows handlers to engage in everyday occupations more independently. The participants explained that because of the assistance they receive from their service dog, they can perform tasks more safely, conserve energy, and require less help from other people while performing daily occupations including bathing and showering, dressing, functional mobility, personal hygiene and grooming, and toilet hygiene. P2 described how her service dog is extremely helpful in assisting with her daily task of dressing: " . . . When I get ready for bed at night, all I have to do is kick off my sneakers and [my dog] picks them up and puts them away, she knows where they go. And if, like, the next morning I'm someplace else in the house, and ask her for my sneakers, she will go get them and bring them to me." All participants stated that one of the biggest assets of owning a service dog is the dogs' ability to assist with functional mobility, including transferring, reaching to the floor, ascending and descending stairs, and carrying items. Additionally, the participants described how their service dogs help them in more complex daily activities such as doing the laundry, shopping, meal preparation, traveling, and performing work-related tasks. For all participants, the assistance provided by their service dogs allowed them to continue to engage in valued habits and routines. All participants stated that their service dogs impact their safety both at home and in the community, which in turn impacts the abilities of themselves and/or loved ones to engage in various activities in the community. For example, when talking about her service dog, P1 stated that: "I couldn't tell you how many times [my dog] has kept me from falling. If I lose my balance, she plants her feet like a rock and doesn't move . . . so I feel very safe. My husband, that was one of the things he remarked from the get-go was that it made him feel so much better with me being home alone . . . [because] she was there [and] because she takes care of me." P4 commented how having the constant support of her dog has enabled her to go outside alone: "Before I got [my dog], I never went outside by myself unless someone was coming to pick me up. Once I got her, I had to go out alone because she needed to play. I realized how good it felt to go outside on my own. I actually started going outside on nice days to just sit and read for my classes. I also got out of my wheelchair and sat in the grass because I knew she could help me back into my wheelchair when I was ready to go." Because of the assistance and support provided by their service dogs during completion of daily occupations, the participants reported an increase in their energy level and safety, and they ultimately came to rely less on others for everyday needs. --- Impact of Service Dog Partnership on Community Integration The second theme that emerged focused on how participants' service dogs impacted their experiences in the community. Responses were broken down into two subthemes: positive situations in public, and challenges which led to the education of others. --- Positive Situations in Public All participants noted that their service dog made them feel like they could go out into public more. While visiting public places, they felt a sense of security because the service dog was solely focused on the handler's well-being. Participants discussed that with their service dog by their side they felt that they could participate in more social situations as well. Many common anxieties about going into public that were experienced by the participants diminished when they had their service dog by their side. P3 described how her partnership with her dog gave her the confidence to go into the community without relying on other people's assistance: "[My dog] helps me get things done without having to ask people all the time. I don't have to hold my husband's hand all the time when I can't walk. I can do things by myself. For the first time ever, last year I was able to go swimsuit shopping by myself in the mall because I had [my dog] as a counter balance and as an alert dog so I knew I was completely safe. I knew I could do it all by myself." All participants reported feeling more confident and competent going into community settings with their service dogs by their side to retrieve items, assist with transferring, opening and closing doors, and help with any other necessary tasks. --- Challenging Situations and Education of Others in Public While going out in public with a service dog it is common for others to want to pet, stare at, and ask questions about it. All participants reported that they often must educate others that the service dog is working and should not be distracted from his or her work. Participants alluded that it is common for them to be stopped while they are out; as P1 describes: " . . . for the most part its usually positive, it can be a little tiresome repeating a million questions . . . what's that thing on her back and . . . what does she do for you and why do you have that thing on her back, that looks heavy . . . " Unfortunately, not all community business employees are as receptive of service dogs as others or understand what it is doing for its handler. As described by P1, service dog teams may face challenges even in businesses they frequently visit: " . . . well one morning I went in and [my dog] went to go do the 'go pay' and it was a young kid . . . all of a sudden it was 'ah I'm not touching that money that dog doesn't even belong in this place'." This situation led to the education of the employee, the business, as well as other residents and other businesses in the community. The participants expressed that some social settings present challenges. Often when people do not know how to respond appropriately to an individual with a service dog, misinterpretations can occur. However, the participants discussed how they have learned to provide education to people who may not understand the role of a service dog. --- Comparison of Service Dogs versus Other Forms of AT --- Adaptability of Service Dogs The third theme focused on benefits and drawbacks associated with obtaining and maintaining service dogs versus other forms of AT. Participants reported that each of their service dogs had learned to adapt to fit specific needs in different contexts to help maximize their handlers' independence, which was a significant benefit associated with service dog partnership. As P1 described: " . . . If its late at night [and] I need medication or just a snack or something . . . I will text down [stairs] and say 'hey . . . if I send [my dog] down will you get me a baggy of crackers or can you put two Tylenol in a Ziploc baggy or whatever and send it up for me?' . . . I send her, I say 'go take it' and then . . . she brings whatever I asked for up in a baggy." All participants expressed how they have developed ways of tailoring their service dog's skills to fit their individual needs. They valued the ability of their service dogs to adapt and change over time and felt that this was a valuable characteristic of their service dogs that they hadn't encountered with other forms of AT used in the past. --- Extra Effort and Expenses There are also potential drawbacks associated with the use of a service dog as a form of AT. For example, there are expenses associated with ownership and the upkeep of a service dog, which are not present with other forms of AT. The organization from which the participants in this study obtained their service dogs utilizes a sliding fee scale; clients are asked to pay anywhere from $1000 to $5000 towards the initial cost of their dog. Participants noted that there are also costs and effort associated with initial training, including travel to the training site/organization and community training outings. Participants also highlighted the multiple expenses associated with long-term service dog ownership, including vet care, food, grooming supplies, and toys. While the participants noted that their service dogs require extra work and expenses, they claimed that the benefits and support that they provide outweigh the additional work. --- Fluctuations in Performance of Service Dogs Service dogs are living creatures, and demonstrate fluctuations in daily performance that are not encountered with other forms of AT. All participants commented that they have learned to be prepared for these instances. P4 described how she handles these situations: "If I tell [my dog] to take something and she decides, for some reason that she doesn't want to take it, I can't take no for an answer . . . so I have to persist until she cooperates . . . so you know, in that way sometimes, what I think is a two second project, turns into a five minute ordeal [laughing]. And it's like, oh my goodness, I don't know if I had time for that." Since the handlers can never guarantee how a dog will react to all situations, they must learn to plan for them. P1 is familiar with these fluctuations in her dog's performance, and has modified some situations in which she asks her dog to complete task work: "Once in a blue moon, yea they get their 'attitude' . . . I don't give her anything glass because occasionally she gets an attitude where she'll just look at me and drop the bags and I don't give her eggs [laughing] at the grocery store for that same reason." The participants all stated that they had to learn to understand that their service dog is just that-a dog-and that they must be flexible and prepared for variations in the dog's performance, depending upon the day and situation. --- Value of Relationship with Service Dog The final theme that emerged focused on the value of the relationship formed with their service dogs, and how the presence of this relationship made service dog partnership preferable to the use of other forms of AT in many situations. Due to the constant companionship and interaction, strong bonds form between the handlers and their service dogs. P3's description of a situation in which she had to utilize a scooter highlighted the importance of the relationship between her and her service dog: "[My dog is] . . . just great at helping in general . . . I did use a scooter once, right after a seizure when I was in a [grocery store] . . . I tell you if I ever had to use something again I still think I'd just use the dog because they have an emotional substance to them that you just can't get from a walker or a scooter or a wheelchair... They just do so much more for you and they give much more to you when you're in pain; they feel it, and they try to help you so much and give you so much back that it is just so worth it." All participants reported that they have developed a strong relationship with their service dog because of their constant interaction. They noted that their dogs seem to understand them and their capabilities, and can respond as needed to provide appropriate assistance and support. For example, P2 expressed how well her service dog understands her physical tolerance level and knows when she needs to refrain from an activity: "She knows me better then I know myself, she'll tell me when I'm done . . . fatigued . . . [if] I try and get up and take a couple steps or something, she'll stand in front of me, not beside me." The participants disclosed how their service dogs have impacted their lives by providing a constant sense of security and support. They placed a high value on the relationship that they developed with their service dogs, and felt that the service dogs modified task performance based upon their current condition. Overall, participants felt that the handler-dog relationship was the key factor that made their service dog superior to other forms of AT used in the past. --- Discussion The results of participant interviews suggested that service dogs have had a positive impact on their handler's lives, and have allowed them to be more independent in daily occupations. Not only do the participants' service dogs aid in the performance and completion of ADLs and IADLs, but they have also been a constant source of support, and increased their handlers' participation in a variety of social contexts. Previous research has indicated that because assistance and service dogs possess the ability to assist persons with disabilities by improving their independence and participation in occupations, they can be considered an alternative form of AT [7,8,12,20]. The participants in the present study reported that they continued to use some forms of AT they had utilized before obtaining their service dog. Despite this, the participants identified that the service dogs, functioning as a form of AT, increased independence and participation in occupations for individuals with mobility impairments more than many other forms of AT available to them. Additionally, they recognized the value and importance of the relationship they formed with their service dogs in terms of helping them to feel secure in completing daily activities at home and in the community. For all participants, this relationship is what ultimately differentiated their service dog from other forms of AT utilized in the past, and what made service dog partnership superior to the use of other forms of AT in many situations. Interestingly, the participants in the present study identified the importance of personalization of service dogs to fit each handler's specific needs. This concept was not originally addressed in the research questions, but emerged during the participant interviews. All participants reported using their service dog in conjunction with AT devices that they were already using. However, they also expressed how they established specific, unique cues or gestures with their service dog to help their dog to best meet their own needs. Therefore, service dogs have the potential to offer evolving, customized assistance that individuals may not be able to obtain from other forms of AT. The results of this study indicated that there are significant benefits associated with the use of service dogs; however, there are factors unique to service dogs that must be addressed with persons considering this form of AT. In the present study, participants discussed the extra time, cost, and energy involved in grooming, feeding, exercise, and caring for their service dogs. They also noted that service dogs, as living creatures, demonstrate some fluctuations in performance that may not be seen in other forms of AT; they had to be prepared to work through these situations. Nonetheless, all the participants expressed how the benefits of owning a service dog surpassed the extra costs, time, and energy required. These are all factors that likely need to be considered when exploring the use of a service dog as a form of AT. The present study found that service dogs impact every aspect of their handlers' lives including participation in daily routines and occupations within the home and community. Occupational therapy practitioners concentrate on client performance in areas of occupation, including daily routines and occupations. It might be beneficial for occupational therapy practitioners to work more closely with service dog training organizations. Occupational therapists are trained to provide client-centered assessments and interventions to best meet each client's individual needs. Similar to findings reported by Shintani et al. [8] and Fairman and Huebner [13], the results of the present study suggest that therapists could work in collaboration with service dog training organizations to assist with the client assessment and education/training process. Several limitations were present within this study. A main limitation was the small sample size of only four Caucasian female participants. Additional information about participants was not gathered as part of the interviews, which may impact the generalizability of findings. All the dogs were trained through the same service dog training organization, leading to a lack of diversity of training and placement experiences. Additionally, the individuals who participated in this study described positive experiences with their service dogs. However, participants who may have had negative experiences might not have been motivated to participate in the study. Consequently, the results of the study are not necessarily generalizable to the greater population. --- Conclusions The purpose of this qualitative descriptive study was to learn how service dogs impact engagement in occupation among individuals with mobility impairments, and learn about experiences utilizing a service dog as a form of AT. After completing interviews with four female participants and analyzing the data, it was found that the participants' service dogs substantially impact their everyday lives. Service dog partnerships influence the participants' abilities to independently perform everyday occupations. Additionally, the relationship the participants formed with their service dogs provided them with a sense of increased security and support, thus encouraging them to be more active at home and in the community. The positive outcomes reported by participants indicated that service dogs could be recommended more as a form of AT for persons with mobility impairments. The use of service dogs as a form of AT by people with disabilities is an emerging area [11]. Additional research is suggested to examine "best practice" recommendations regarding the process of obtaining and utilizing a service dog. This suggests the need for more rigorous studies with a larger sample size, variance in gender, and a wider geographical range. --- Author Contributions: This manuscript was based on a research project completed by Rachel Csatari, Alyssa Kolanowski, Amy Londry, and Rachel Dawson as part of requirements for the Master of Science in Occupational Therapy program at Saginaw Valley State University. Ellen Herlache-Pretzer served as the faculty advisor and assisted with research study design and implementation and contributed to data analysis, interpretation of results, and final manuscript construction. Melissa Y. Winkle served as an advisor and conceived the initial focus and design of the research study and contributed to data analysis, interpretation of results, and final manuscript construction. Rachel Csatari, Alyssa Kolanowski, Amy Londry and Rachel Dawson completed research study design and data collection; they were active in data analysis, interpretation of results, and final manuscript construction. ---

It is becoming more common for people with disabilities to procure service dogs as a form of assistive technology (AT). However, there is little qualitative research examining the impact of service dogs on engagement in valued daily activities (occupations) among persons with mobility impairments. This study used a qualitative descriptive methodology to learn about the experiences of four female service dog owners with mobility impairments, with a focus on the impact of service dog use on the performance of daily occupations and participation in social activities, and their experiences utilizing a service dog as a form of AT. Data analysis indicated that each participant's service dog made a significant impact on their everyday lives and their ability to independently perform everyday activities; however, there are also unique challenges associated with service dog ownership that must be considered when evaluating benefits of service dog partnership. Overall, the positive outcomes reported by participants indicate that service dogs can be considered a beneficial, adaptable form of AT for some persons with mobility impairments.

To the editor The prodigious Greek philosopher Aristotle, with other renowned classical and contemporary thinkers, plausibly observed that the human person is by nature a social being, 1 or in the Aristotelian term, a political animal. As a social being or a political animal, man's sense of purpose is always intrinsically connected with the nature of socialization. In other words, the way a person deals with other human beings in the process of socialization defines how an individual creates meaning in relation to his own existence. Hence, socialization is important not only in the search of the human person for existential meaning but also for keeping himself psychologically lucid. Departure from this natural tendency of the human person to socialize and to participate in the existential discourse of society would tragically result into a certain feeling of dejection and anxiety. 2 In the case of the present situation that the society in general is currently facing, in the midst of the COVID-19 pandemic, this tendency to express oneself in the process of socialization has been pacified. Different governments across nations had implemented various forms of community quarantine just to prevent the widespread of the disease and the deleterious effect of the virus to different sectors of society. 3 The preventive measures of the government in controlling the spread of the virus while good in itself pose a danger not only on the mental health of individuals but also their socio-economic condition. These aspects-the mental health of individuals, relational aspect of the human person and the socio-economic condition of individuals are interrelated with each other simply because one aspect, respectively, affects the condition of the other two aspects. In the case of the social condition brought by the pandemic, many people across countries have lost their jobs when various businesses needed to be shut down because of the mandated quarantine or because of the lack of resources in funding their operation; if these businesses would not shut their operation they would consequently end up minimizing their overall operation cost by reducing employed personnel and shortened their production hour just to cope up with their monetary lost which, resulting to a sense of depression and anxiety on the part of those who are heavily affected -the ones who lost their jobs. This condition has left those people who have lost their jobs to spend their hard-earned savings to provide the basic needs of their families and think of practical ways to survive given the absence of a suitable job. The withdrawal from communal life and participation in social affairs certainly poses a threat to the socio-economic condition of an individual, which in return, would affect his own mental health. This proposition is true especially in the case of the most deprived ones in the social stratum, 4 leaving them more deprived and utterly vulnerable. However, in the midst of the catastrophic phenomenon that the general populace is currently experiencing, the natural tendency of the human person to socialize is still apparent. The pandemic or any forms of restrictions could not stop the human person's participation in the process of socialization, but instead, makes his yearning for the other person even stronger; the human nature to socialize could not be stopped by the pandemic simply because it is imbedded in his nature, and it is this same social setting that the pandemic brings gives sufficient reason for the human person to be connected to others, especially the suffering ones. Many people were moved into action in helping those who are deeply affected by the pandemic. The silent yet obvious cry of those afflicted by the pandemic serves as a force that enable many people to socializes in the spirit of fraternal charity with a profound hope to alleviate the suffering and replace it with a deep sense of hope for a better tomorrow. A hope that shines through the feeling of hopelessness that the pandemic brings. Fraternal charity seen in the process of socialization is a proactive advocacy and response to the anguish of the vulnerable. 5 While people suffer in this time of global crisis, the ray of hope coming from the natural tendency of the human person to socialize, done in the spirit of fraternal charity, is an assurance that humanity could withstand the disaster that threatens its very own existence. Who would have thought that the COVID-19 pandemic could bring out the best in many people to be a neighbor toward the other even if the situation requires corporal isolation? Who would have thought that the pandemic could result in a social paradox? ---

Government across all nations had promulgated precautionary measures in controlling the wide spread of the disease. One that takes precedence is the practice of community quarantine where people are mandated to stay at home and avoid going outside if is not utterly necessary. This mandate caused a lot of catastrophic outcomes in the socio-economic condition and mental health of many. Many people are in psychological and existential despair for the loss of their jobs and the isolation that they are experiencing. However, in the midst of this undesirable condition, the natural tendency of the human person to socialize is still present. Done in the spirit of fraternal charity, an individual's way of socialization gives hope to those who are in despair. The COVID-19 pandemic does not deter the human person to exercise his fraternal instinct but gives him sufficient reason to employ it all the more, creating the social paradox of human presence.

Introduction As income inequalities persist, and are even increasing in many countries [1], relative poverty affects many families. However, apart from small pockets of dire poverty, relative poverty in affluent countries does not mean absolute deprivation, but merely that the level of economic resources is distinctly lower than the average. In comparison with most other families, relatively poor families will command fewer economic resources and consume fewer goods and services. Relative poverty may nevertheless go hand-in-hand with an access to a material standard of living which, from a historical perspective, is fairly high. This is for instance the case in Norway, the setting of the present study. Using the European Union's definition of relative poverty, i.e., household-equivalized disposable family income below 60 per cent of the median [2], a 2003 Norwegian survey found that among families who qualified as poor according to this criterion, about 95 per cent had a washing machine, 95 per cent had a deep freezer, and around 80 per cent had a car, a personal computer, and a dishwashing machine. Lack of food and clothes were practically non-existent, and almost all had a fairly suitable dwelling [3]. Should this type of poverty be a health policy concern, in the sense that policy makers should seek a substantial reduction of relative poverty in order to improve population health? An affirmative answer to this question presupposes that relative poverty has a causal impact on health. Here this question is examined with respect to adolescents' health. As serious somatic disease rarely occurs in these age groups, other health-related indicators such as risk behaviours, overweight, and self-rated overall health may be more suitable for examining health inequalities among young people. In this paper the focus is on subjective health, i.e., on self-reported somatic and mental symptoms. We ask: Is living in relative poverty a cause of such subjective health complaints among adolescents? Diverging answers to this question are found in the literature. The Family Economic Stress Model [4][5][6] argues that economic hardship will result in family stress due to the mismatch between needs and resources. Family stress will trigger parental conflict, frustration, and hopelessness which affect the lives of the offspring and become manifested in higher levels of subjective health complaints. The Investment Model [7] suggests that lack of economic means could lead to a neglect of children's need for attention and support, because parents have to prioritize immediate material concerns. These two models differ in emphasis, but both assume a causal effect from economic resources to offspring's subjective health. This contrasts with accounts which regard associations between family economy and offspring's developmental outcomes as mostly spurious, a viewpoint forcefully put forward by Mayer's What Money Can't Buy [8]. In this book, the main narrative is that parents' personal characteristics which facilitate higher earnings are basically the same traits which create the secure and supporting family environment that promotes good subjective health among children. Thus, there is no important direct causal influence from relative poverty to offspring's subjective health. If these two are statistically associated, the reason is their joint origin in parental ability and dispositions. Certainly, both accounts are plausible. Restricted money resources may trigger quarrels between parents and harm family life with detrimental consequences for the offspring's subjective well-being. Moreover, it is likely that there will always be some parents who both have problematic economic careers and lack the personal qualities which promote subjective health among their children. Individual families exemplifying both patterns will probably be found in any empirical material, and a study of causality will help to establish which pattern predominates in a given population. Many empirical studies have demonstrated that families' relative poverty, as well as parental characteristics such as low education, unskilled occupations and unemployment, tend to be associated with less good health in the offspring. Examples can be found in the United States [9] and Australia [10], as well as in the Nordic countries [6,[11][12][13][14][15][16][17][18], Britain [19][20][21][22] and Germany [23][24][25]. Exceptions from the predominant pattern can also be found [26,27] and studies differ considerably with regard to design and variables, but overall, the results indicate higher levels of ill health among adolescents from low income families. To assess causality from these studies is rather difficult, however, as data well suited for causal analysis are often lacking [28]. With few exceptions [22], only cross-sectional data have been available, making the time-ordering of variables uncertain. Moreover, information about health and socioeconomic status has often been collected by survey answers from only one source-either from parents only, or from children/adolescents only. Therefore, statistical associations may sometimes be artificially produced because of variations in respondents' response styles; for instance respondents who give negative verdicts of all types of circumstances. In addition to these difficulties, it is evident that adolescents' subjective health is influenced by a number of other circumstances apart from the family's economic situation. A regular finding is for instance that subjective health complaints are more often reported by girls than boys [29]. Individual susceptibility will have a role, as will neighbourhood characteristics and school experiences [30]. Also, the choice of age groups could be consequential. The equalisation of health in youth thesis [31,32] suggests that socioeconomic variations in subjective health are practically absent in late childhood and early adolescence, before re-emerging when adolescents approach early adulthood. If so, data covering late adolescence are needed in order to detect a causal effect of relative poverty. This paper is an attempt to shed further light on these topics. Using longitudinal data material with information collected both from parents, from the adolescents themselves, and from public administrative registers, we make a causal analysis of the association between relative poverty and adolescents' subjective health, i.e., their reporting of various somatic and mental symptoms. We understand causality in terms of the counterfactual model [33][34][35]. This implies that we seek answers to what if-questions: If the relatively poor adolescents had not been poor; would their health have been better? Conversely, as regards the non-poor adolescents; would their health have been worse in the hypothetical case that they lived in relative poverty? Propensity score matching is employed in the analyses. As this method, although more and more used in causal analyses [36][37][38], is still not widely known, we first describe shortly some main aspects of this method [34,39,40] before we proceed to data description, analysis, and discussion. --- Causal Analysis by Means of Propensity Score Matching If we have reasonably valid data about families' economic situation and the offspring's subjective health, we can estimate how subjective health differs between adolescents in relatively poor and adolescents in non-poor families. However, this observed difference is likely to be different from a true estimate of the causal effect of relative poverty, because the samples of poor and non-poor families will probably differ not only with respect to economic resources, but also with respect to other circumstances which could be involved in the "production" of subjective health. Thus, the two samples are imbalanced: They are differently composed with regard both to their economic situation and to a number of other relevant characteristics. A solution to this problem is to try to eliminate the imbalance by constructing a matched control sample, i.e., to select, in the sample of non-poor adolescents, a subsample which corresponds as closely as possible to the sample of relatively poor adolescents with respect to all relevant circumstances. If this could be done perfectly, we would have two samples which differ only along the poor-non-poor dimension. In other words, we would have approached the balanced composition of the "treatment" group and the "control" group which is the aim of randomization. If so, the difference between the relatively poor and the matched non-poor adolescents would approximate the true causal effect. However, all data sets have limitations, and many circumstances, some of them unobserved, are likely to vary between the relatively poor and the non-poor adolescents. Therefore, it is practically impossible to construct a matched sample so that each relatively poor adolescent has a duplicate in the non-poor sample with exactly the same values on all relevant background variables. A way out of this difficulty is to construct a matched sample which is similar to the sample of relatively poor-not with respect to the specific values on a large set of variables, but with respect to the values on a single dimension: the probability of becoming relatively poor. This probability can be calculated for each individual in the entire sample, both among those who actually became poor and those who avoided poverty. This calculation is usually made by fitting a logit or probit regression model which includes all variables available in the data which could reasonably be considered as being part of, or related to, the trajectories and social processes which lead into relative poverty. The probability of entering relative poverty, calculated in this way, is termed the estimated propensity score. Causal analysis by means of propensity score matching implies that we try to remove the imbalance between the samples by selecting a control sample which has the same distribution of estimated propensity scores as the sample who actually was exposed to relative poverty. The method rests on the assumption that a comparison of units with equal propensity scores can effectively substitute for a perfect multidimensional matching on the observed variables [41]. With two samples which have identical distributions of propensity scores, the desired balance with respect to confounding variables can be achieved, and the difference in outcome will therefore approximate the true causal effect of being exposed to relative poverty. Thus, matching by estimated propensity scores may remove the imbalance between the two samples with respect to the observed variables. However, the technique does not provide a guarantee against bias arising from unobserved variables [42]. Matching by propensity scores does not avoid the problem posed by unobserved heterogeneity, but the method is a useful tool when we try to estimate causal effects in observational data. In comparison to regression techniques, matching by estimated propensity scores can have some advantages [34,35]. For instance, the adjustment for confounding factors achieved through conventional multivariate regression will usually rest on assumptions about linearity and additivity. In contrast, matching in general, and propensity score matching in particular, is a non-parametric strategy which can be used without making assumptions about the functional form of the associations, or about the presence of interaction effects between the control variables. Multivariate regression analyses will often lead to inferences based on extrapolation outside the range of the observed data points, while matching by propensity scores can avoid this difficulty. While regression analyses often imply that an explanatory variable has "an invariant, structural causal effect that applies to all members of the population" [34], propensity score matching is a convenient tool for examining how effects differ between various subcategories in the sample. --- Data, Variables, and Statistical Analysis --- Data and Analyzed Sample Data come from the project Children's level of living-the impact of family income conducted at Norwegian Social Research and co-financed by Norwegian Women's Public Health Association [43,44]. Statistics Norway was commissioned to obtain personal interviews with a sample of families with children, in three interview waves 2003-2009. Information from Statistics Norway's educational register and taxation register has been linked to the sample by means of the personal identification number. Data were made available for research after being anonymized according to the regulations of the Norwegian Data Inspectorate. In this study, adolescents born 1991-1993 are analyzed, because this birth cohort was asked about subjective health both in the 2009 interviews when aged 16-18, and in the 2003 interviews when aged 10-12. This enables analyses both of the level of subjective health in late adolescence and of changes in subjective health during adolescence. As late adolescence often will be a critical period with far-reaching consequences for adult life, a focus on this life phase is particularly interesting. A supplementary reason for examining this age category was that socioeconomic variations in subjective health may be easier to detect among 16-18 years old than among younger adolescents [31]. Altogether, 557 adolescents born in 1991-1993 participated both in the 2003 and 2009 data collection waves. Among them, 510 gave complete answers to the subjective health questions in both years, and these 510 adolescents are analyzed in the present study. Although random sampling from population registers was utilized in the upstart of the project, the sample analyzed in this paper cannot be considered a representative sample of Norwegian adolescents born in 1991-1993, mainly because of sample attrition. Of those who originally were included in the gross sample, only 38 per cent were interviewed in 2009. Moreover, the sample was first divided into one subsample drawn randomly from the 2000 population register among all families with children, and another larger subsample drawn randomly among families with children who had low incomes in 2000-a particular purpose of the project was to study living conditions among low-income families with children. In the present study, these two subsamples have been pooled, which can be justified as the data collection procedure was identical in the two subsamples. Moreover, upward income mobility has been substantial in the low-income sample, resulting in quite diluted economic differences between the two subsamples in 2009. The topic of the present study is not to make precise estimations of the overall life situation among Norwegian adolescents aged 16-18, but to analyze possible causal effects of relative poverty. This purpose may be obtained fairly well even though the analyzed sample deviates somewhat from a fully representative sample. A population register analysis of all families with children in Norway in 2007 [45] suggests that the sample analyzed in the present study has some low income bias, but higher income strata are well represented as nearly 40 per cent of the sample had equivalized incomes above the national median in 2008. --- Measurements of Subjective Health and Relative Poverty The measurement of subjective health in this study corresponds to the measurement used by the large cross-national project Health Behaviour in School Children [17,29]. Answers to eight questions, given in personal interviews, about frequency of headache, stomach pain, back pain, feeling low, bad temper, nervousness, dizziness and sleeplessness were coded from never = 0 to several times a week = 4 and added into an index. The index' theoretical range is from zero to 32. Two outcomes are analyzed in this study; the level of symptom burden in 2009, and the change in this burden from 2003 to 2009. While the health outcome was gauged by survey answers given by the adolescents themselves, the classification of the sample into relatively poor and non-poor was based on tax register data obtained from Statistics Norway. This ensures a more objective assessment of the family's economic resources than assessments based on subjective survey statements. The tax registers provided information, for each year 2000-2008, about the sum of all family members' post-tax income, and the sum of financial assets, i.e., the value of bank accounts, shares, and similar assets which swiftly can be converted into cash. Statistics Norway's registers were utilized in order to obtain information about each adolescent's family situation and how it changed because of new siblings, divorce, etc. In this way, a fairly precise measurement of each family's economic situation has been obtained for each year in the period under study. For all the 510 adolescents who had answered the questions about subjective health both in 2003 and 2009, the relevant tax register information was available. The tax register information was utilized for measuring the families' economic resources in a way which reflects two considerations. First, a family's real economic strength may be inadequately indicated by one-year snapshots or short-term fluctuations from year to year. Therefore, we have constructed a measurement which reflects the average economic situation during the years 2004-2008, i.e., the period between the interviews in 2003 and 2009. Second, as economic resources are not only income-related, but depend also on monetary supplies besides income [46,47], the measurement combines income information with financial asset information into one single scale. The measurement was calculated by adding the sum of all family members' post-tax income and financial assets for each year 2004-2008, dividing each year's sum by household composition weights , making adjustments due to changes in price levels , and finally averaging the equivalized and price-adjusted measurements across the five years 2004-2008. The mean value on this scale was Norwegian Kroner 406,000 ; the median was considerably lower , indicating the skewness of the distribution of economic resources. Drawing the line between relative poverty and non-poverty will be somewhat arbitrary. We chose to consider families with less than NOK 200,000 on average 2004-2008 as relatively poor. This "poverty line", about 70 per cent of the sample's median, resulted in classifying 109 out of the 510 analyzed adolescents as living in relative poverty during the years prior to 2009. --- The Estimation of Propensity Scores Causal analysis by means of propensity score matching starts with an estimation of propensity scores [34,39]. In the context of this study, this implies calculating the probability of being relatively poor in 2004-2008 for each individual adolescent in the sample. In general, all available variables-"as many predictors as possible" [35]-which could be involved in or associated with the families' entry into, or avoidance of, relative poverty, should be included in this estimation. The families' previous economic situation, the parents' employment activity, parental characteristics such as education and health, family structure, and family size, are examples of variables which are likely to be associated with the probability of being relatively poor. We The adolescents were classified as living with both parents, with a single parent, or in a stepfamily, i.e., living with one parent and his/her new partner. Variables about overall self-assessed health among the adults in the family in 2003, and the interviewed adult's mental health in 2003, were also made with information from the 2003 interviews with one of the parents. In the estimation of propensity scores, we also added a variable indicating subsample belonging . Categorical variables were indicated by dummy variables in the model. Missing values on the variables used for estimating propensity scores were generally few ; these were replaced by the sample's median value in order to preserve all the 510 adolescents for further analyses. The propensity score estimation was made by a probit regression model , and the resulting coefficients were recalculated into probabilities assigned to each adolescent in the sample. STATA version 11.2, with the software psmatch2, was used for these estimations [40]. --- Estimating Counterfactual Effects by Radius and Kernel Matching Estimated propensity scores can be utilized in further analyses in several ways, for instance as a stratifying tool [34] or as a covariate in OLS multivariate regression [35]. In this study, we utilize more advanced techniques: Radius matching and Kernel matching. These two methods are variants of the matching algorithms included in STATA's software psmatch2 and recommended in the literature [34,39,40]. We chose to use two different techniques; our sample is restricted in size and results may be subject to random errors, and alternative estimation techniques may provide a robustness test of the findings. Below we describe a few main aspects of these two techniques. The assumption underlying propensity score matching is that two samples with identical distributions of estimated propensity scores will be balanced with respect to a number of possible confounders. The matching sample serves as a basis for the estimations of counterfactual effects; the outcome value in the matching sample is likely to indicate what the outcome value would have been in the exposed sample, in the hypothetical situation that exposure to the assumed causal factor had not taken place. It is not unproblematic, however, to construct a matching sample. For instance, as the estimated propensity scores, i.e., the probability of becoming relatively poor, constitute a continuous scale, there will often be instances where no exact match can be found. An adolescent in the sample of relatively poor may for instance have 0.333 in propensity score, while among the non-poor, it could easily happen that no one has exactly this score, but fairly close scores are present, for instance in the 0.28-0.32 range or the 0.34-0.37 range. Which non-poor adolescents should be included as matches, and how should the matches be weighted? Matching algorithms provide different techniques for handling these questions. In Radius matching, the selection of matches among the non-poor adolescents are restricted to those with propensity scores within a certain range, defined by a caliper value. Thus, if an adolescent exposed to relative poverty has propensity score 0.333, and the caliper value is set to 0.02, adolescents in the non-poor sample with propensity scores in the 0.313-0.353 range will be selected as matches. If no matches are found within the specified range, the exposed unit will be excluded from further analyses, because inclusion would threaten the comparability between the two samples. A small caliper value will result in very similar distributions of propensity scores which may improve the estimations of counterfactual effects. However, more sample units will be excluded which may threaten the validity of the estimations, and if the analyzed samples become too small, random errors may increase. A larger caliper value will, on the other hand, keep more sample units in the analyses, at the cost of more differences between the two samples in the distribution of propensity scores. In our estimation by means of Radius matching, we used caliper value 0.02, which provides a fair balance between the number of cases kept in the analysis and the similarity in propensity score distributions. In Kernel matching, the value stipulated for bandwidth serves the same purpose as the caliper in Radius matching, i.e., designating what cases are to be included in the matching sample. When using Kernel matching, we chose bandwidth value 0.03 in order to check whether the pattern of results remained when more cases were included in the analysis. With Kernel matching each unit included in the matching sample is weighted in proportion to the distance in propensity scores between the exposed unit and the matching units. Propensity score matching facilitates the estimation of whether effects differ between various subcategories. Here, two types of effects are estimated. The Average treatment effect on the treated refers, in this paper, to the estimated effect of relative poverty on subjective health in the sample of relatively poor . Correspondingly, the Average treatment effect on the untreated refers to the hypothetical effect of relative poverty on the subjective health among those adolescents who were not poor during 2004-2008. These two effects may be different for several reasons. It could happen, for instance, that the average effect of relative poverty among the relatively poor is influenced by a higher exposure to deprivation in a more general sense. Conversely, the counterfactual effect of becoming relatively poor among those adolescents who actually were not poor, might be less severe if neutralized by a generally more favourable life situation. We have utilized the calculations of T-values in STATA psmatch2 software in order to evaluate the statistical significance of the two effects. In order to broaden the basis for interpretations, we will, as mentioned above, analyze adolescents' subjective health not only by two different matching algorithms, but also by measuring subjective health in two ways; first, as the level of subjective health in 2009, and secondly, by taking advantage of the panel structure of the data and analyze change in subjective health from 2003 to 2009. The latter version has the advantage that it will approximate a removal of bias due to any stable unobserved characteristic that could have influenced subjective health at both time points. --- Results In the analyzed sample of 510 adolescents, the mean value on the subjective health index was 9.96 in the 2009 interviews when the adolescents were aged 16-18. The average change from 2003 to 2009 was +2.30 ; thus, overall subjective health complaints increased from early to late adolescence. Gender differences were considerable . In this study, however, the two genders will be analyzed together in order to preserve the size of the analyzed sample. This will not influence the estimation of the effects of relative poverty, since the proportion of girls in the two samples is quite similar. Table 1 shows the values for the outcome variables, separately for the relatively poor and the non-poor adolescents. Clearly, the relatively poor adolescents reported more subjective health complaints in 2009 than the non-poor adolescents . When using the conventional p < 0.05 threshold, the difference was statistically significant . Also, subjective health worsened more on average from 2003 to 2009 among the relatively poor; the mean value increased by 3.70, compared to 1.92 among the non-poor, and also this difference was statistically significant . Furthermore, Table 1 shows how the two samples differed with respect to the variables which were utilized in the estimation of propensity scores. The non-poor sample had experienced a better family economy before 2004, and their parents were mostly better educated than the parents of the relatively poor adolescents. The relatively poor adolescents had more often parents who were afflicted by health problems, they lived more often in one-parent families and/or in families with no employed adults, and they had more often a non-Western immigrant background. Table 1 illustrates the difficulties which have to be dealt with when trying to establish whether relative poverty, by itself, contributes to the higher level of subjective ill health among the relatively poor adolescents. Not only was the economic situation in the families of the non-poor much better; the non-poor experienced more advantageous environments also regarding a series of other life circumstances, such as the parents' educational level, employment, and health. The differences between the two samples are further demonstrated in Figure 1, which indicates how the estimated propensity scores, i.e., the probability of being relatively poor, were distributed in the two samples. Among those who were relatively poor, the mean estimated propensity score was 0.490 ; among the non-poor, the mean was 0.136 . Thus, both samples are represented across a wide propensity score range, but the shapes of the distributions are drastically different. The non-poor had fairly many with extremely low probability of being poor, while a few of the relatively poor adolescents had a probability of being poor exceeding 0.9. Figure 1 illustrates the large disparities between the two samples in their probabilities of becoming relatively poor, and this underlines the challenge for causal analysis since the two samples were so dissimilar as to many life aspects which could influence their subjective health. Nevertheless, Figure 1 also demonstrates that for most propensity scores levels, at least a few among the non-poor have propensity scores which are similar to the propensity scores of some of the relatively poor adolescents. There is therefore a considerable common support area, i.e., in the probability range from 0.033 to 0.893, both poor and non-poor can be found, which allows for using the matching techniques. We utilize the two methods described above-Radius and Kernel matching-for estimating the counterfactual effects of relative poverty. The results are given in Table 2. The estimated counterfactual effects of relative poverty among those adolescents who did not experience poverty during 2004-2008-termed the Average treatment effect on the untreated in section 3.4-are clearly weaker . The size of the effect on the 2009 level of subjective health does not seem negligible at first sight , but they are far from statistically significant. Regarding change in subjective health during adolescence among the non-poor adolescents, the estimated effects indicate that for this category of adolescents, the impact of a hypothetical exposure to relative poverty would have been practically nil. --- Discussion --- Main Results and Interpretation This study has asked whether relatively poverty in contemporary Norwegian society is detrimental for adolescents' subjective health, which was measured by their reporting of somatic and mental symptoms. The findings indicate that for adolescents who lived in relatively poor families, the economic situation in their families had a negative effect on their subjective health trajectory during adolescence from age 10-12 to age 16-18. Also the results regarding the level of subjective health when these adolescents were 16-18 years old, suggest a similar conclusion about some negative effect of limited economic resources in the adolescents' families, although this latter effect was weaker. This study has employed statistical techniques which aim at neutralizing the confounding influence from other factors than the assumed cause. Caution must always be applied when drawing causal conclusions from observational studies. Nevertheless, the results are at least compatible with the hypothesis that among the adolescents who lived in relatively poor families, the restricted economic resources in these families contributed to the causal processes which led up to their less favourable subjective health situation in late adolescence. This conclusion can only be drawn for those adolescents who actually lived in relative poverty, however. For those adolescents who lived in families with economic resources above the relative poverty level, the counterfactual modelling utilized in this study could not reveal any potential negative health effect in the hypothetical case that these families had been exposed to relative poverty. Thus, the findings point towards a differentiated conclusion: For those adolescents who actually experienced relative poverty, their economic situation aggravated their subjective ill health; for those adolescents who were not exposed to relative poverty, it is not likely that their subjective health would have worsened if they actually had lived in relative poverty. A possible interpretation of this empirical pattern could take into consideration that relatively poor adolescents are often experiencing other disadvantageous circumstances apart from their families' economic situation. They are, for instance, more often living in single-parent families, they have often less educated parents, or parents who are out of work, or parents afflicted by health problems . The non-poor adolescents are less affected by such circumstances, which could mean that there are more protective factors in their environments which buffer against the potential detrimental health consequences of few economic resources in the family. Among the relatively poor adolescents, on the other hand, who more often lack such protective environments, relative poverty could add to their other disadvantages in a way which leads to deteriorated subjective health. Whether this occurs in line with the Family Economic Stress Model or the Investment Model [5,7] as discussed in the introduction, or through some other type of process, cannot be further pursued in this paper. How important are these effects on the subjective health of relatively poor adolescents? Certainly, an array of factors contribute to young people's subjective health. A family's economic situation, in the context of the contemporary Norwegian welfare state, is only one of many factors which could contribute to adolescents' symptom burden. It should nevertheless be noted that the results of this study suggest that if the relatively poor adolescents had lived in non-poor families, their subjective health development during adolescence would not deviate, on average, from that experienced by other adolescents. The observed difference between relatively poor and non-poor adolescents with regard to the deterioration in subjective health 2003-2009 was smaller than the effects for the relatively poor adolescent estimated by propensity score matching . The detrimental effect of relative poverty detected in this study seems therefore, in statistical terms, to account for the difference between relatively poor and non-poor in how subjective health developed during adolescence. --- Strengths and Limitations The data available for this study have several advantages. Information about subjective health has been obtained in personal interviews-not with proxy respondents, but with the adolescents themselves. Various other information about the adolescents' situation was collected from one of the parents, while the crucial independent variable in this study, families' economic resources, was constructed on the basis of register data which probably are more objective and valid than survey answers. The data were furthermore obtained from a prospective panel design, enabling a fairly certain time ordering of variables. Thus, these data avoid some of the sources of error which have plagued many youth studies [28]. Moreover, the causal analyses have utilized the techniques of propensity score matching, which arguably is a promising tool for social science when the purpose is to approximate estimations of causal effects in observational data [34]. A critical aspect of propensity score matching is the procedure for estimating propensity scores, i.e., the calculation of the probability of being assigned to the category exposed to the assumed cause. This study has had access to rich information which could imply that the estimated probabilities do not deviate dramatically from the true propensity scores. However, an inclusion of more predictors in this calculation-for instance variables indicating parents' personal characteristics, their social skills, and their previous working career-could certainly have improved the estimation of the propensity scores. Various limitations are also evident. Although the adolescents' families represent many levels of economic circumstances, we cannot reject the possibility that the self-selection of respondents which occurs in interview surveys has resulted in a sample bias which could influence the results. Sample attrition has been substantial, and the analyse have been performed on a sample which is restricted in size. This is clearly a source of uncertainty. Moreover, the results from the two utilized propensity score matching techniques are not identical. Deviating results may occur in small samples because the techniques vary in terms of what units are included in the matching samples. The basic similarity in the results from the two matching techniques gives however some credibility to the main findings. Still, the propensity score matching technique cannot overcome the basic problem affecting all causal analyses based on observational studies: The potential impact of unknown, unobserved, variables. Generalizing the results of the present study to the situation in other countries would imply assumptions which are difficult to assess. The Norwegian case, with its special economic, political, and cultural situation, could be special. Similar studies in other settings are needed in order to examine whether the effects on relatively poor adolescents' subjective health which were detected in this study, correspond to similar effects in other countries. --- Conclusions Living in families with a limited access to economic resources, in the contemporary Norwegian social context, appears to have detrimental effects on the development of subjective health during adolescence among those adolescents who are exposed to relative poverty. In families with more economic resources, it is likely that better access to other advantageous environments buffers against the potentially detrimental health effects of relative poverty. The results indicate that inequalities in families' economic resources contribute to the health inequalities among Norwegian adolescents. --- Conflicts of Interest The authors declare no conflicts of interest.

Studies have revealed that relative poverty is associated with ill health, but the interpretations of this correlation vary. This article asks whether relative poverty among Norwegian adolescents is causally related to poor subjective health, i.e., self-reported somatic and mental symptoms. Data consist of interview responses from a sample of adolescents (N = 510) and their parents, combined with register data on the family's economic situation. Relatively poor adolescents had significantly worse subjective health than non-poor adolescents. Relatively poor adolescents also experienced many other social disadvantages, such as parental unemployment and parental ill health. Comparisons between the relatively poor and the non-poor adolescents, using propensity score matching, indicated a negative impact of relative poverty on the subjective health among those adolescents who lived in families with relatively few economic resources. The results suggest that there is a causal component in the association between relative poverty and the symptom burden of disadvantaged adolescents. Relative poverty is only one of many determinants of adolescents' subjective health, but its role should be acknowledged when policies for promoting adolescent health are designed.

"Recently, a reality TV show featuring fatherchild interactions has sparked a heated debate about father involvement in family education. As more and more men among the Post-70s or the Post-80s generation become fathers, many traditional beliefs and practices in child upbringing start to change. Fathers have become more involved in family education in China." Correspondence concerning this article should be addressed to Hsiu-Zu Ho, e-mail: [email protected] "I argue that the [television] series [Where Are We Going, Dad?] is an ideal cultural site to witness the discourse of the changing parenting practices and gender roles in contemporary China". Adapted from a South Korean reality show, the Chinese version Where Are We Going, Dad? has gained huge popularity in mainland China ever since it premiered in October 2013. The show depicts the everyday interaction of five celebrity fathers with their children during a three-day countryside excursion. It ranked as the top Chinese TV show within two months after its first episode aired and spurred more than ten million comments on Weibo , igniting "a popular debate not only on parenting but also on gender equality within the family" . The show has been popular not only in China, but in other Asian societies including Hong Kong, Singapore, and Taiwan . The show has completed its sixth season, attracting undiminished attention nationwide. Its immense success had also inspired along the way the creation of its movie version and another reality TV show called Dad Is Back! that similarly depicts father-children relationship with a focus on mostly indoor activities in their daily family life. According to Yang , what has had viewers hooked to the show is the lens it provides into the "clash between the traditional and 'more progressive' views on parenting, specifically the role of the father." Yang notes that, after each episode, many avid users of the internet comment on Weibo, with regard to father involvement . For example, one netizen commented: "The real appeal of the show is that it teaches and prompts us dads to reflect on how to better communicate and interact with our kids" . Another wrote: "Endless work leaves me with little time with my kid. I have no say in the family right now because my kid only listens to his mom. After watching the show, I really feel the need to spend more quality time with my kid" . One father reported that a homework assignment of his elementary-schoolaged son was to view and write about his feelings towards the new hit movie version of the television show . The impact that this popular television series and movie is having on both the adult and younger generations of traditional patriarchal societies is of great interest and warrants further research . With the rapid change in the economic, political, social-cultural, and educational aspects in contemporary China, the influence that this popular television show has on the current beliefs and practices regarding parenting roles in this traditionally patriarchal society are of great interest but so far underreported. To address this gap in the literature and to further our understanding of parenting roles and involvement in Chinese culture, the present exploratory investigation examines the perspectives of mothers, fathers, as well as their third-grade children in a suburban area in China regarding their parenting role beliefs. These parenting role beliefs refer to attitudes and values about the gender-specific responsibilities mothers and fathers take on in the family's childrearing practices . Parenting role beliefs may not always reflect the actual behaviors and practices conducted in the home. Therefore, this research also compares the self-reported frequency with which mothers and fathers engage in various parenting activities . --- Sociocultural Context of Contemporary Chinese Society Chinese society is strongly influenced by the teachings of the ancient philosopher Confucius, who emphasized interpersonal harmony and relational hierarchy. The aspect of relational hierarchy delineates a strict order of authority and circumscribed social roles within the household. Particularly, Confucian patriarchal ideology considers women subordinate to men and emphasizes the father's roles in the family as head of the household and provider and the mother's role as nurturer and caretaker . These traditional gender role beliefs encourage women to manage household chores and raise children, thereby allowing men to concentrate on work outside of the home, as goes the old saying, "men are breadwinners; women are homemakers." While emotional support of children is traditionally the mothers' responsibility, in the home, fathers are tasked with setting boundaries, disciplining, and teaching children . The traditional Chinese father role is considered authoritarian-highly controlling and demanding of their children yet emotionally distant and uninvolved . Since the 1950s, the Chinese Communist government has enacted a series of policies that have made profound and swift societal impact. In its first decade of power, the Chinese Communist government announced less gender-bound, more egalitarian principles and offered equitable opportunities to women to be employed by state and collective firms . The Marriage Law of 1950 promoted equal rights between genders that allowed and encouraged women to choose their own romantic partners rather than be placed in traditional arranged marriages . As a result of those developments, Chinese women became more financially independent and less reliant on marriage as a means to economic survival . Related to the family unit, researchers have also noted the impact of China's family planning policy on family dynamics. Instituted in the 1978 to address societal and economic concerns, this one-child policy has had the effect of cultivating a more child-centered family culture, one in which both fathers and mothers invest greater time and attention on their children . --- Chinese Gender and Parenting Role Beliefs Modern society has increasingly required men to take on more responsibilities at home. An emerging body of international research across societies has demonstrated the importance of fathers' emotional and physical involvement with their children. Several studies have indicated father involvement to play an important role in predicting children's academic success and psychological well-being . Research conducted in Shanghai have indicated that fathers are trying to be more emotionally involved and physically present by doing more activities and communicating more with their children . Assessments of parenting styles in the metropolitan area of Shenzhen suggested the emergence of the supportive "panda father" archetype who uses less punitive and more reasoning strategies to manage their children's behaviors . There is evidence that Chinese fathers and mothers are in greater alignment about parenting styles . Other research has also indicated that urban fathers are actively engaged with their children, especially in play activities but also in caretaking activities such as feeding children, helping them wake up and go to bed, taking them to and from school, and comforting them when they are ill . Despite reports of increased father involvement in parenting practices, some studies have suggested that beliefs about gendered divisions of labor in parenting appear to change at a slower rate . Egalitarian perceptions can be defined as beliefs that parenting roles should not be separated by gender. Earlier research investigating the beliefs and thoughts about gender roles among the Chinese population have found that women held more egalitarian perspectives on gender roles and endorsed fewer traditional gender role perspectives than did men . Ito and colleagues' more recent investigation surveyed fathers in Beijing about childcare responsibilities and parental role beliefs. Although many report they do participate in childcare tasks, their paternal identities still revolve primarily around the roles of breadwinner, head of household, and teachermuch less so caregiver or supportive spouse . Explanations for this phenomenon have emphasized the intransigent nature of ideology. Wong argues that few parents will openly champion traditional Confucian values, but many still hold fast to genderstereotypical roles. The daily practices and adjustments related to parenting are easier to negotiate than gender ideologies and expectations between spouses . It is worth noting that parental role beliefs may vary depending on personal and environmental characteristics. Research suggests that employment status and education are positively related to egalitarian attitudes toward gender roles in China . The vast majority of studies on parental role beliefs are conducted in urban areas, but there is evidence that the level of industrialization and urbanization in the area affects gender ideologies. In more industrialized and urbanized regions, individuals tend to possess more egalitarian attitudes toward gender and parenting roles . Age also appears to play a part. In Tu and Chang's study, younger women tended to be less conservative and less in favor of the traditional division of labor compared to their older peers. Plans to delay parenting may also positively predict progressivism. In a study by Zhang who examined gender beliefs of college students, participants who anticipated delaying marriage and childbearing were more inclined toward egalitarian gender role viewpoints. While studies have observed the effect of age, too few have examined attitudes about gender roles in the younger generation. Parenting research is dominated by perspectives of mothers, much less so fathers, and far less often children. Zhang's work gains insights from the children's point of view, albeit from college-age adult children . We argue this paucity is a missed opportunity to investigate parental role beliefs from multiple perspectives. The present study was conducted to expand the literature on parenting role beliefs and students' academic performance and to fill the research gap about the influence of various factors, in particular popular media, on parenting role beliefs development. This study is also a chance to capture multiple viewpoints on family dynamics from both generations of parents and children-mothers and fathers, sons and daughters. A class of third-grade students and their parents were surveyed to answer the following questions: Do perceptions of parenting roles vary with gender; that is, Chinese mothers vs. fathers, and Chinese girls vs. boys? Do levels of parental activity engagement differ between mothers and fathers? Is student academic performance related to parenting role beliefs as well as to parents' level of activity engagement? Do various factors, in particular popular media, influence the parenting role beliefs of parents and their young children? --- The Present Study The present study surveyed 34 third-grade students , from a class in a public school located in a suburban area in Nanhai, Guangdong Province, China. Both mothers and fathers of the students also participated in the survey process. All participating mothers had completed at least high school, and the majority of fathers had completed four years of post-secondary education. Thirty percent of mothers and 100% of fathers worked a full-time job; 70% of mothers did not work. In addition, each household had, on average, two children with one third of the families having only one child. Historically regarded as a rural area, the suburban city of Nanhai, from which we drew our sample, has experienced rapid economic development in recent years. As the one-child policy has traditionally been less stringently upheld in rural areas, families in Nanhai have typically been allowed two children without incurring penalties, particularly when their first child was a girl. Moreover, with regards to household structure, 45% of parents reported living in a multigenerational household , while 55% of parents reported a nuclear family structure. See Table 1 for additional descriptive information on the participants. The Beliefs Concerning the Parental Role Scale was modified to assess gender role beliefs regarding parental responsibilities for our Chinese sample. The 25item survey elicited parent responses to address which parent is in charge of what childrearing tasks? Or are they equally engaged in certain tasks? Some examples of the items include: "When a child gets sick at school it is mom's job to leave work or find someone to take care of the child," "In general, the father should have more authority than the mother in deciding what extra-curricular activities are appropriate for the child". A five-point Likert scale was used for each of the 25 items . Survey items that are worded in a reverse direction were recoded prior to scoring. Similar to the parent questionnaire, a 25-item survey was also developed to assess gender role beliefs of young students regarding their perceptions of who should do what in particular parenting responsibilities. Utilizing Cronbach's alpha, the reliability coefficients for the 25 items were .91 for the parents' questionnaire and .78 for the students' questionnaire indicating a high level of internal consistency for these measures. Parents were also surveyed on the frequency with which they engaged in twelve specific activities, such as discussing social events, working on homework, discussing TV programs and movies, and playing games. The reliability coefficient, using Cronbach's alpha, for the parental engagement activity items was .78. In order to tap into potential factors that may influence participants' parental role beliefs, nine items were included in the survey asking participants to rate the amount of influence that individuals such as grandparents, parents, spouse/siblings and peers, neighbors or colleagues, past/current school curriculum, popular reality shows such as WAWGD, other types of media , and social network services where 1 = "no influence" to 5 = "extreme influence." All parent and student assessments were translated into Mandarin Chinese and then back-translated into English for verification. --- Results Results of dependent t-tests indicated no significant mean difference between the overall scores of mothers' and fathers' parenting role beliefs . With respect to the association between fathers' and mothers' parenting role beliefs, results of correlation analysis show a significant positive correlation = .84, p < .05) indicating that couples tended to have similar beliefs about "who should do what" in terms of caretaking tasks. Independent t-tests results similarly revealed no significant mean differences in parenting role belief scores between girls and boys. With respect to overall activity involvement of parents, no mean differences were found between fathers and mothers. Among mothers, age was negatively correlated with level of engagement activity = -.52, p < .05). That is, compared to older mothers in this study, younger mothers tend to be more frequently engaged in activities with their children. While the association of father's age with level of engagement was also in the negative direction, the correlation was not significant = -.21, p = .34). Correlation analysis revealed a significant association between children's class rank and children's own parenting roles beliefs = -.46, p < .05), indicating that the higher the child's academic ranking in the class, the more egalitarian the child's parenting role beliefs. Results also showed a significant association between mother's engagement and children's class rank = -.40, p < .05), indicating that the greater the mother's engagement in specific activities, the higher child's academic ranking in the class. The study further analyzed the influence of popular reality television shows on parents' parenting role beliefs and found that parents' perceived influence of such reality television shows was indeed positively correlated with their own parenting role beliefs = .57, p < .05; and for fathers: r = .68, p < .05). That is, the more the parents believed such television shows influenced their parenting role beliefs, the more their assessed beliefs were indeed egalitarian. Furthermore, students' perception of parental influence was positively correlated with students' own parenting role beliefs = .44, p <. 05); that is, the more children believed their parents played an important role in the development of their parenting role beliefs, the more egalitarian were their beliefs. --- Discussion The present study sought to address research inquiries related to parenting role beliefs and practices in contemporary mainland suburban China through multiple perspectives. The inclusion of mothers and fathers as well as daughters and sons provides a unique opportunity to compare and examine beliefs across genders and generations. To address our first inquiry, that there were no differences in parenting role beliefs between fathers and mothers in our findings provide support that suburban Chinese mothers and fathers may hold similar egalitarian parenting role beliefs. Second, the frequency with which fathers engaged with their children in various activities was similar to that for mothers. These results are consistent with a growing trend found in the more recent literature that, more and more, Chinese men and women are sharing responsibilities in the home domain . There was also a strong positive association between parenting role beliefs of fathers and mothers; that is, the more strongly mothers endorsed progressive gender role attitudes, the more likely fathers would also report such beliefs. This finding is not altogether unexpected since individuals tend to seek like-minded others in spousal relationships . Nonetheless, research on gender and parenting role beliefs have indicated more conservative views among Chinese men, while our finding suggests more congruent attitudes about parenting between spouses. These first three findings may speak to the impact of rapid societal and economic transformations on cultural values such that both genders report viewpoints and behaviors in favor of shared financial and household responsibilities. Our findings also suggest that the changes in parenting role beliefs may, in part, be a consequence of popular cultural media. Specifically, our results indicated that parents who believed television shows depicting progressive father roles were influential to their parenting beliefs were, on average, more likely to affirm egalitarian parenting role beliefs. Popular media is undoubtedly a reflection of sociocultural changes. Analyses have credited reforms such as the one-child policy with encouraging closer father-child relationships, like those seen on WAWGD . While exceptions to the one-child policy were made in suburban areas like the site of the present study, the impact of the policy in this community may be felt through media and cultural products. While this study sheds some light on the impact of popular media on the attitudes of parents in China, more research is needed to support these results. China's recent shift to a two-child policy presents promising opportunities to understand how policy affects the family unit and as well as how parenting roles play out in popular culture and in the home. Our interests also extended to the less frequently addressed topic of possible gender differences in parenting role perceptions among the younger generation. In addressing this question, we compared the overall parenting role beliefs scores of boys with girls and found that, similar to their parents, their attitudes about parenting behaviors did not significantly differ. These results are particularly encouraging because research has shown that adults feel pressured to conform to new gender role norms and expectations . Chinese parents may also be vulnerable to social desirability and inflate their responses to questions about parenting responsibilities. Young children, on the other hand, may be less susceptible to these demands and more inclined to report gender attitudes based on their own observations of parents' performance of social roles at home. As found in the present study, students who endorsed more egalitarian views tended to rate their parents as influential to their own parenting role beliefs. Therefore, these findings lend credibility to the notion that egalitarian gender ideologies are becoming more prevalent among young people in similar communities in China and may, in part, reflect the realities of their home environment as well as messages of popular media. Corroborating prior research on the effect of parents' involvement on students' academic performance , we found that parents' engagement in specific activities with their children was positively associated with children's school ranking. Our results suggest that children's beliefs are also linked to this indicator of academic performance; that is, the higher their class ranking, the greater the tendency for the students' parenting role beliefs to be more progressive. More evidence with other indicators of academic achievement is needed to determine the nature of the association: whether the relationship is causal or whether these constructs are a function of other factors, such as parents' level of education. If there is support for a causal relationship, it behoves scholars to explore the meditational processes by which gender and parenting role beliefs lead to educational outcomes. One limitation of the study relates to its context and sample. The suburban location of our investigations has both advantages and disadvantages. With most Chinese parenting research taking place in more urbanized areas, our research in Nanhai serves the purpose of expanding understanding of parenting ideologies and practices in different settings. Still, the location of the study coupled with its small sample size limits the generalizability of our findings. Future studies would benefit from testing these research inquiries in multiple urban, suburban, and rural environments and with larger sample sizes. Another limitation of this research is the self-reported nature of the data. As discussed, responses about gender and parenting role beliefs can be influenced by social desirability. Moreover, self-reports of parenting responsibilities and frequency of involvement can be inaccurate. Further research would benefit from behavioral documentation of activity involvement, similar to the time diaries parents kept in Chuang and Zhu's study. Still, the present study brings in a multitude of perspectives on parenting and gender role beliefs and suggests new links between these attitudes, academic ranking, and popular media, which show promise as avenues for future investigation. --- Appendix Parental Role Beliefs Questionnaire 1. A father should pursue the career of his choice even if it cuts into the time he has to spend with his family.

Recent research examining beliefs about gender roles among the Chinese population has shown that parenting roles are becoming less gender-bound in contemporary Chinese society. In the context of socioeconomic and political changes, fathers are becoming more engaged in their children's lives. As depicted in Chinese media (e.g., popular television shows and movies), father-children relationships in everyday family activities are being modeled. Utilizing a sample of 34 third-grade students from a suburban Chinese classroom, the present study investigated parenting role beliefs from multiple perspectives-those of students (distinguishing between boys and girls), as well as their parents (distinguishing between fathers and mothers). Results showed that parenting role beliefs did not significantly differ between fathers and mothers, nor between young male and female students. Children's academic ranking was found to be significantly associated with their own parenting role beliefs and their parents' engagement in specific activities. Furthermore, parents' perceived influence of watching popular reality television shows was positively correlated with their parental role beliefs. Additionally, parental influence, as perceived by students, was positively correlated with students' own parental role beliefs, such that the more children felt their parents played an important role in their parental role beliefs, the more egalitarian their beliefs.

Background Glaucoma is an ophthalmologic disease which is characterized by progressive visual field defect corresponding to excavation of the optic disc. [1,2] The number of patients who get medical service for glaucoma has been increasing sharply in the Korean society. [3,4] According to the claim data of Korean National Health Insurance and Health Insurance Review and Assessment Service , [5] the number of those who get medical care for glaucoma was 699,463 in 2014, 92.5% increase from 363,329 in 2007. What is more, severe glaucoma can lead to permanent visual impairments unless it is managed. Based on the WHO Global Data Bank statistics on blindness, [6] about 5.2 million people have blindness caused by glaucoma, which is about 15% of total blindness. Especially in Korea, HIRA data show that glaucoma is the most influential cause of visual impairments among all other diseases including diabetic retinopathy and retinitis. [7] Although it may cause immense loss to respective patients and severe burden to the society, its clinical progress can be controlled after a few examining procedures. [8,9] Several factors are known to affect the glaucoma, and socioeconomic status is one of the risk factors for glaucoma. The effects of other factors such as sex and age have also been studied in accordance with the effect of socioeconomic factors. [10] However, few studies have discussed about the socioeconomic status in the risk of visual impairments in developed Asian countries, [11,12] which have the real importance of studying glaucoma. Therefore, in this study, we checked the connection between socioeconomic status and the visual impairments caused by primary glaucoma, classifying according to the order of two incidents, a glaucoma diagnosis and an occurrence of visual impairments. In addition, we divided the research population into several subgroups by covariates of the insurance type and researched in the same way. --- Methods --- Data source We used National Health Information claims data from KNHI database from 2002 to 2013. Korean National Health Information contains cohort data including information on insurance claims for individual medical service, such as patient information, disease code, dates of the service, and the types of medical facilities. [13] These data can represent the whole Korean population since the 1,025,340 subjects included in the data are stratified random sample, and are selected from the total population based on the sex, age, income quintile, region, and health insurance type. Loss of the subjects by censored data is supplemented with newly sampled newborn babies. Based on the representativeness and stability of database, several researches are published using the database. [14,15] We conducted a cohort study of newly diagnosed glaucoma patients with medication to identify the connection between socioeconomic status and the visual impairment. --- Sample selection Among all the collected subjects in the database, 1728 with newly diagnosed primary glaucoma from 2004 to 2013 were selected. Patients with other types of secondary glaucoma such as trauma, inflammation, and drug-driven glaucoma were excluded. Those who have diseases that can cause the visual impairment from any other cause such as diabetic retinopathy, retinitis, and disorders of vitreous body are also excluded from the selection. We also verified that those patients are newly diagnosed by excluding those who had ever got a medical service for primary glaucoma, recorded from 2002 to 2003 in the National Health Information data. The glaucoma patients who already had visual impairment from 2002 to 2003 are also excluded. Since it requires persistent management to control the progress of glaucoma, selecting those who have 2-year absence of the medical care for glaucoma may assure the first diagnosis. --- Interesting variable As an indicator of the socioeconomic status, we used an income level. According to the data of National Health Information, income levels are collected on the basis of the amount of monthly insurance premium. The insurance premium is imposed based on salary, real estates, and other financial income. These data are categorized into decile, and include one additional group for those with the lowest income who get medical aid. We reorganized the group into three categories, low income , middle income , and high income for better analysis. The effect of inflation can be neglected since the income groups are designated by relative proportion. --- Outcome variable The dependent variable of the study is whether the primary glaucoma patients are diagnosed with visual impairments or not. Ophthalmologists measured the best corrected visual acuity using Snellen chart. In terms of visual fields, it is evaluated by the certified examination such as Humphrey visual field, Goldmann perimetry, and Octopus perimetry. Then the national government decides the classification of grade based on the severity of visual acuity and available visual field as shown in Table 1 [16,17]. Visual impairments are designated by visual acuity of eyes with best possible corrections, such as eyeglasses, contact lenses, and surgical treatment. VF is measured by kinetic perimetry. Prominent level VI should be confirmed with retinoscopy, fundus examination, and corneal test. According to the International Classification of Diseases 10th edition, the low vision includes categories 1, 2, and 3 of visual impairment. WHO defines low vision as "a person with low vision is one who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 to light perception, or a visual field of less than 10 degree from the point of fixation, but who uses, or is potentially able to use, vision for planning and/or execution of a task." Meanwhile, the current definition of blindness contains either one or both eyes with no perception of light, and less than 3/60 in better eye. Level VI in Korea includes visual acuity impairment and visual field impairment. In addition, we supplemented temporal elements between the glaucoma diagnosis and the occurrence of visual impairments; which incident does come prior to the other. Therefore, three different levels of the dependent variable are designated; those who are not diagnosed with visual impairments, those with visual impairments before glaucoma diagnosis, and those with visual impairments after glaucoma diagnosis. --- Other covariates Age , sex, residential area , insurance type for employees, self-employees, and medical aid recipients), hospital level , Charlson comorbidity index excluding hypertension and diabetes, medical history of hypertension, diabetes, cataract, and refractory error each. Year at diagnosis is also adjusted as a continuous variable. --- Statistical analysis To determine the differences in visual impairments among different socioeconomic statuses, we performed a multiple logistic regression analysis. Since stepwise selection is described here, A significance level of 0.1 is required to allow a variable into the model and one of 0.15 to stay in the model. We also examined the full model under consideration of inflated variation in supplementary tables. The group of glaucoma patients without visual impairments was used as the standard group, and each of the group with visual impairment diagnosis before the glaucoma diagnosis, or the group with visual impairment diagnosis after the glaucoma diagnosis was compared to the standard group. All statistical analyses were conducted using SAS 9.4. --- Results Table 2 displays the characteristics of selected population in Korean patients with Primary Glaucoma. From 2004 to 2013, the number of newly diagnosed patients with primary glaucoma was 1728. The percentage of age group with below 49 was 31.3% while that of age group over 50 was 68.7%. Male recorded higher percentage of total patients, which were 51.7%. Among the patients, 52.2% were classified as high income group, while 28.4% for middle, and 19.4% for low income group. Table 3 shows demographic characteristics based on the presence of visual impairment. It turns out to be statistically significant in terms of age group , sex , income group , insurance type , diabetes , by the global test. Multivariate analysis on odds ratio of visual impairment among the patients with primary glaucoma is shown in Table 4. We used stepwise selection for preventing inflation of variance. In case of the patients diagnosed with primary glaucoma after the occurrence of the visual impairment, both low income group and middle income group have higher odds ratio of the visual impairment, compared to the high income group. We did not find statistical significance in case of the patients diagnosed with primary glaucoma before the occurrence of the visual impairment in terms of the differences in income group. Increased age is related to the higher odds ratio for visual impairment among particiants with previous visual impairment before glaucoma diagnosis. Considering the factors of diabetes, glaucoma patients with diabetes unaccompanied by complications shows higher odds ratio of the impairment in case of the diagnosis of glaucoma followed after the occurrence of visual impairment, although it is statistically insignificant slightly. Interestingly, the presence of refractory error is related to the visual impairment after the diagnosis of glaucoma. We also performed the full model under consideration of variance inflation . Sensitivity analysis on OR of visual impairment between Korean self-employees and employees with primary glaucoma is presented in Fig. 1. Based on information of insurance types collected from KHNI, patients are classified into two different groups of insurance types, self-employees and employees. With each of the insurance type groups, we conducted a multivariate --- Discussion Throughout this study, we determined the effect of socioeconomic status on the risk of visual impairment in patients with primary glaucoma in a cohort study using stratified random samples from Korean Health Information collected by KNHI. As a result, the effect of socioeconomic status on the risk of impairment was significant only when the occurrence of the visual impairment preceded the diagnosis of glaucoma. Primary glaucoma patients with lower income had significantly increased visual impairment when they had not diagnosed with the disease. Multivariate analysis with subgroups divided into two different groups of insurance type also showed the same aspect of the trend. Glaucoma is considered to have less noticeable symptoms that the patients with it can hardly recognize. [18,19] Even though glaucoma is substantially worsened, central vision is known to be maintained relatively longer. Among The result of multivariate analysis on visual impairment of newly diagnosed patients with primary glaucoma classified by the type of National Health Insurance . The patients who are self-employee of NHI and employee of NHI are examined separately. --- a b Fig. 1 Multinomial logistic regression analysis based on the National Health Insurance type, a Self-employees and b Employees. Compared to the high income group, middle and low income group show higher odds ratios for visual impairment before the first diagnosis of glaucoma, in both self-employees and employees. However, the association is stronger in self-employees than in employees different types of primary glaucoma, chronic open-angle glaucoma is hard to notice due to the adaptation of nerves to high intraocular pressure, and the symptoms of acute closed-angle glaucoma such as headache and nausea are easily confused with other diseases. Normal-tension glaucoma, another type of primary glaucoma, is accompanied by relatively low intraocular pressure, which makes it even hard to find out. [20] It is crucial to figure out how socioeconomic status affects the visual impairments among glaucoma patients. There are possibilities that the lack of awareness of glaucoma as serious disease may influence low detection rate. Basically, there is low awareness of glaucoma in Korean population. According to Korea National Health and Nutrition Examination Survey , only 9% of glaucoma patients are aware of their diseases. [3,10] In addition, patients with lower economic status have even less perception of glaucoma. According to the crosssectional study in US, less affluent and less educated group of people has lower frequency of visiting eye care provider. [21] Accordingly, people with low socioeconomic status and low frequency of using medical services have increased impairments of closed-angle glaucoma. The accessibility of using medical services affects the detection of glaucoma, and that accessibility is influenced by socioeconomic status including income and education. [21,22] Not only detection but also severity of glaucoma can be affected by socioeconomic factors. [23] Another study has examined the relationship between socioeconomic status and the ratio of severe glaucoma to total glaucoma, and glaucoma patients with serious economic poverty has increased proportion of severe one. [23][24][25] This strongly supports our findings since severe glaucoma can lead to visual loss if it is neglected. However, there is no significant connection between the visual impairment and the income in case of glaucoma patients who have already been diagnosed. Since the cost for glaucoma treatment is relatively less compared to healthcare for other eye conditions [26] and the universal health coverage in Korea cover the medical cost almost [27], the patients with low income can also use proper medical care for glaucoma preventing it from worsening. Moreover, we did not find any significance in the relationship between the impairment and the residential area, or the size of medical facility. Glaucoma is kind of a life-long disease that needs to be continuously managed, and in general, the excessive intraocular pressure can be controlled by medication. Interestingly, we found the significance of mild diabetes in case of the occurrence of impairments that preceded the prevalence of glaucoma. Those glaucoma patients with mild diabetes had higher OR of the occurrence of visual impairments if their glaucoma was not checked. It is unclear whether the result of significance in glaucoma is a driver or a passenger factor of the occurrence of impairments. If the diabetes acts as a driver factor of the occurrence of impairments, diabetes may be the confounding variable that mediates the hidden relationship between socioeconomic status and the difference in the severity of the glaucoma. In case of presuming the diabetes as a passenger factor of the impairments, we can predict that poor concerns about health care and low frequency of using medical facilities may both influence patients' lack of recognition of glaucoma and diabetes that they have. There are a few studies that concern to the diabetes as a risk factor for glaucoma [28][29][30], but the causal relationship has not been proved clearly. Further analysis on the effect of diabetes on glaucoma is needed for lucid explanation. Before drawing conclusion from the results, the limitation of this study should be discussed. First, considering low detection of glaucoma, which is about 1.5-2% in Korea [3,10] and those patients having glaucoma concurrently with visual impairments, the absolute amounts of selected samples are not that a lot. Second, we could not keep track of patients with glaucoma without symptoms. Those patients may not feel necessity to use medical service, thus their information would not be collected and included in the database. Similarly, some of the patients with visual impairments may not visit a clinic or a hospital to be diagnosed, and the information of their impairments would not also be included in the data either. Third, Korean National Health Information claim data we used do not contain the information of medical records so we did not determine the severity of glaucoma of each patient. Thus, we cannot completely neglect the possibility that the severity of glaucoma may differ between income groups even if there was no significance of visual impairment found in the case of the glaucoma that has already been diagnosed. Fourth, there are still unmeasured confounders or unadjusted medical conditions, related to visual impairment. To overcome this shortcoming, we excluded diabetic retinopathy, retinitis, disorders of vitreous body, and aging macular degeneration, which are the most common diseases causing visual impairment in Korea. The history of cataract and refractory errors are adjusted for multiple linear regression analysis. Fifth, it is not able to consider age as a continuous variable. For deidentification in database, the Korean government provides this public data with some limitations. As part of these, the data do not include the exact birth date. Rather, it describes the age intervals. Although there is still some variance in the same category, we have adjusted the age group of ten years interval. In spite of the limitations, there are several strengths in our study. First, this study was the first to examine the socioeconomic effects on the visual impairment by applying temporal order of the incidents. There were many studies using cross-sectional data to identify the correlation [31], but none of them classified samples into two different cases of the time order using cohort data. Since our study showed different aspects between different cases of time order, it would be much meaningful to understand the influence of socioeconomic status on the visual impairments by glaucoma. Second, our study not only dealt with the glaucoma but also focused on the visual impairments. Since glaucoma needs to be persistently managed, and visual impairment itself is more direct issue that threats people's quality of life, our study approached more to practical matters; the accessibility on the examination of glaucoma should also be enhanced as the developed clinical techniques in treatment. Third, we excluded patients with other diseases that can cause visual impairments so we can verify that occurred visual impairments in the samples are solely driven by glaucoma. --- Conclusions In case of patients with primary glaucoma after visual impairment, those with lower income are more vulnerable to the occurrence of visual impairments. Since disparities of the visual impairments by glaucoma are only detected when the glaucoma had not been diagnosed and recognized yet, the differences may have been derived from the disparities of the awareness of the glaucoma. These findings call attention to the correlation between socioeconomic factors and the visual impairments by glaucoma, and raise public health needs over the importance of glaucoma awareness and early eye screening for glaucoma. --- --- Additional file Additional file 1: Table S1 Authors' contributions HS was a major contributor in writing the manuscript. HHS and YB proposed the idea of the study and contributed in designing the methods. GAK and JSK provided ophthalmologic interpretation of the results. ECP reviewed the study and the manuscript. JS performed statistical analysis, and interpreted the data regarding socioeconomic status. --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Glaucoma is one of the most leading causes of permanent visual impairments in Korea, and social expenses spent for the glaucoma are increasing. This study is to identify association between socioeconomic status and the visual impairments caused by primary glaucoma in Korea. Methods: This study is based on a cohort study using stratified representative samples in the National Health Insurance claim data from 2002 to 2013 with 1,025,340 representative subjects. Target subjects were patients who are newly diagnosed with primary glaucoma from 2004 to 2013. We conducted a multiple logistic regression analysis depending on the occurrence of visual impairment and its temporal order compared to the glaucoma diagnosis. Results: Among 1728 patients with primary glaucoma, those with low and middle income shows higher odds ratio (OR) of the visual impairments than those with high income group (low income; OR = 3.42, 95% Confidential Interval (CI):2.06-5.66, middle income; OR = 2.13, 95% CI: 1.28-3.55), in case of the occurrence of the visual impairments preceded the diagnosis of glaucoma. Conclusions: Glaucoma patients without pre-existing glaucoma history before visual impairment have higher association between socioeconomic status and the occurrence of visual impairments by primary glaucoma. Since glaucoma had not been diagnosed and recognized yet, the differences may have been derived from the disparities of the awareness of the glaucoma. These findings call attention to the correlation between socioeconomic factors and the visual impairments by glaucoma, and raise public health needs over the importance of glaucoma awareness and eye screening for glaucoma, especially for low socioeconomic status.

INTRODUCTION Along with the mental health services reform and efforts to change the logic of care in this area, was recognized the magnitude of the global burden of mental disorders and the need for integrated and intersectoral responses . The proposed organization of mental health services under the network logic is one of the strategies to broaden the care access and change the focus of the disease to the psychosocial needs of people with mental disorders . Such a network should be structured with points of care focused on both health care and social reintegration of individuals and families . This proposal corroborates the World Health Organization recommendations of consolidation of universal health systems from an integral, interprofessional perspective, with priority of community spaces. The recognition of the Psychosocial Care Network as one of the priority thematic networks by the Brazilian state has contributed to the visibility of mental health demands and influenced the development of research in this area. Studies have shown the variety of compositions and interactions between mental health services in each locality. As the network is woven into the daily routine of services and in relationships between structures and social agents, workers and managers play a fundamental role in mobilizing resources to meet users' demands . Different researchers have highlighted that psychosocial care is not limited to specialized mental health services and involves building relationships with health institutions and other sectors in order to put into practice the psychosocial rehabilitation and insertion into territories . The articulation of mental health services in the logic of networks has been the object of several studies . Despite the recognized importance of normative definitions, decrees and ordinances for composing the Psychosocial Care Network , the differentiation and relationships between the scientific field and the bureaucratic field must be highlighted, as well as the influences of relations, conflicts and tensions between the various social agents in the daily routine of services . Studies have been developed from documentary analysis and/or interviews with managers and professionals of specific categories , but only two studies involved different professional categories. One of them was performed with workers and managers of Type III Psychosocial Care Centers of the state of São Paulo and the other with higher level professionals from various points of the Psychosocial Care Network in the western region of São Paulo . Thus, this study is justified by the need to address the various points of the municipal care network in order to produce evidence on how the Psychosocial Care Network has been implemented in different locations. It is about the sedimentation of studies related to the constitution of the psychosocial field, and the capture of relations between network structures and the mediations performed by social agents. In this regard, the framework of Pierre Bourdieu's constructionist structuralism was adopted to delineate the guiding question of the study 'What is the perception of workers and managers about the psychosocial care network of a mediumsized municipality in the inlands of the state of Minas Gerais?' --- OBJECTIVE To analyze the perception of workers and managers about the Psychosocial Care Network in a medium-sized municipality in the inlands of the state of Minas Gerais. --- METHOD --- Ethical aspects The project was approved by the Research Ethics Committee and complied with the ethical precepts recommended by Resolution number 466/2012 of the National Health Council. Participants signed an informed consent form and received a copy of it. Each participant was identified by a number to ensure anonymity. --- Theoretical framework and type of study This is a qualitative, descriptive and exploratory study in which Pierre Bourdieu's constructionist structuralism was adopted as a theoretical framework. This approach recognizes the existence in the social world of "objective structures, independent of agents' consciousness and willingness that can guide or coerce their practices and representations". At the same time, there is "a social genesis of the schemes of perception, thought and action that constitute the […] habitus and, on the other, there are social structures, in particular [...], of fields and groups [...]" . According to Bourdieu , the adoption of the habitus construct derived from his interest in breaking with structuralism without falling into subjectivism. Habitus is understood as "a system of durable and transposable dispositions which, by integrating all past experiences, functions, at each moment, as a matrix of perceptions, appreciations, and actions" . Such a system is updated and recomposed at each moment and implemented in specific fields. The fields are understood as a field of forces, of battles fought sometimes for their transformation, sometimes for their reproduction. The allocation of specific capital of/in the field will conform its structure . Thus, understanding the field of psychosocial care contributes significantly to the analysis of managers and workers' perception about the Psychosocial Care Network in the municipality studied and more specifically, to the delineation of tensions in this field. The plurality of capitals is emphasized by Bourdieu, who presents the economic, cultural, social and symbolic capitals. All agents, in their path of training, performance and economic condition, elaborate their capitals, from which we can understand the positions taken over in the field . The capitals of agents of the present study come from different spaces and express the way they fit into social reality, groups and institutions. In turn, the perception about the network is related to these agents' capitals and their positions in the psychosocial field . In line with the adopted theoretical framework, we sought to identify the matrix of perceptions of social agents, which guides their representations of the Psychosocial Care Network, and their actions in the field of psychosocial practice . In the exercise of this analysis, were considered the relationships and tensions in the field, from which we sought to identify the disposition of these social agents in relation to the reproduction of the status quo or transformation of their practices. --- Study scenario The medium-sized municipality in the inlands of Minas Gerais was intentionally selected because of the implementation of substitutive services already in the 1990s and the diversity of points of the care network. The municipality had two Type II Psychosocial Care Centers -one municipal and one philanthropic; a Child and Youth Psychosocial Care Center ; one Type III Alcohol and Drugs Psychosocial Care Center ; a Psychiatric Hospital ; a team from the Street Office Program ; a team of the Mental Health Matrix Strategy ; five Therapeutic Residence Services , of which three municipal and two philanthropic. --- Data source The eligibility criteria were to work as manager or technical reference at any point of the Psychosocial Care Network and be in the exercise of these duties during the study period. Exclusion criteria were being away from work at the time of data collection due to sick leave or vacation. There were nine managers at the time of data collection, namely: one director of Psychosocial Care, three managers of municipal Psychosocial Care Centers; two managers of the philanthropic Psychosocial Care Center -one administrative worker and one clinical worker; a manager of the Psychiatric Hospital; a manager of the three municipal Therapeutic Residence Services; a manager of the two philanthropic Therapeutic Residence Services. As the staff of the Street Office program and the Mental Health Matrix Strategy did not have managers, the social worker and the nurse of the Street Office program and the psychiatrist of the Mental Health Matrix Strategy were interviewed. Twelve workers were eligible to participate, and all joined the study. Table 1 presents the profile of participants. guiding questions were: What are the services offered in the institution? In your opinion, does the network offer the necessary conditions for the care of people with mental disorders and their families? How do you understand the challenges faced by the institution and by the Psychosocial Care Network? The interviews were conducted by the lead researcher -who has a degree in Social Sciences, a PhD in Sociology and experience in qualitative research -in places defined by participants with conditions of confidentiality and privacy. The average duration of interviews was ninety minutes. After transcription, the audios were deleted. A copy of the transcript was delivered to each person involved, which is one of the requirements for the rigor of qualitative research . No entries or deletions of information were requested by respondents. --- Data analysis Pierre Bourdieu's framework of constructionist structuralism was used for the analysis focused on capturing the multiple relationships and positions taken over by the study participants in the psychosocial field and how they interact with other fields. The process of data interpretation and analysis was conducted based on the structuralist research protocol , according to which it is necessary to understand the structuring of the field where social agents build their perceptions and position themselves. Initially, the composition of the Psychosocial Care Network of the municipality of Minas Gerais was outlined. The Psychosocial Care Network was considered as the field from which were captured the habitus and capital expressed by the social agents. Based on the positions of study participants, were outlined the relationships of institutions of Psychosocial Care Network with one another, and with other institutions. --- Thematic Structure 2 Workers and Users Element 1.1 -Mental health at the different levels of care • Expectations regarding expanded acess to mental health care. • Infrastructure of the network, services and conditions for workers. --- Element 1.2 -Relationship between mental health services, other health services, education and social protection • Positive relationships and tensions between health services and mental health services. • Positive relationships and tensions between mental health services, education services and social protection services. --- Element 2.1 -Psychosocial care and tensions in the worker-user relationship • Aspects that guide psychosocial care. • Challenges of dealing with families. • The prejudice that permeates the relationships of health professional with users. --- Thematic Structure 1 Workers and Services Figure 1 -Thematic structures, elements and results --- Data collection and organization Recruitment of participants took place at their workplace. Data collection was performed through semi-structured interviews. The of Psychosocial care network: managers' perception and tensions of the field Querino RA, Borges RS, Almeida LY, Oliveira JL, Souza J. The lead researcher performed successive readings of the transcripts and highlighted recurring topics and themes. After completing the individual readings, the convergences and divergences identified were jointly evaluated in order to delineate a group of relationships between the elements for the development of thematic structures. At the end of this process, two thematic structures were defined: workers and services; workers and users . --- RESULTS The thematic structures and main results are presented in Figure 1. --- Thematic structure 1 -Workers and services --- Element 1.1-Mental health at the different levels of care The results contemplated here relate to how participants understand mental health in the Psychosocial Care Network, the expectations regarding expanded access to care, and challenges related to the network consolidation. Overall, participants mentioned mental health actions at the different levels of care, despite the still prevailing idea that mental health demands should be met only in specialized services: [The] health care unit does not provide care because there they say: -Look, mental illness is not in our scope, because we have no psychiatrist. It's a network still with a culture of specialized care, focused very much on Psychosocial Care Centers and the Psychiatric Hospital. […] The matrix strategy and training of primary care teams were mentioned as efforts to fulfill these demands, with expectations regarding the expansion of mental health actions in primary care: Regarding workers' conditions, the need for more qualification and the issue of remuneration were mentioned: We have been working like warriors, because we earn very little, we face a heavy workload to serve a difficult to manage population --- Element 1.2 -Relations between mental health services, other health services, education and social protection The results on participants' perception of the relationship between mental health services and other health services are described in figure 2, which was prepared from the perspective of social network mapping. The following statements illustrate the relationships presented in figure 2. Interactions between Family Health team professionals and Therapeutic Residences were described as follows: The Family Health team doctor comes here, the nurse, community agent, the dentist comes here, they brush patients' teeth, do the mouthwash program with residents, do the treatment [...]. The outpatient clinics were highlighted as less integrated with other network services. [...] in the electronic waiting list, after five months, we don't even find the user anymore. The relationships established between the various Psychosocial Care Centers, and between these and other mental health institutions were also cited. Some resources that facilitate the articulation between services were mentioned: Figure 3 presents the relationships of mental health services with legal, education and social protection institutions, as reported by study participants. The statements below illustrate some interlocutions with leisure and social protection institutions mentioned by participants. --- Element 2.1 Psychosocial care and tensions in the worker-user relationship Respondents emphasized that user care is provided by multiprofessional teams with priority of group approaches and resocialization activities. They also mentioned user embracement, listening and establishing bonds as a priority in the care of users: --- Most activities are done in groups […] therapeutic groups […], relapse prevention, twelve-step philosophy support group […], resocialization activities outside the Psychosocial Care Center, visits to universities, parks, shopping, tours, museum […]. The service that aims at user embracement, listening, listening in every way, even listening to the silence, to the user's body and providing care for what he needs there. --- The way you receive the user, with neutral eyes [...] I need to see the user as a person […]. The psychiatric hospital manager described hospitalizations as "flexible" and aimed at reintegration into the network: We provide care on a more flexible therapeutic plan, in the sense of a hospitalization that they call integral […]. It is the withdrawn from the crisis, stabilization, referral to the mental health network for continuity of treatment in the outpatient system. Actions related to health, recreation and daily organization were also mentioned as part of the psychosocial care offered by Therapeutic Residence Services: Families were recognized as part of psychosocial care for users. However, the challenge of including families in this care and the need to expand the work with them were emphasized. --- Another challenge mentioned was the tension between families and users themselves: Care to the family is not easy, you know, because they don't come, it's not just up to us, there's no adherence of the family. --- [...] a bit of this difficulty is to bring the family closer to treatment, to collaborate more, participate more in the reality of this treatment […]. . Because by the ordinance of the Prosecution Service, the therapeutic residence would be for those who do not have family ties. These people have family here […]. Their main reason for being in the Therapeutic Residence is by court order [...]. As the family does not want to care for them, the prosecution passes the torch to the municipality, to Residence Services. Prejudice was mentioned as a barrier to the access to health services and social care: --- .] certain professionals do not even come close at the time of care. They prefer that the person accompanying them, the nursing technician or the nurse, tells everything that is happening to the resident. They do not listen to the resident […]. --- DISCUSSION In light of Pierre Bourdieu's theoretical construct it was possible to capture the articulation between the various capitals of the social agents participating in the study. The cultural capital is a set of qualifications, knowledge and skills constructed by agents, in which different scientific areas that form the psychosocial field are articulated. As described in the results, the set of social accesses expressed in the variety of contacts and relationships of social agents was evident in the speeches of interviewees, who brought to light the relevance of this capital for the articulation of the various networks. The symbolic capital, in turn, refers to the recognition of these social agents expressed by the role played in institutions and programs, whether as managers or socially authorized professionals to speak on behalf of the service. The complexity and interaction of these capitals support these agents' representations of the psychosocial care network . As pointed out in the results, two major groups of relationships were identified from the perception of social agents: 1) of workers with services and 2) of workers with users. In the first group, terms such as partnership, support, co-participation, dialogue, good communication, joint discussions, assistance, asking for help, providing support, giving feedback, triggering, good relationship and participation in the therapeutic project give nuances to the matrix of perceptions that guide the professionals' representation of Psychosocial Care Networks in their municipality. As the orientation of agents' practices and representations is not exempt from the interests of the field, it is a fact that this predominantly positive perception about mental health in care services is crossed by different limits and challenges arising from the counter-hegemonic model proposed by the notion of psychosocial care. Participants expressed their expectations of a broader access to mental health care, especially more mental health actions in primary care and optimism about the potentiality of this level for mental health. This perspective is consistent with the proposed network action, which values the specificities of each institution and service . In addition, the strengthening of mental health in primary care is in line with the community approach and the perception of territories as an existential territory "that involves spaces constructed as material and affective elements of the environment, that when appropriated and managed expressively, constitute places to live" . Such strengthening can also contribute to mobilize other community resources and expand the support network of users and families, which are fundamental for psychosocial rehabilitation . In the municipality studied, this insertion has occurred through the team of the Mental Health Matrix Strategy and the Family Health Strategy. Efforts to value and involve workers from Family Health Support Centers, Basic Health Units and matrix units are urgent to ensure the performance of different primary care workers in mental health care . Nevertheless, the emphasis on primary care as a key aspect for improving the Psychosocial Care Network and the criticism on the lack of some components suggest that participants improvement expectations are more focused on unconsolidated actions and services, and they have little consideration for the potential of improvements in their own locus of activity, which is essential to complement the network qualification. The analysis also showed that the institutions establish deep relationships with other health services, education and social protection services that are essential for psychosocial rehabilitation. These relationships should be expanded by adding other territorial resources . Most described relationships need improvement and outpatient clinics were identified as the least integrated in the network. It is worth highlighting the specificity of the outpatient work process to the detriment of Psychosocial Care Center proposals, highlighting the notion of "intensive" care of Psychosocial care network: managers' perception and tensions of the field Querino RA, Borges RS, Almeida LY, Oliveira JL, Souza J. and prioritization of social reintegration rather than a medicalizing approach focused exclusively on symptom reduction. Although outpatient clinics have different characteristics in relation to the psychosocial rehabilitation proposal, they have been the focus of recent policies that recommend their expansion and raise the issue of field strengths and disputes regarding transformations or reproductions of certain care models. On the other hand, participants also reported some tensions regarding the network structure. In the perception of these agents, aspects such as low participation of some institutions/ components, poor communication between the elements that make up the structure, referrals and difficult access, barrier to the continuity of care and delay in counter-referral services outlined these tensions. However, the tensions mentioned were more related to service partners than to the own participant, suggesting again a tendency to understand that the network improvement depends more on external transformations than on the more effective disposition of one's own experiences. In a previous study, poor communication and difficulties with the articulation between the various network services were identified as challenges of priority networks . The literature has indicated the mobilization of light technologies as a possibility for the greater activation of institutions and monitoring of cases . Hence the importance of investments in workers' continuing education. According to study participants, there are resistances and barriers to the care of people with mental disorders in nonspecialized services, which strengthens the focus on specialties. The reports emphasized difficulties to meet urgent and emergency care, a topic addressed in other studies . A study involving 156 workers from different regions of the country enrolled in the course "Crisis and Urgency in Mental Health", offered in partnership by a federal university and the Ministry of Health, revealed that care was provided primarily with drugs, mechanical containment and hospitalization . This highlights the importance of strengthening the action in network and investing in continuing education to consolidate care and overcome the centrality of the psychiatric hospital in crisis management . Nevertheless, previous studies have problematized the idea that the solution to most limitations in the field of mental health is training , since even among some highly specialized teams, such limits are present. As indicated in an international study, difficulties with attending stigma-related comorbidities have resulted in neglect of clinical demands and excess mortality of people with mental disorders, which is in flagrant disagreement with equity and human rights . A study conducted in the Brazilian context revealed the permanence of users in the Psychosocial Care Center for long periods, due to the few opportunities for insertion in institutions and services, which indicates the importance of expanding community spaces . The so-called "chronification" can contribute to problematize psychosocial rehabilitation, which is the objective to be achieved in an intersectoral way, with protagonism of users and their families . In this sense, the organization of services according to the logic of the territory has profound consequences not only for users' lives, but also for communities. It is about rehabilitating the territories in order to "collectively build new forms of living with difference" . In the second group of relationships, tensions were also identified in the relationship between mental health professionals, families and users. The approach and involvement of families in the care process have been highlighted as important strategies for mental health care and the strengthening of policies and services . It is relevant to overcome disciplinary, control and tutelage strategies and foster their emancipation and autonomy . The prejudice of some professionals towards people with mental disorder was also emphasized. Barriers related to prejudice occur in many countries and are a challenge for access to health and the search for assistance. In a review study, were highlighted different types of stigmas, namely the perceived public stigma, personal attitudes toward members of a stigmatized group, internalized or anticipated stigma, and attitudes toward seeking help . This typology is interesting to understand the findings of this study since, according to respondents, there are stigmas in the community, among health professionals, as well as in users' positions and attitudes. Identifying them can contribute to envision coping strategies . Thus, the tensions and conflicts observed in the Psychosocial Care Network arising from the habitus and the positions of social agents represent possibilities for change . In contrast, the actions offered by services within a perspective of resocialization, user embracement, group and multiprofessional care, as well as approaches of harm reduction, recreation and daily organization, were the resources/capitals mentioned by participants. Such resources/capital are in line with the psychiatric reform and demonstrate the search for sedimentation of the psychosocial care model . --- Study limitations The collection of data with different interest groups, such as users and workers, would certainly enrich the list of results and enable the triangulation of perceptions, especially considering that within the psychosocial field, there is a variety of positions and wide differentiation of social agents. The involvement of managers and workers from institutions with which the various points of the Psychosocial Care Network articulate would contribute to broaden the intersectoral approach. The choice of individual interviews can be considered as a limitation of the study design, because collective strategies for data construction would foster a joint reflection about the Psychosocial Care Network. The data collection process preceded the mental health policy changes determined by the federal government that brought a lack of financing of community services and setbacks in relation to the care model, with emphasis on hospitalization. Therefore, participants' considerations about advances in the Psychosocial Care Network should be understood in context and referenced to the previous policy. --- Contributions to public mental health policy Although data collection has been delimited within the municipality, this study contributes to important reflections on relationships and tensions in the psychosocial field and may foster debates and action plans related to the optimization and strengthening of the Psychosocial Care Network. One of the highlights of the study design were the contributions of Pierre Bourdieu's theoretical perspective for valuing the relationships between social agents and the structures of the Psychosocial Care Network in mental health care, and the importance of understanding the symbolic disputes in the psychosocial field . of Psychosocial care network: managers' perception and tensions of the field Querino RA, Borges RS, Almeida LY, Oliveira JL, Souza J. The present study indicated relevant actions of psychosocial care improvements and recognized the legal advances in the last three decades. However, the model of care based on community services has experienced setbacks in relation to institutionalization , which reinforces the existence of conflicts and tensions in the psychosocial field and in its relations with the health and social care fields . Different perspectives are in conflict and dispute in the field and understanding them can contribute to advances in the care model. --- FINAL CONSIDERATIONS The study findings show that the perception matrix of participants originates from their position in the psychosocial field. Since most of them are managers, it was somewhat expected there would be more references to positive aspects of the services where they work than to the existing limits. Most tensions and difficulties mentioned were related to services other than their own, especially to other sectors. In general, the habitus of social agents was expressed much more by their disposition to transform than to reproduce the status quo. Such disposition was perceived in statements with expectation for the expansion of primary care actions and optimism about improvements in the Psychosocial Care Network. Social agents demonstrated disposition to contribute to change processes in order to overcome the focus on specialties, lack of training of some teams, and lack of infrastructure and some components, especially those related to leisure and community life.

Objective: to analyze the perception of workers and managers about the psychosocial care network in a medium-sized municipality in the inlands of the state of Minas Gerais. Method: qualitative, descriptive and exploratory study involving twelve participants from different points of the network. The semi-structured interviews were analyzed in the light of Pierre Bourdieu's framework of constructionist structuralism. Results: the actions offered by the services were based on the perspectives of resocialization, user embracement, group and multiprofessional care, and on approaches to harm reduction, recreation and daily organization. These were configured as the network resources/capital. Tensions were identified in family embracement and in relationships between families and users, as well as in the prejudice towards people with mental disorders. Final considerations: the social agents were willing to contribute to processes of change in order to overcome the focus on specialties, the lack of training of some teams, lack of infrastructure and of some components, especially those related to leisure and community life.

Introduction During the last decade, loneliness has emerged as an important determinant of health [1][2][3][4]. Studies have suggested that loneliness is a major risk factor for morbidity and mortality [5,6]. It seems that loneliness is indirectly associated with these outcomes through psychological and behavioral factors [6]. During the COVID-19 pandemic, loneliness was a major concern for public health, increasing the need to understand the factors associated with it [7]. Most of the research regarding loneliness has been conducted in the developed world and individualistic societies, however, there are studies looking at other societies [8]. In a study comparing loneliness across cultures in 237 countries, findings showed that in societies that were more individualistic there were higher rates of loneliness that decreased with age [9]. In a recent editorial, a list of risk factors and negative effects associated with loneliness in old age was given. The authors suggested that building a compassionate social community could be a key approach to dealing with loneliness [10]. Social capital may help build such communities. Identifying key elements within SC that may inhibit or promote the ill effects of loneliness would be helpful for future intervention. --- Social Capital and Health Putnam's SC is an umbrella term that draws together relationships within networks, norms of reciprocity, mutual support and trustworthiness [11,12]. Social capital is often defined as the norms, networks and associations that facilitate co-operative action [13]. Social capital can be divided into both structural dimensions and cognitive dimensions [14]. The current study measures cognitive SC represented by trust and reciprocity and structural SC represented by social involvement [15]. Social capital is associated with many health outcomes [16][17][18][19][20][21]. In a systematic review, Coll-Planas et al. found mixed effects of SC interventions targeting older people's quality of life, wellbeing and self-perceived health [22]. Social capital is now considered a social determinant of the health discourse [23]. Social capital may serve as a protective factor for health and a resource for individuals and communities to improve quality of life [12,19]. However, how this works and if this is generalizable between communities is not clear [24]. The association between SC and health may be context-dependent, depending on the specific community studied [15,25]. In a previous study in Israel, Jews reported higher levels of SC compared to Arabs, except for higher rates of social contacts, and all measures of SC were associated with selfrated health among Jews. However, among Arabs, the association between SC measures and health was not significant, except for social support. Therefore, studying these two populations may have an added value for understanding the association between social attributes and health [25]. --- Social Capital and Loneliness Loneliness and SC both seem to affect health, moreover, SC may serve as a resource by which individuals can decrease loneliness or prevent its ill effects. Studies suggest that there is an association between living in an area with high SC and lower levels of loneliness [26][27][28]. This association may not be causal, and there may be an interaction between socioeconomic status and age. A study in a suburb of Barcelona, Spain, suggested that there was an interaction between SES, neighborhood SC, age and loneliness. The authors suggest that increasing neighborhood SC could be an effective way of reducing the prevalence of loneliness [26]. Evidence is beginning to come out that promoting SC to tackle loneliness and its health effects could be an interesting approach to decrease inequalities [29]. However, not many studies have looked at all three variables simultaneously. Therefore, there is a need for more information regarding the associations between these social factors to be able to estimate the generalizability to all communities. Over two decades of research with more than 850 studies looking at SC and health have resulted in elusive and contradictory results, especially regarding interventions [30]. Shiell et al. suggest interventions utilizing SC to improve health are especially context-specific. Israel can serve as an interesting setting for studying different communities as it is a multicultural society with two major ethno-cultural groups: Jews and Arabs [31,32]. About one fifth of Israel's population comprises Arabs; of them, about 85% are Muslims and 15% are mainly Christians and Druze. Jews and Arabs in Israel differ in socioeconomic status, religion, culture, and language. The Arab society is a more collectivist society in transition to a more western lifestyle. Health indicators in Israel suggest poorer health among Arabs compared to Jews [31,32]. For this study, we chose four towns that differed in ethnicity . --- Aim of the Study The study's aim was to assess the association between loneliness, cognitive and structural SC and health ). Additionally, we want to see whether these associations are similar in the different towns. We hypothesize that the association between loneliness and health is mediated or moderated by both cognitive and structural SC . The study's aim was to assess the association between loneliness, cognitive and structural SC and health ). Additionally, we want to see whether these associations are similar in the different towns. We hypothesize that the association between loneliness and health is mediated or moderated by both cognitive and structural SC . Figure 1. Hypothesised model depicting the association between loneliness and health. --- Material and Methods --- Design and Sample This study is a secondary analysis of data collected in cross-sectional population surveys in four towns, as part of their health profile and needs assessment. This is performed as one of their commitments to the Healthy City Network [33]. As the questionnaire is a uniform questionnaire, it allows for analyzing and comparing data from the four towns. Four surveys were conducted in four Israeli towns during the years 2011-2016. The study population was randomly selected, in each town, as a stratified sample of households by residential area, age, and sex, by the Israel Central Bureau of Statistics , which also provided a Kish grid for a random selection of the interviewees out of a list of inhabitants aged 22 and above, in each household. The sample size calculation in each town relied upon the following: 50% prevalence of a variable, a 95% confidence interval, a 5% relative sampling error, and 70% compliance. Interviews were conducted in person, using a structured questionnaire, at participants' residential locations, by trained interviewers. Participation rates were 54% in the mixed Arab-Jewish town , 79.3% in town A, and 89% in both towns D and B. The sample included 1898 Arabs and 2722 Jews, altogether being 4620. Participants were residents of two Arab towns , one Jewish town , and one mixed town . The towns in the study represent two lower socioeconomic status Arab towns, level 2 and 3 out of 10, , a mixed town with Arabs and Jews and a Jewish town [34]. Interviews were conducted in Arabic or Hebrew according to the town and preference of the individual. --- Material and Methods --- Design and Sample This study is a secondary analysis of data collected in cross-sectional population surveys in four towns, as part of their health profile and needs assessment. This is performed as one of their commitments to the Healthy City Network [33]. As the questionnaire is a uniform questionnaire, it allows for analyzing and comparing data from the four towns. Four surveys were conducted in four Israeli towns during the years 2011-2016. The study population was randomly selected, in each town, as a stratified sample of households by residential area, age, and sex, by the Israel Central Bureau of Statistics , which also provided a Kish grid for a random selection of the interviewees out of a list of inhabitants aged 22 and above, in each household. The sample size calculation in each town relied upon the following: 50% prevalence of a variable, a 95% confidence interval, a 5% relative sampling error, and 70% compliance. Interviews were conducted in person, using a structured questionnaire, at participants' residential locations, by trained interviewers. Participation rates were 54% in the mixed Arab-Jewish town , 79.3% in town A, and 89% in both towns D and B. The sample included 1898 Arabs and 2722 Jews, altogether being 4620. Participants were residents of two Arab towns , one Jewish town , and one mixed town . The towns in the study represent two lower socioeconomic status Arab towns, level 2 and 3 out of 10, , a mixed town with Arabs and Jews and a Jewish town [34]. Interviews were conducted in Arabic or Hebrew according to the town and preference of the individual. --- Measures Sociodemographic variables were collected in person via self-report: gender, age and education. In town C, respondents were asked to define themselves as Jews or Arabs. Religiosity was assessed using two different versions of the question, one for Arabs and one for Jews, as the terms used in Hebrew and Arabic are different. The variable was dichotomized as not religious [2] and religious [1]. For Arabs, not religious included answers 3-not so religious and 4-not religious; religious included 1-very religious and 2-religious. For Jews, not religious included 4-not so religious, and 5-not religious or secular, and religious included 1-ultra-orthodox, 2-religious and 3-traditional. Two health measures were analyzed: A. self-rated health was measured using the question "How do you evaluate your general health status?" Very good, good, not so good, or not good. The answers were dichotomized into very good and good and coded as a 1, while, not so good and not good were coded as a 0. B. Mental health was measured by asking the following question: "During the last year have you suffered from the following problems: irritability/stress/anxiety sleep problems sadness/depression and tiredness". Respondents could answer yes or no to each problem. The number of problems mentioned were summed to give a scale from 0 to 4 and dichotomized. Low mental health was defined as 0 and 1, and high-2-4. These four items were taken from the national yearly social survey of the Israeli Central Bureau of Statistics [35]. Loneliness was assessed using one item, "Are there situations in which you feel lonely?" [36,37], with four response options ranging from never to often. This was dichotomized to never or infrequently = not lonely and feeling lonely often or sometimes = lonely. The cognitive measure of SC was measured asking A. "Generally do you think 1. people can be trusted or 2. you have to be careful of trusting people". B. "Do you think that people in your town or neighborhood: 1. usually help each other, 2. usually only look after themselves". A composite variable was defined by adding the number of positive answers , which was further collapsed for the logistic regression as low and high . Structural SC was measured by asking about participation in eight social activities. Respondents were given a list of activities and asked if they had participated in each activity during the last year, not at all , infrequently frequently . The answers were added up to give a scale from 1 to 24. The activities included: sports events, meeting friends, going to the mosque or synagogue, going to parties or performances, going on hikes or tours with others, attending political or professional activities, volunteering, meeting family that do not live with the respondent. --- Data Analysis Data were analyzed using SPSS-25. Chi 2 and one-way ANOVA were conducted to examine differences among the four towns. Logistic regression models were run with cognitive SC, SRH, and mental health dichotomized as the dependent variables. For the two health measures, the first step, gender, age, education, religiosity and loneliness were added to the regression. For the second step, structural or cognitive SC was added and in the third step, an interaction between loneliness and structural or cognitive SC were added in order to test the moderation effect of SC on the association between loneliness and health . See Figure 1. This moderation effect was further elaborated by running separate regression for people with low and high SC. Linear regressions were run for structural SC as the dependent variable, with the above mentioned independent variables. A regression model was run separately for each town after finding significant interactions between town and loneliness. The mediating models were calculated with the R mediation package, version 4.0.2, the model was performed with the library mediation. All variables were standardized. The models were first calculated while controlling for gender , age and education, then the other variables were added. The Average Causal Mediation Effect was the measure of the mediation effect [38]. --- Ethics Exemption from ethical approval was granted by the University Hospital's Ethical Committee. The interviewees were told they were free to stop the interview at any time with no implications to them. As the interviewees agreed to answer the questionnaire this suggests informed consent. --- Results Altogether, 4620 adults were interviewed in four towns, two Arab towns , one mixed town with 804 Jews and 246 Arabs in the sample, and one Jewish town . The samples from the towns differ significantly in all their characteristics except for the percent of men and women interviewed . The two health measures were correlated . Better self-rated health was reported by Arabs in the two Arab towns and Jews in town C compared to Jews in town D. Arabs living in Arab towns and Arabs in town C report better mental health than the Jews in towns C and D. In town C, the difference between Jews and Arabs for all measures was significant, except for mental health, where there was no significant difference between the two population groups. It seems that both aspects of health in the two Arab towns are better than in the Jewish or mixed towns . In a logistic regression of the total population, adjusting for gender, age and education, there was no difference in SRH between Arabs and Jews, however, mental health was worse among Jews after the adjustment . Residents of town A by far reported higher levels of loneliness compared to the other respondents, 38.4% reported feeling lonely often or sometimes, whereas in the other towns, both Arab and Jews, reported between 14.1% and 25.3% feeling lonely often or sometimes. Respondents in town B reported the lowest levels of loneliness . The cognitive measure of SC was highest in the Arab towns A and B, and lowest in Jewish town D. However, within town C the Arabs had significantly lower levels of cognitive SC compared to Jews. Another measure of SC was the levels of participation in social activities , these were higher in the two Arab towns A and B. In town C, Jews reported significantly higher levels of social activities compared to Arabs. Generally, respondents reported spending time with family and friends and going to parties most frequently . The activities reported varied significantly between the towns, going to a movie was more frequent in towns C and D. Spending time with family, attending sports events, parties and outings were more frequent in town A, and attending prayers in a prayer house was the most frequent activity in town B compared to the rest. This suggests the towns differ in their patterns of social lifestyle. Logistic and linear regressions with cognitive and structural SC respectively as the dependent variable were run, adjusting for age, gender, education and religiosity . Loneliness is associated with cognitive SC only in town C, where those reporting loneliness also reported lower cognitive SC . Being religious is significantly associated with high cognitive SC in the total sample and cities A and D. Gender, age and education are not associated with cognitive SC in the total population and vary in their association by town. Structural SC was significantly inversely associated with loneliness in three of the four towns . This association was not significantly different between the towns . Generally, structural SC is more dependent on gender, age and education compared to cognitive SC that is associated only with religiosity in the total population . Note: The reference categories of the dichotomized variables are: Gender = male, religiosity = religious, loneliness = not lonely, p < 0.05 Bold. Table 4 presents the logistic regressions for all the study population and separately for each town with SRH or mental health as the dependant variable and participation in social activities as the measure of structural SC. In these logistic regressions, we adjusted for gender, age, education and religiosity. As expected, when analysing all towns together the more respondents reported being lonely the worse was their self-rated health and they reported worse mental health . Structural SC was also significantly associated with SRH and mental health in the total population. We then added the interaction between loneliness and structural SC to test moderation effects . The interaction between loneliness and structural SC was significant for both types of health measures, while the strength of the association between structural SC and SRH or mental health decreased in the total population. To further explore the moderation effect, we analysed the association between loneliness and SRH and mental health of the total population, in two separate logistic regressions, one included respondents reporting low structural SC and another regression with respondents reporting high structural SC than among people with high structural SC . Similar results were revealed in relation to mental health. The association between loneliness and mental health was stronger among people with low structural SC than among people with high structural SC . There was no significant moderation effect with cognitive SC, both for SRH and mental health . Adding town to the interaction did not yield a significant interaction . When running the regressions separately for each town with SRH or mental health as the dependant variable, loneliness was associated with SRH and mental health in towns B, C, and D, but not in town A. Structural SC was associated with SRH in all towns. In towns B, C and D, the addition of the interaction decreased the association between structural SC and SRH leaving it not significant. The interaction between loneliness and structural SC did not reach significance when the regressions were run separately for each town . To test the mediation effect of structural SC on the association between loneliness and SRH we calculated the mediation analysis for the total sample and each town separately. The mediation effect of structural SC was significant for the total population, when including the interaction between town and loneliness. The ACME was significant . When running the regressions separately for each town the mediation remained significant for each town: in town A , town B , town C , town D . Therefore, it seems that structural SC is a mediator in the association between loneliness and SRH. Structural SC was also a significant mediator in the association between loneliness and mental health in the total population including the interaction between town and loneliness, . When running the regressions separately for each town the mediation was significant in town C and town D but not in the Arab towns A and B. Table 5 presents the logistic regressions for all the study population and separately for each town with SRH or mental health as the dependant variable and cognitive SC and loneliness as the independent variables. Again, we adjusted for gender, age, education and religiosity. Cognitive SC was associated with both SRH and mental health in the total population, where respondents with higher cognitive SC reported better health. Adding the interaction of loneliness and cognitive SC to the model decreases the association, leaving it non-significant. The interaction was not significant both for mental health and SRH, in the total population. Cognitive SC was associated with SRH in towns C and D , however it was significant only in town D. Adding the interaction eliminated the significance. The interaction was significant only in town C, therefore there may be a significant moderating effect in town C. Cognitive SC was significantly associated with mental health in towns A, C and D, however, the direction varied. In Town A, the OR was 1.42 whereas in towns C and D the OR was 0.70 and 0.46 respectively. Adding the interaction eliminated the significance in all three towns. The interaction was significant for the two towns C and D. This suggests that cognitive SC may be a moderator in the association between loneliness and mental health in towns C and D . To test the mediation effect of cognitive SC on the association between loneliness and SRH we used the mediation analysis for the total sample and each town separately. There was no significant mediating effect for cognitive SC in the association between loneliness and SRH in the total sample or any of the towns separately. Cognitive SC was also not a significant mediator between loneliness and mental health in the total sample, and in the towns separately. Structural SC may serve as a moderator and a mediator in the association between loneliness and health, both SRH and mental health. This seems not to be true for all towns. Cognitive SC may be a moderator only for mental health and only in two of the towns, however not a mediator. It seems that the different components of SC vary in the way they mediate or moderate the ill effects of loneliness in the various communities and the two health measures. The reference categories of the dichotomized variables are: Gender = male, religiosity = religious, loneliness = not lonely, * p < 0.05 Bold. --- Discussion This study tries to understand if social capital , both structural and cognitive, can help alleviate some of the ill effects of loneliness on health in certain communities. Studying these associations might support communities and social services in directing their investments to prevent the ill effects of loneliness on health. The model we tested, which presents the association between loneliness and health and the effect of social capital on that association, indicated differences between cities. The direct association between loneliness and Self Reported Health and mental health, which was found in 3 of the 4 examined cities, is consistent with many previous studies [10,39,40]. As for the effect of social capital on this association, we separated the two components of social capital as was suggested by Rodgers and colleagues that each component of social capital represents a very different attribute of the community and may have very different effects on people in general. Putting them together under the umbrella of social capital does not suggest they have the same impact on society [41]. As part of the model, we analyzed the association of each social capital component with SRH and mental health. As in most previous studies, both cognitive and structural social capital were found to be positively associated with self-reported health in the total population and every town [16][17][18][19][20][21]. Less consistent findings were revealed for the association of social capital and mental health, as was reported by De Silva [15]. In 3 out of 4 cities, higher structural and cognitive social capital were associated with better mental health. In a review of cross-sectional and longitudinal studies measuring the association between social capital and common mental disorders [42] a negative association was found with cognitive social capital, but they did not find associations with structural social capital, except for studies among mothers in low-income settings, where participation in civic activities was positively associated with common mental disorders. Such a positive association we found only in town A. It seems that the type of social activities may influence the direction of the association. Croezen and his coauthors found that participation in religious organizations is negatively associated with depressive symptoms while participating in sports or social clubs or political organizations are positively associated with depressive symptoms [43]. In our analysis, we did not differentiate between types of social activities. Findings suggest that structural social capital serves both as a significant mediator and a moderator in the association between loneliness and health, both SRH and mental health. We found a stronger association between loneliness and SRH and mental health among people with a low level of structural social capital compared to those with high structural social capital. Therefore, it is possible that being in contact with other people via participation in social activities may serve as a possible intervention to dampen or alleviate the ill effects of loneliness on health. Coll-Planas et al. suggest it is an understudied intervention strategy [29]. In a qualitative focus group study, they describe the ways in which a weekly group-based program can alleviate loneliness among older adults by promoting peer support and participation [44]. In our present study, we suggest structural social capital may improve self-reported health in all communities, however, it may improve mental health only in two of the communities, not in the Arab communities. It seems that generalizing from one community to the other is not possible and we suggest that before attempting to utilize a specific intervention it should be studied in that specific community. In other words, the contextual social environment is a major attribute to the way loneliness and social capital may affect health. Cognitive social capital does not have a mediating effect. A moderation effect was found in relation to self-reported health in one town only and in relation to mental health in two of the towns. In the communities studied in these cross-sectional surveys, trust in social surroundings does not necessarily improve health. Several interesting differences were found between the towns, for example, in town A, which is the poorest town, the highest rates of loneliness were reported. This is consistent with the findings of the highest risk of loneliness in the least wealthy groups, which were described in the Survey of Health, Ageing and Retirement in Europe [45,46]. Loneliness in town A was negatively associated with structural social capital and the latter was associated with self-reported health, but there was no direct association between loneliness and SRH , as was found in the other towns. This may indicate that town A may differ from the other towns in its contextual social environment. Poverty may explain the differences to some extent, but of course, there may be other explanatory social factors not measured [47]. The social and cultural differences between the two populations are large, with the Arabs being a poorer population, and more collective [31,32]. The differences between the communities correspond with national data [48]. However, there were also differences between the two Arab towns in our study. The moderation effects identified in this study suggest that increasing the social contacts of lonely people, who may have a decreased ability to utilize resources available to help with their health, may affect their health by providing these resources to them. Cognitive social capital was significantly associated with both self-reported health and mental health in 3 out of the 4 towns. In town A, a weak association was detected with self-reported health and an association with mental health in the opposite direction. Similar to the results of town A in this study, in a previous study, trust was not associated with health among Arabs, however, in the Jewish community, it was [25]. The authors suggested that in more affluent communities, such as the Jewish communities, social capital may be associated with health to a higher extent and less so in more traditional communities. It may be that the concept of trust varies between the two communities, the more individualistic community and the more collective community. The lack of association between trust and self-reported health was reported in another study from South Africa [49], where the authors state that the results contradict many studies that do show these associations [50][51][52]. It seems that the impact of social capital on health varies with the setting, population and health measure [53]. Religiosity may also serve as a factor in the social context, as there were differences in religiosity between the towns, therefore it was important to adjust for this measure. Studies have shown that loneliness is more common in people without strong religious beliefs [54,55]. In this study, religiosity was associated with mental health in the total population and in the Arab town A but not in the other towns. Religiosity was associated with self-reported health only in the Jewish town D and not in any of the other towns, again suggesting variations in the social context in the different towns. Further studies should look at levels of collectivism that could have an impact on these relationships. Dykstra suggested that contrary to the assumption that people in individualistic societies are more lonely, northern Europeans tend to be less lonely compared to the more familistic southern European countries [56]. This corresponds with our results. Another aspect of the differences between the communities may be a cultural difference in how the different communities perceive loneliness. The questions used in this survey may vary in their validity and reliability between the communities, not only between Arabs and Jews, as suggested in several previous studies [57,58], but also between the Arab communities themselves, or the Jewish communities. In town A, people may tend to express and complain about feeling alone, more so than in other communities. As people in town A reported higher levels of loneliness, we would expect them to report less social activities, however, higher levels of participation in social activities were reported in town A compared to the other towns. As social activities were associated with lower levels of loneliness in all towns, the more activities within a community the less loneliness we would expect to find. The fact that even though people in town A reported high levels of loneliness and high levels of social activities suggests that in town A social activities do not alleviate loneliness in the same way as in the other towns [59,60], or as mentioned earlier, it may depend on the types of social activities [43]. Both social capital measures were higher in the Arab towns and lower in the mixed and Jewish towns. Other studies in the past suggested otherwise, where social capital measures were lower among Arabs [25]. The only measure of social capital that was higher among Arabs was social contacts, this measure may be a similar measure of social activities, even though they are measured in a different way. As the Arab community is a more collective community where close contacts are frequent, this is expected. However, in the previous study trust was higher in the Jewish community compared to the Arab community, but not so in this study. This may have changed with time and now present a true difference between the communities, or it may also be that town D, as the only Jewish town present in this study, do not represent other Jewish towns. In a study assessing acquiescence bias among Arabs and Jews, we found that Arabs tend to agree with questions more so than Jews [58]. Therefore, the higher rates among Arabs in this study could be due to this bias and not a true measure of their social capital. In town C, the patterns of association between the variables in this study are similar to the Jews in town D, especially for the Arab community when dividing the sample into the two communities, Arabs and Jews. Living in close proximity in the same town may have an effect on both communities. For example, Arabs in town C gave estimates of their health more similar to the Jewish population than to the Arab population in towns A and B, this may only be the effect of the SES level but may also represent the effect of cohabitation. In addition, social capital was lower in town C compared to towns A and B and more similar to town D. Therefore, it seems that living in a mixed town reduces social differences between the two ethnic communities. We may conclude that communities differ in the way social capital serves as a resource within that specific community and depend on the context of a certain community, for example, socioeconomic status and levels of collectivism. What specific attributes of a community are important in this context are not clear yet. In an important paper, Shiell et al. suggested rethinking social capital and social capital interventions aimed at improving health [30]. They suggest that studies measuring social capital and health inadequately take into account the context in which the study takes place. In their opinion, the way forward requires a renewed focus on specific components of social capital and how context affects the interaction between social capital and health. Our study supports these assertions. A few study limitations should be mentioned. The study is a cross-sectional study that cannot infer causality, therefore follow up studies are needed to ascertain the directionality of the associations between social capital, loneliness and health. The cross-sectional methodology is not the optimal methodology in many cases. However, according to Spector [61], the cross-sectional methodology is appropriate when the association between variables is not clear, the timeframe for the effect is not known and we want to measure the association in four distinct communities. This methodology can help assess preliminary ideas on how we can move forward to alleviate the ill effects of loneliness on health. The measure of loneliness is a single-item measure and as such is not ideal, however, there is no consensus on how to measure loneliness to date, standardisation is needed [62]. In other studies, certain parts of social capital are incorporated into the loneliness measure, such as frequency of contacts with friends, family and children and participation in social activities [47]. In this study, we assessed perceived loneliness as a single item and refer to levels of contact with other people separately as structural social capital. We do not regard this as a limitation of the study, on the contrary, separating the two aspects of loneliness provides a more in-depth analysis of factors effecting of loneliness and health. An additional limitation of the study is the possible difference in the validity and reliability of the measures in Arabs and Jews. This has previously been discussed. A broader look at the context of the communities is needed to further understand the complex dynamics between the studied variables and the possibility of how changing social capital can serve as an intervention to improve health [30]. --- Conclusions This study suggests that increasing structural social capital could possibly compensate for loneliness and alleviate the harm it can do to health. However, we cannot generalize from one community to the other or for the various components of social capital. Therefore, this study reinforces the need for the performance of separate health profiles and the assessment of possible interventions in each community separately. We may say that structural social capital is both a mediator and a moderator for the total sample with variations between the towns. --- Data Availability Statement: Data available on request. ---

Loneliness has been associated with poor health. Social capital (SC) could possibly prevent the ill effects of loneliness. The study aims to assess the association of loneliness with physical and mental health in four different communities in Israel and study the impact of structural and cognitive SC on that association. A cross-sectional face-to-face survey with 4620 adults in four towns was conducted. The questionnaire included self-rated health (SRH), mental health (MH), loneliness, cognitive and structural SC and socioeconomic characteristics. Logistic regression analysis and mediation and moderation effects were calculated. Loneliness was associated with worse SRH (OR = 0.4-0.5) and worse MH (OR = 2.0-10). Both SC variables were associated with health. However, towns differ in these associations. Structural SC serves as a significant mediator between loneliness and SRH in all towns and is a mediator between loneliness and MH in two towns. Cognitive social capital was a moderator between loneliness and MH in two towns. This study suggests that increasing SC could possibly compensate for loneliness and buffer its effect on health. The study reinforces the need for the performance of separate health profiles to assess possible interventions for each community, as not always can we generalize these results to all communities.

INTRODUCTION This article reports on outcomes from a randomized effectiveness trial of the New Beginnings Program , a program that has demonstrated positive effects in two randomized efficacy trials ). There are two primary functions of an effectiveness trial . The first is to translate the intervention developed as an experimental prototype to a service that can be effective when delivered in community agencies . The second is to test whether the positive effects observed in the efficacy trials can be generalized across "a wide range of populations, settings, and times" when the program is delivered as a community service. The public health significance of this effectiveness trial is supported by the high prevalence of divorce in the United States and the increased risk divorce confers for children in multiple areas of functioning . Next we describe findings from the efficacy trials of the NBP. We then summarize changes that were made to translate the program from an experimental prototype tested in the efficacy trials to a community service. Finally, we describe the questions addressed in this evaluation of the NBP as a community service. --- Findings from Randomized Efficacy Trials of the NBP The NBP is a group-based program designed to impact two factors that have been empirically associated with child outcomes following divorce-quality of parenting and child exposure to interparental conflict. The theory of the program is that program effects to improve these factors will lead to improved child outcomes following divorce. The initial randomized efficacy trial found that compared to families in a waitlist control group, families in the NBP showed an improvement in parenting and a reduction in child mental health problems at posttest . The second efficacy trial with mothers who had primary residency of children ages 9-12 tested the effects of the parenting program alone, the parenting program plus a concurrently run child coping program, and a literature control condition. The results indicated that at posttest there was a significant effect of the parenting program to strengthen parenting and reduce children's externalizing problems. At the 6-month follow-up, the parenting program reduced children's externalizing problems as reported by parents, children, and teachers. Follow-up evaluations at 6 years and 15 years found a broad range of benefits, including reductions in mental health problems and disorders, substance use and abuse, and high-risk sexual behavior ; less involvement in the criminal justice system; and use of mental health services , as well as improvements in indicators of positive functioning such as self-esteem and grade point average . Consistent with the program theory, many of these effects were mediated through improvements in quality of parenting . The findings from this trial indicated no significant additive benefit of the child coping program at any assessment, so most analyses compared the combined parenting program and the parenting-plus-child coping program to the literature control. --- Translation from an Experimental Prototype to a Community Service The NBP was delivered in both efficacy trials at a university prevention research center, and all aspects of implementation were controlled by the research team, including recruitment of participants as well as selection, training, and supervision of leaders. Translating the program into a community service required developing collaborations with the family courts to recruit families and with community agencies to deliver the program. A fuller description of the program translation process and the consumer research that informed these changes is presented elsewhere and is briefly reviewed next. We collaborated with four family courts in Arizona, which agreed to show a 12-min invitational DVD during the brief parent information program that was mandated for all divorcing and separating families with minor children. For the program to be acceptable to the court, we needed to offer the program to divorcing and separating families, fathers as well as mothers, and families with a broad age range of children . Further, the number of eligibility criteria was greatly reduced compared to the efficacy trials. Thus, the families in the effectiveness trial were expected to be quite different from those in the efficacy trials. Because Arizona has a large Hispanic population, we expected the sample to be ethnically diverse, as compared with the efficacy trials, where the sample was primarily non-Hispanic White. As compared to the sample of primary residential mothers in the efficacy trials, we accepted fathers and mothers with a broad range of parenting time as long as it was sufficient to practice the parenting skills taught in the program. The collaboration with the court in inviting parents and the broadening of the eligibility criteria enabled us to offer the program to the population of divorcing and separating families, thus greatly enhancing the potential public health benefit of the program. The program was delivered by providers in community agencies. The agencies were selected using a competitive solicitation process similar to the way the court normally solicits agencies to deliver services. As compared to the efficacy trials where we screened and selected leaders, the agencies selected the leaders to deliver the program. As described next, the program was modified to make it easier and less costly for community-based providers to deliver the program and to make it appropriate for delivery to an ethnically diverse population. --- Evaluation of the Effectiveness of the NBP An effectiveness trial provides a critical bridge between demonstrating a program's potential impact in an efficacy trial and assessing its impact when it is delivered at scale . The current article addresses two sets of questions that are important in establishing effectiveness of the NBP. First, does the NBP improve protective factors and reduce risk factors as well as improve children's adjustment? Program effects were assessed on the two theoretical mediators targeted by the program-quality of parenting and child exposure to inter-parental conflict. These mediators have been found to relate to outcomes for children of all ages , so it was theoretically appropriate for the program to target a broad age range of children. Program effects on children's mental health problems and competencies were assessed because short-term effects on these variables have been found to predict long-term effects in cascading models over 15 years . Second, are the effects of the NBP moderated by characteristics of the participants? Moderators of program effects were tested because prior evidence showed moderated program effects in the efficacy trials ) or because the sample included sufficient variability on participant characteristics to which we wished to generalize inferences about program impact . Testing generalizability of programs across populations is one of the major objectives of an effectiveness trial . We also tested level of interparental conflict as a moderator because of the intense interest in high conflict as a risk factor for poor outcomes of children following divorce ). --- METHOD Participants The sample consisted of 830 families randomized to NBP or comparison in which either the mother or father enrolled. The sample size was selected to have adequate power to detect main and moderated effects. At the pretest assessment, 262 of the 830 parents were divorced, 442 were legally married but divorcing, and 126 were never legally married but were in court to establish or change a parenting time agreement following separation. Parents were ethnically diverse. The Hispanic parents were primarily of Mexican heritage, with the remainder from Puerto Rico , Cuba , or another Latino country . Parents had a wide range of education . Parents ranged from 18 to 63 years old , and children ranged from 3 to 18 years old ; 47.8% of the children in these families were female. At the pretest assessment, mothers reported more overnights with their children in the past month than did fathers , t = -14.68, p < .01. The trial was conducted in partnership with family courts in two urban and two small-town, rural counties in Arizona. Parents were primarily recruited by viewing a 12-min invitational DVD shown during a 4-hr parent information program mandated for all parents seeking a divorce or separation. Parents provided demographic information, completed a 15item risk index previously shown to predict children's postdivorce adjustment , and indicated their interest in participating in a randomized effectiveness trial. Parents were also recruited through judge, lawyer, and self-referrals and through media announcements. Parents who expressed interest were screened by phone based on the following eligibility criteria: filing for divorce or modification of a divorce decree within the past 2 years or, if never married, being in court in the past 2 years to establish or change a parenting time agreement following separation; having at least one child age 3 to 18 with whom the parent spends 3 hours or more each week or one overnight every other week; being able to complete the program and assessments in English; and not being mandated to a parenting class by the Juvenile Court or Child Protective Services. Following completion of the pretest interview, 886 parents were randomly assigned using computer-generated random numbers, with a 53%-to-47% ratio for the NBP to comparison condition. These 886 parents included 112 paired parents in which both father and mother participated in either the NBP or comparison condition. However, we excluded data from the second parent enrolled in each of these 56 pairs, resulting in a sample of 830 parents for our analyses. The trial was conducted in four cohorts between 2012 and 2014. The CONSORT diagram in Figure 1 summarizes how many parents were invited, screened, randomized, and assessed at pretest, posttest, and 10-month follow-up. Data were collected in four Arizona counties using telephone interviews with parents and children and using online or paper-and-pencil questionnaires for teachers. During the pretest assessment, parents were asked for permission to interview their 9-to 18year-old children and for permission to interview the teacher of their 6-to 18-year-old children who were currently enrolled in school and not being homeschooled. Data were obtained at pretest, posttest, and/or 10-month follow-up from 559 of the 757 children age 9 or older and from teachers of 687 of the 712 eligible children whose parent provided permission to collect teacher-reported data. Parents and children were paid $50 and $30, respectively, for their interviews. Teachers in the first cohort were paid $10, and those in the second through fourth cohorts were paid $5 for their assessments. Interviewers were masked to condition. Success of masking was assessed at posttest and 10month follow-up by asking interviewers whether they thought they knew which condition the parent was in, and, if so, which condition; 95.4% at posttest and 95.3% at 10-month follow-up reported not knowing or answered with the incorrect condition. The study was approved by the Institutional Review Board at Arizona State University. --- Intervention and Comparison Conditions NBP-The NBP targeted three potentially modifiable parenting domains-parent-child relationship quality, children's exposure to interparental conflict, and effective discipline, all of which have been identified as being associated with children's postdivorce adjustment . The small theory of the intervention was that program effects to strengthen parent-child relationship quality and effectiveness of discipline and to reduce children's exposure to interparental conflict would lead to a reduction of child mental health problems . Drawing from social learning and cognitive-behavioral approaches, the NBP used parent training, videotaped modeling, role-playing, and weekly home practice to teach and review parenting skills during 10 group sessions and two individual phone sessions. Parents who did not attend a session were invited to come early to the following session and observe a 15-to 20-min self-administered make-up DVD that presented the skill taught in the missed session. The program was adapted from the NBP tested in the efficacy trials with divorced mothers of children ages 8-15 to prepare it for delivery on a much larger scale in community agencies . Parents received tips for using the program skills with children across the broad age range. A comprehensive process to broaden the program material and skills to meet the needs of the parents from diverse cultural groups was undertaken. Data from these sources were used to make modifications that maintained fidelity to NBP's core components but tailored presentation of the program skills to meet the needs of the parents from these groups . Prevention scientists and providers with expertise in working with Mexican American and African American families reviewed the protocol, and Mexican American and African American parents who participated in a pilot test of the program provided feedback. Across all the cultural informant types, the topics covered in the NBP were seen as appropriate cross-culturally. However, numerous suggestions for "surface structure" changes were made and implemented. For example, the program was modified to include more culturally relevant examples, the program activities were broadened to incorporate extended family members, and the videotaped skills demonstrations included greater ethnic diversity of the actors. Other changes included offering culturally sensitive rationales and explanations of program skills that were compatible with goals and values of ethnic minority parents; acknowledging the potential cultural barriers to specific program skills or recommendations, such as systematic reinforcement for positive behaviors and the NBP's recommendation against spanking; and providing more opportunities for all parents to consider ways to make program skills fit their cultural styles and preferences. For example, extensive reliance on good listening skills was perceived as conflicting with Mexican American and African American parents' role-based desires to provide advice and guidance to their children. We followed our cultural informants' suggestions to acknowledge these strong desires and the difficulty that parents might have using listening skills prior to or in place of parental advice and to augment the discussion of how just using good listening could benefit their children. The manual was revised to ease leader burden by providing DVD-assisted delivery, and a more economical training protocol was developed that included online training for each session. To reduce cost, the program was shortened from 11 sessions to 10 sessions and was delivered by a single leader rather than two as in the efficacy trials. The program was delivered to 26 mother groups and 24 father groups . Active Comparison-Whereas prior efficacy trials of the NBP used a waitlist or literature control condition, the effectiveness trial used an active comparison condition due to the necessity of offering a credible intervention to all families enrolled through the family courts. During two group sessions, the leader didactically presented the risk and protective factors targeted in the NBP. Parents were encouraged to exchange their ideas for strengthening postdivorce parenting skills and reducing children's exposure to interparental conflict. Parents were also asked to set goals that they wanted to accomplish in the program. Important to note, parents did not role-play parenting skills and were not instructed to practice the parenting skills at home. The program was delivered to 22 mother groups and 22 father groups . Group Leaders-The programs were delivered by 38 group leaders . Leaders each led only one experimental condition. --- Measures The time frame used for all measures was "within the past month." Parents completed the full battery of parenting skills and child behavior problem measures for a randomly selected "target child." Parents also completed the Child Monitoring Scale for all children age 9 or older.1 Data were also obtained from all children age 9 or older whose parent provided permission for the interview and from teachers of children age 6 or older who were enrolled in school and whose parent provided permission for the interview. We report internal consistency reliability at pretest where applicable as well as references for reliability and validity of measures. Parenting Skills-Parents and children responded to several measures assessing two dimensions of parenting skills: parent-child relationship quality and discipline. The same measures were administered to parents and children unless specified. Family routines were assessed by a seven-item adaptation of the Family Routines Inventory, which Jensen, James, Boyce, and Hartnett reported as having adequate reliability and validity . Involvement was measured by six items adapted from Menning assessing activities parents engaged in with their children . The scale has good predictive validity for father involvement following divorce . Communication was assessed by the 10-item Open Communication subscale of the Parent-Adolescent Communication Scale, which Barnes and Olson reported as having adequate reliability and validity . Closeness was measured by a single item, "How close do you feel to your child/ parent?" which has been found to predict well-being of children following divorce . Parents and children completed an 11-item version of the Child Monitoring Scale, which has been found to have good reliability and validity ; parents completed this measure for each target and nontarget child age 9 or older. The remaining measures completed by parents and children each had good reliability and predicted outcomes in a previous efficacy trial of the NBP . Parents and children completed three subscales of the Child Report of Parental Behavior Inventory : acceptance faults"; parent-report α = . 87, child-report α = .95), rejection , and consistency of discipline . Parents completed three subscales of the Oregon Discipline Scale : follow-through should have been punished for?"; α = .75 in this sample), appropriate use of discipline , and inappropriate use of discipline . A ratio of appropriate to appropriate plus inappropriate use of discipline was computed. Parent-Report Confirmatory Factor Analysis Model.: Parent-report of parent-child relationship quality and discipline were assessed using factor scores from a two-factor confirmatory factor analysis model estimated in Mplus 7.3 . Indicators of parent-child relationship quality were involvement, family routines, parentchild communication, closeness, and acceptance. Indicators of discipline were consistency, follow-through, and appropriate use of discipline . When fitting the two-factor model, we allowed involvement and family routines to correlate due to their conceptual similarity and acceptance and consistency of discipline to correlate due to being measured by items on the same scale. The two-factor model closely fit the data at pretest, χ 2 = 69.86, RMSEA = .06, CFI = .96; posttest, χ 2 = 57.77, RMSEA = .06, CFI = .97; and 10month follow-up, χ 2 = 41.25, RMSEA = .05, CFI = .97. When investigating measurement invariance across parent gender, the metric invariance model did not significantly deteriorate fit relative to the configural invariance model, and the scalar invariance model did not significantly deteriorate fit relative to the metric invariance model. The scalar invariance model closely fit the data at pretest, χ 2 = 102.18, RMSEA = .05, CFI = .96; posttest, χ 2 = 84.76, RMSEA = .05, CFI = .97; and 10-month follow-up, χ 2 = 94.05, RMSEA = .06, CFI = .95. When investigating measurement invariance across parent ethnicity, the metric invariance model did not significantly deteriorate fit relative to the configural invariance model, and the scalar invariance model did not significantly deteriorate fit relative to the metric invariance model. The scalar invariance model closely fit the data at pretest, χ 2 = 102.53, RMSEA = .06, CFI = .96; posttest, χ 2 = 101.35, RMSEA = .06, CFI = .96; and 10-month follow-up, χ 2 = 77.28, RMSEA = .05, CFI = .96. Thus, the measurement model for parenting was invariant across parent gender and ethnicity. Parent-report of rejection and monitoring were analyzed as two separate measures beyond parent-child relationship quality and discipline. We treated rejection as a separate measure because it did not load highly with the other indicators of parent-child relationship quality . We treated monitoring as a separate measure because parents completed this measure only for children age 9 or older but completed all other measures for children of all ages. Child-Report Confirmatory Factor Analysis Model.: Consistent with parent-report, we initially fit a two-factor model of parent-child relationship quality and discipline. Because these factors were highly correlated , we then estimated a one-factor model of positive parenting. Indicators of positive parenting were involvement, family routines, parent-child communication, closeness, acceptance, rejection, consistency of discipline, and monitoring. When fitting the one-factor model, we allowed involvement and family routines to correlate due to their conceptual similarity and acceptance, rejection, and consistency of discipline to correlate due to being measured by items on the same scale. The one-factor model closely fit the data at pretest, χ 2 = 53.25, RMSEA = .07, CFI = .98; posttest, χ 2 = 32.63, RMSEA = .05, CFI = .99; and 10-month follow-up, χ 2 = 44.58, RMSEA = .06, CFI = .98. Interparental Conflict-Parents reported on interparental conflict using four items that asked about children's exposure to conflict adapted from the Children's Perception of Interparental Conflict Scale that has previously been reported to have good reliability and validity plus two items written for this study that reported on arguing in front of the child . Only parent-reports about arguing in front of the child were used, because the program was designed to reduce exposure to conflict rather than the occurrence of conflict per se. Parents who reported no contact with the other parent were assigned the lowest score on this scale. Children reported on their exposure to interparental conflict using 13 items from the Children's Perception of Interparental Conflict Scale plus the two items concerning the parents arguing in front of them. Children also reported their perception of "being caught between their parents" using the seven-item Caught in the Middle Scale, which has previously been found to have good reliability and validity , and on their exposure to badmouthing using two items . Child Mental Health Problems-Parents completed the Child Behavior Checklist for children aged 6 to 18 and the Preschool CBCL for children ages 3-5 . The T scores were calculated for CBCL and Pre-CBCL subscales based on child age and gender and combined to assess internalizing, externalizing, and total problems across the broad age range . Children ages 9 or older completed the Brief Problem Monitor to assess internalizing , externalizing , and total problems. Teachers completed a parallel version of the Brief Problem Monitor to assess internalizing , externalizing , and total problems for children age 6 or older who were currently enrolled in school. The T scores for child-and teacher-reports were calculated based on child age and gender. Developmental Competencies-Teachers completed the Teacher-Child Rating Scale, which has previously shown good reliability and validity to evaluate learning problems , task orientation , frustration tolerance , assertive social skills , and social competence . --- Data Analytic Strategy We assessed the equivalence of families randomized to the NBP and comparison conditions on 33 parent-reported demographic and baseline measures using t tests and chi-square tests. Univariate and multivariate outlier analyses were conducted to identify influential data points . To assess the impact of attrition on internal and external validity, we compared the attrition rates across conditions using chi-square tests and performed 2 × 2 analysis of variance or logistic regression on each baseline measure . Intent-to-treat analyses were conducted by regressing each parent-, child-, and teacherreported outcome on condition and the following baseline covariates: baseline status on the outcome, baseline risk , county of residence, parent gender, and an indicator of whether both parents were enrolled in the effectiveness trial . All analyses were performed in Mplus7.3 using full information maximum likelihood estimation, which includes cases with missing scores. Intraclass correlations by intervention group were low , whereas ICCs by family were high . A sandwich estimator was used for the standard error computations to adjust for clustering by family for parent-report of monitoring, child-report, and teacher-report . We investigated whether the program effects were moderated by baseline status on the outcome, parent gender, parent ethnicity , child age, and interparental conflict, 3 one moderator at a time. Significant moderated effects were probed via simple main effects, which were computed at the mean and at 1 SD above/below the mean of a continuous moderator and at each level of a categorical moderator . To control the Type I error rate, we applied a false discovery rate correction separately for each domain of outcomes with multiple measures: parent-report of parenting; child-report of interparental conflict; and parent-, child-, and teacher-reports of child mental health problems and developmental competencies. For these measures, we report the main and moderated effects with FDR pvalues ≤ .10. For domains of outcomes with a single indicator, we report main and moderated effects with ps ≤ .05. Cohen's d is reported for the significant main effects and simple main effects . For all significant main or simple main effects on internalizing, externalizing, or total problems, we assessed clinical significance by comparing the proportion of children in the NBP versus comparison who moved from the clinical or borderline clinical range at pretest to the normal range at posttest or 10-month follow-up. --- RESULTS --- Preliminary Analyses The two conditions significantly differed on three of the 33 demographic and baseline characteristics. Relative to those in the comparison condition, parents in the NBP were higher on child-report of positive parenting and lower on child-report of interparental conflict and badmouthing at pretest . To adjust for these imbalances, we included these three baseline covariates in the outcome models and assessed the robustness of the results. None of the conclusions changed, so because including significant baseline characteristics to the outcome models is an inferior option to using covariates related to the outcome , we report the results without including these three baseline covariates in the outcome models. No influential data points were identified based on univariate or multivariate outlier analyses. 2 Parents completed all other measures only for the target child. Thus, clustering by family did not apply for the other parent reported measures. 3 Parent-report of interparental conflict scale served as the moderator for program effects on parent and teacher reported outcomes. When used as a moderator, the full 13 items of the adapted Child Report of Interparental Conflict scale plus the two arguing in front of the child was used to best capture the full range of conflict as a moderator of program effects. Child report of interparental conflict scale served as the moderator for program effects on child-reported outcomes. The attrition rates did not significantly differ across conditions at posttest, χ 2 = 0.44, p = .51, or 10-month follow-up, χ 2 = 0.58, p = .45. However, four of the 60 attrition status main effects were significant and two of the 60 Condition × Attrition Status interaction effects were significant. On average, parents who did not complete the posttest interview reported less education, lower risk, and fewer child internalizing problems at pretest than those who did, and parents who did not complete the 10-month follow-up interview reported less education than those who did. Parents in the comparison condition who did not complete the posttest interview reported fewer child externalizing and total problems at pretest than those who did. Parents in the NBP who did versus did not complete the posttest interview did not significantly differ on child externalizing or total problems at pretest. --- Treatment Integrity Of the 445 parents randomized to the NBP, 107 never attended, 92 attended between one and four sessions, 192 attended between five and nine sessions, and 54 attended all 10 sessions. The mean number of sessions attended was 5.59 . Interested readers should refer to Mauricio et al. for additional information on mothers' and fathers' attendance as well as attendance trajectory class differences on baseline characteristics. Of the 385 parents in the comparison condition, 65 never attended, 55 attended one session, and 265 attended both sessions. A significantly greater proportion of NBP parents than comparison parents never attended, χ 2 = 6.44, p = .01. Fidelity of implementation of the NBP was assessed by objective rater coding of leader behavior for one activity per session, selected to represent the different kinds of program activities . Activities were coded as totally completed , partially completed , or not completed at all . The mean fidelity of implementation score across activities was2.86, indicating a high level of fidelity to the manual. --- Effects on Parenting Skills and Child Exposure to Interparental Conflict Table 1 presents the results of the analyses for parenting skills and child exposure to interparental conflict at posttest and 10-month follow-up. Posttest-Parents in the NBP reported more effective discipline and greater monitoring relative to those in the comparison condition. Parent ethnicity moderated the effect of the program on parentreport of parent-child relationship quality and rejection , such that non-Hispanic White parents in the NBP reported greater parent-child relationship quality and lower rejection relative to those in the comparison condition. There were no significant main or moderated effects of the program on child-report of exposure to interparental conflict at posttest. 10-Month Follow-Up-The program effect on parent-report of monitoring was moderated by child age and baseline interparental conflict . Relative to those in the comparison condition, parents in the NBP reported less monitoring of younger children but greater monitoring of older children . Parents in the NBP who were at the mean or at 1 SD above the mean of baseline interparental conflict reported greater monitoring of their children relative to those in the comparison condition . At 10-month follow-up, there were no significant main or moderated effects of the program on parentreport of child exposure to interparental conflict or on child-report of parenting skills or exposure to interparental conflict. --- Effects on Child Mental Health Problems and Developmental Competencies Table 2 presents the results of the analyses for child mental health problems and developmental competencies at posttest and 10-month follow-up. Posttest-Parent ethnicity moderated the effect of the program on parent-report of internalizing problems , externalizing problems , and total problems . Non-Hispanic White parents in the NBP reported fewer internalizing problems , externalizing problems , and total problems relative to those in the comparison condition. Child age moderated the effect of the program on child-report of internalizing problems , such that younger children in the NBP reported fewer internalizing problems relative to those in the comparison condition . Child age also moderated the effect of the program on teacher-report of externalizing problems , task orientation , assertive social skills , and frustration tolerance . Teachers reported more externalizing problems , lower task orientation , and lower assertive social skills in the NBP relative to the comparison condition. Teachers reported lower frustration tolerance for younger children in the NBP but higher frustration tolerance for older children in the NBP relative to those in the comparison condition. 10-Month Follow-Up-Parent ethnicity moderated the effect of the program on parentreport of internalizing problems and child-report of internalizing problems and total problems . Relative to those in the comparison condition, non-Hispanic White parents in the NBP reported fewer internalizing problems and children of non-Hispanic White parents in the NBP reported fewer internalizing problems and total problems . There were no significant main or moderated effects of the program on teacher-report of child mental health problems or developmental competencies at 10-month follow-up. Clinical Significance-Follow-up analyses on the eight significant main or simple main effects on child mental health problems indicated that only two showed a significantly or marginally significantly greater proportion of NBP versus comparison children moving from the clinical or borderline clinical range at pretest to the normal range at posttest or 10-month follow-up. For parent-reported externalizing problems, a significantly greater proportion of non-Hispanic White children in the NBP than in the comparison condition moved from the borderline or clinical range at pretest to the normal range at posttest, χ 2 = 4.64, p = . 03,16.4% versus 9.3%. For child-reported internalizing problems, a marginally significantly greater proportion of non-Hispanic White children in the NBP than in the comparison condition moved from the borderline or clinical range at pretest to the normal range at 10month follow-up, χ 2 = 3.14, p = .08, 24.0% versus 14.8%. The percentage of children who shifted from the borderline or clinical range to the normal range are based on the full samples where either the parent or the children completed the pretest and 10-month followup assessments. The percentage of children in the borderline or clinical range at pretest, and thus were eligible to shift, did not differ significantly between the NBP and comparison condition for either child-report of internalizing problems or parent-report of externalizing . --- DISCUSSION This effectiveness trial tested whether the positive short-term effects of the NBP found in two efficacy trials could be obtained when the program was delivered by community agencies to a heterogeneous population of divorced and separated families. Significant moderated effects of the NBP to strengthen postdivorce parenting and to reduce children's mental health problems were found, with ethnicity of the parents and age of the children being the primary significant moderators. The findings are discussed in terms of explanations for the subgroup differences in effects and implications for translating the NBP into a community service. Similar to the two efficacy trials ), the NBP had a significant effect to strengthen multiple aspects of positive parenting as reported by both parents and children. However, the effect sizes were in the small range, whereas they were in the medium range in the efficacy trials. Such decreases in effect sizes from efficacy to effectiveness trials are common when psychosocial interventions are implemented in community settings and may be due to differences in the implementation of the intervention or characteristics of the participants. The fidelity of implementation in the current trial was quite high and comparable to that reported in the second efficacy trial . However, participant attendance was considerably lower in this trial as compared to the second efficacy trial . In the current trial, 24.0% of those randomly assigned to the NBP never attended a single session and 44.7% attended four or fewer sessions. It is likely that effect sizes on parenting outcomes in the effectiveness trial were attenuated by families who attended no or very few sessions. Although the NBP led to positive changes in discipline and monitoring for non-Hispanic White and Hispanic parents, the NBP improved two aspects of parenting and decreased child mental health problems at posttest and 10-month follow-up for non-Hispanic White parents only. In addition to the program effects being nonsignificant for the Hispanic parents, the effect sizes were very small for this group and often favored the comparison condition . These differential effects may be due to lower attendance among Hispanic parents and a greater likelihood of dropping out after the first few sessions among Hispanic mothers . A second possible explanation is the lack of ethnic match between the Hispanic parents and their group leaders . For Hispanic families, 76% in the NBP had a non-Hispanic group leader, whereas only 57% had a non-Hispanic group leader in the comparison condition. These possibilities are not independent; for example, it may be that lack of ethnic match with group leaders had a negative impact on attendance of the Hispanic families. Ongoing work is exploring these as possible explanations for the lack of program effects for Hispanic families. A third potential explanation for the lack of effects for Hispanic families is lack of measurement equivalence. However, findings from the test of measurement invariance across ethnicity in the assessment of parenting just reported makes this explanation unlikely. Research is also needed to investigate whether the failure of the NBP to impact parent-child relationship quality and rejection for Hispanic families might reflect cultural differences in the meaning of these constructs or a cultural mismatch with the intervention strategies. The lack of Program × Parent Gender interaction effects on parenting or child mental health outcomes indicates that the program, which was originally tested with mothers, is also appropriate for fathers. The only indication of differential program effects across parent gender was a marginally significant Program × Parent Gender interaction effect on childreport of positive parenting. Tests of the simple main effects indicate a positive effect of the program to improve child-report of father positive parenting but not mother positive parenting at posttest. Because divorced fathers have increasing parenting time over the past decades and prior interventions for divorced parents have focused on mothers , there is a pressing need to understand the effects of preventive interventions for divorced fathers. A separate publication focuses on the father subsample and presents additional encouraging evidence of NBP effectiveness on father parenting and child mental health . For teacher-report there was a pattern of iatrogenic effects at posttest for children age 8 and younger on externalizing problems, task orientation, assertive social skills, and frustration tolerance, although there was a positive effect on frustration tolerance for the older children. In the efficacy trial , there was also a negative effect of NBP on teacher-reported shy-anxious behavior at posttest. Concern about long-term negative effects of NBP is mitigated because in the current trial , none of the negative effects persisted at follow-up. In the current trial, the only marginally significant difference between the groups at 10-month follow-up favors the NBP. It may be that the changes parents engaged in during the program were difficult for younger children to integrate immediately and led to some short-term distress on their part, which was manifested in their behavior at school. The fact that this effect was only reported by teachers may be because teacher ratings of child problems are only modestly correlated with those or parents or children , indicating that teachers provide a unique perspective on child behavior problems. The use of an active control condition is an important strength of this study. Other research has found that although there were positive effects of prevention programs when compared to passive controls, there are often no significant effects when interventions are compared to active controls . Given that the active control condition and NBP both included didactic presentation of material on the risk and protective factors, the positive effects of the program in the current trial may be due either to the dosage or to the active components of the NBP . Consistent with the latter explanation, Berkel et al. found that effective home practice of program skills significantly predicted improvements in parenting in this sample. Two limitations of this study need to be noted. First, there were significant Condition × Posttest Attrition Status interaction effects on child externalizing and total problems at pretest, which potentially threatens the internal validity of the findings at posttest. However, using full information maximum likelihood estimation and including baseline status on the outcome as a covariate in the model mitigate bias from this threat to internal validity . Program effects at the 10month follow-up are less likely to be affected by this threat to internal validity. Second, it is not known whether the program effects generalize to other ethnic or demographic subgroups that were not tested. Although the current sample was diverse in terms of ethnicity , age of child , and gender of parent, further research is needed to test program effects on other subgroups . The findings from this effectiveness trial are encouraging of further work to translate the NBP from an experimental prototype to a community service. Similar to others , we see the translation from efficacy to sustainable community service as an ongoing process, guided by feedback from implementation in community settings. Three aspects of the feedback from the current trial will be critical for ongoing implementation of the NBP. First, the partnership with the family courts allowed the program to be presented to a large number of divorced and separated families. Building on this partnership is a promising direction for future implementation of the NBP. Second, the low level of enrollment and attendance, which is typical of implementation of parenting programs in the community, indicates the need for research on ways to increase the uptake of this program. Third, the lack of program effects on Hispanic children's outcomes indicates the need for further study on how to strengthen program effects with this subgroup and to study the NBP's effects in other ethnic groups. This research should be conducted within the framework of an ongoing collaboration with community providers with the goal of constantly learning how the NBP can best be used to improve outcomes for children following parental separation and divorce. --- FUNDING This research was funded by grant # R01 DAO26874 from the National Institute of Drug Abuse, which is gratefully acknowledged APPENDIX A Adjusted means by parent ethnicity for parent reported parent-child relationship quality at posttest. Note. The asterisk denotes a significant mean difference between the New Beginnings Program and comparison conditions. --- APPENDIX B --- FIGURE C2. Adjusted means by parent ethnicity for parent reported rejection at posttest. Note. The asterisk denotes a significant mean difference between the New Beginnings Program and comparison conditions. --- FIGURE C3. Adjusted means by parent ethnicity for parent reported internalizing problems at 10-month follow-up.Note. The asterisk denotes a significant mean difference between the New Beginnings Program and comparison conditions. --- FIGURE C4. Adjusted means by parent ethnicity for child reported internalizing problems at 10-month follow-up.Note. The asterisk denotes a significant mean difference between the New Beginnings Program and comparison conditions. CONSORT diagram summarizing how many parents were invited, screened, randomized, and assessed at pretest, posttest, and 10-month follow-up. d Hispanic = 0.17 for parent-reported internalizing problems at 10-month follow-up; d Hispanic = 0.20 and 0.23 for child-reported internalizing and total problems at 10-month follow-up; . Specifically, the direction of the simple main effects favored the comparison condition for parent reported externalizing problems at posttest; parent-reported internalizing problems at 10-month follow-up; and childreported internalizing and total problems at 10-month follow-up.

This study presents findings from a randomized effectiveness trial of the New Beginnings Program (NBP), which has demonstrated efficacy in 2 prior randomized efficacy trials. Family courts in 4 counties facilitated recruitment of divorcing and separating parents, and providers in community agencies delivered the program. Participants were 830 parents of children ages 3-18 who were randomized to receive either the 10-session NBP or an active 2-session comparison condition in which parents learned about the same parenting skills but did not complete home practice of these skills. Parents were ethnically diverse (59.4% non-Hispanic White, 31.4% Hispanic, 9.2% other race or ethnicity). Multiple rater assessments of parenting, interparental conflict, and child mental health problems were conducted at pretest, posttest, and 10-month follow-up. The results indicated positive moderated effects of the NBP as compared with the active control condition to strengthen parenting at posttest and to reduce child mental health problems at posttest and 10 months. Many of these moderated effects showed positive benefits for non-Hispanic White families but not for Hispanic families. The findings indicate support for the effectiveness of the NBP when delivered by community-based agencies but also indicate the need for further adaptations to make the program effective for Hispanic parents.

Introduction Cancer is a common health issue in Latin America, being the second cause of mortality in most of the region and causing 19% of all deaths. In this region, cancer mortality burden is considerable since its presentation often occurs at more advanced stages in a context of poor access to cancer care , leaving patients and their families exposed to a poor quality of life and impoverishment due catastrophic expenditure . Although Latin America has achieved important advances in Palliative Care , there is still a considerable gap in PC access and coverage . Regarding to Chile, in a recent report describing the gaps in PC access, there has been a progress in access to PC for cancer patients with a coverage of 93%, but this coverage focuses mainly on pain management with little coverage for non-pain symptoms . This scenario may be even more challenging for PC planning because of delayed cancer diagnosis due the COVID-19 pandemic . Patients with advanced cancer experience symptoms and functional decline throughout the course of their disease, particularly during end of life , requiring support to perform self-care activities . Caregivers of cancer patients are usually family members or friends who provide uncompensated care to a patient, helping with daily living activities -such as bathing, feeding, or mobilization, in performing nursing taskssuch as administration of medications or treatment monitoring, and in providing emotional support when required, among others . As their primary source of support, family caregivers are also exposed to several other strains, such as rearrangement of functions and roles within the household and dealing with work issues and with own personal emotions . Addressing FCs' burden must consider a very broad perspective using subjective and objective aspects. Subjective burden has been conceptualized as the perceived physical, emotional, social, and financial distress as a result of caring for a person with a serious disease , whereas objective burden refers to the amount of time spent on caregiving and the number of tasks that are performed . To our knowledge, few publications have described in Latino communities the objective and subjective burden of care that FCs experience while caring for advanced cancer patients. Also, limited reports have described simultaneously how caregiver and patient characteristics jointly influence caregiver burden experience. Since intensity of stressors vary across different ethnic and cultural groups , among Latino's cultural values, familism must be considered . Indeed, this value may increase FC distress according to the perceived family duties when caregiving difficulties arise . As familism can be associated with strong feelings of reciprocity and loyalty among members of the same family, it is possible that caregiving burden could be underperceived by FCs . Therefore, it seems relevant to better understand the caregiving phenomenon among Latinos to describe the frequency of perceived burden related to these tasks and to identify specific factors associated with it. The aims of this study are to describe the caregiving phenomenon in a population of FCs of advanced cancer patients in a Latino community and to identify patient and caregiver factors associated with subjective burden. --- Methods --- --- Measures Baseline assessments included demographic information such as age, gender, marital status, education, and religion of both patients and FCs. In addition, we included the following validated measures in Spanish: the abbreviated Zarit Caregiver Burden Scale , the Edmonton Symptom Assessment Scale , the Hospital Anxiety and Depression Scale , and the EORTC QLQ-C15-PAL . Data about financial distress, spirituality, and religiosity were collected from patients, whereas FCs were asked to complete single-item questions describing the tasks and activities they performed to characterize the phenomenon of caring. --- Zarit caregiver burden scale The abbreviated Zarit Caregiver Burden Scale was employed to assess the level of subjective caregiver burden. It consists of a 7item questionnaire in which FCs are asked to rate in a 5-item Likert scale how much burden was perceived for different tasks. Scores range between 7 and 35 points, with higher scores meaning higher subjective burden. This instrument was validated in a Chilean population of outpatient FCs. It showed an internal consistency of 0.84 and defined a cutoff of 17 points to consider the FC as experiencing high-intensity burden . This cutoff was defined using an receiver operating characteristic curve and was similar to the cutoff obtained in a Spanish validation of the instrument . --- Edmonton symptom assessment scale A Spanish version of the ESAS was employed to examine the average intensity of 10 symptoms in advanced cancer patients over the past 24 hours. Each of these symptoms is rated from 0 to 10 on a numerical scale . --- Hospital anxiety and depression scale Psychological distress was measured using the Spanish version of the HADS . This 14-item instrument consists of 2 subscales, one for depression and one for anxiety. A score of 8 or higher is considered clinically meaningful for each one of them. The HADS has been previously validated in Spanish, and the internal consistency was reported as 0.75 . Financial distress and spiritual pain were assessed with single-item questions in which patients reported intensity of FD or SP in a 0 to 10 scale, with 0 meaning that patient had no FD or SP and with 10 meaning that the patient had the worst possible FD or SP. Objective burden of care was assessed by single-item questions that were asked to the FC and included "have you taken care of the patient for at least one year?, " "do you live with the patient?, " "do you take care of the patient every day?, " "how many hours per day do you take care of the patient?, " "do you also hold a full-time/part-time job?, " "do you share caregiving responsibilities with someone else?, " and "have you ever had any type of training in caring for people with cancer?. " --- Statistical considerations Descriptive statistics were used to summarize our data. For continuous variables, we reported sample size, mean, and standard deviation for normally distributed variables and median and interquartile range for non-normally distributed variables. For categorical and binary variables, frequency and percentage were reported. Univariate analysis was performed using the abbreviated Zarit Caregiver Burden Scale as the primary outcome. We explored the association between each of the variables with subjective burden, variable that was dichotomized into 2 categories: FCs with intense subjective burden versus FCs without intense subjective burden. T-test, Wilcoxon rank sum test, or chi-square test were used as required. We then performed a multivariate logistic regression analysis to assess the effect of categorical and continuous covariates on subjective caregiver burden intensity, adjusting for possible confounders. For the multivariate analysis, we considered all patient and caregiver variables that were significantly associated with intense subjective burden of care in the univariate analysis, except for patient-reported symptom intensity due to the high correlation between caregiver and patient-reported symptom intensity. It is important to highlight that all variables included in the multivariate model, theoretically, could influence the experience of subjective burden. For example, it has been reported that spirituality, as a proxy of religion, is associated with caregiver burden in caregivers of chronic conditions . Then, we proposed a model to predict intense subjective caregiving burden, using backward and forward selection strategies, with the whole model using both 0.05 and 0.1 cutoffs to create a new simpler model. Using likelihood ratio test, we then assessed whether the final model was nested under the larger original model. Finally, we estimated sensitivity, specificity, and discriminatory capacity of the final model using the ROC curve. All computations were carried out in a standard software package . --- Data protection and confidentiality The study was approved by the local Ethics Committee . All participants provided signed informed consent. Health information was protected, and data confidentiality was maintained throughout the study. Only trained personnel in maintaining confidentiality and the Primary Investigator had access to study records. --- Results A total of 207 advanced cancer patients in PC and their FCs were included. Caregiver and patient demographics are described in Tables 1 and2, respectively. The mean age of FCs was 50 years, and 78% were women. The most common relationships with the patients were being the spouse or children . Sixty-six out of 207 FCs reported high-intensity subjective burden of care. Figure 1 shows the distribution of the abbreviated Zarit Scale scores. Regarding questions assessing objective burden of care, we found that 82% of the FCs take care of the patient daily, with a mean Karnofsky performance status , mean 67 68 66 0.24 Quality of life , mean 65 68 ( 27 Has taken care of the patient 1 year or more. --- Percentage Intense caregiving burden No caregiving burden In the univariate analysis between caregiver burden with FCs' characteristics, high-intensity subjective burden of care was associated with caregiver depression and anxiety . Also, subjective burden of care was significantly associated with FCs' higher perception of patient fatigue, drowsiness, depression, anxiety, and poor well-being . Regarding patients' characteristics, highintensity subjective burden of care was significantly associated with patient-reported religion and lower patient-reported QOL . Although not statistically significant, there was a trend between high-intensity subjective burden of care and patientreported SP. Intense subjective burden was also associated with patient-reported fatigue, drowsiness, anxiety, depression, and poor well-being. Intense burden was also more frequent among FCs who took care of the patient without help and a trend among FCs who take care of the patient daily but was not associated with other variables reporting objective burden of care . In the multivariate analysis, we found that caregiver depression , caregiver anxiety , taking care of the patient alone , caregiver perception of patient's fatigue , and having a religion other than Christian or being atheist remained independently associated with high subjective caregiver burden . To create a simpler model, we performed both backward and forward selection strategies and different cutoffs as described in the Methods section. Using the different strategies, we identified a final model that included 4 variables. We found that caregivers with depression had 2.45 odds of reporting high subjective burden than caregivers without depression and that caregivers with anxiety had 2.49 odds of reporting high subjective burden compared with those without anxiety . We also found that caregivers who took care of the patient alone had 2.73 odds of reporting high subjective burden than those who had help . Finally, we found that the odds of high subjective burden among caregivers increased 1.31 times per each 1 point increase in caregivers perception of patient fatigue . Using the LR test, we found that a simpler model was nested under the larger model , suggesting that the final model is more parsimonious and therefore better. To estimate the usefulness of this model, we estimated its sensitivity and the specificity to predict intense caregiving burden. The sensitivity of the model was 48% , and the specificity was 90% . The positive predictive value was 69% , and the negative predictive value was 79% . The area under the ROC curve was 0.78, indicating that the model had a good discrimination capacity. --- Discussion This study reveals that FCs of advanced cancer patients from a Latino community experienced high-intensity subjective burden, which is associated with increased objective burden, such as taking care of the patient alone, as well with caregiver psychological distress and caregiver perceived patient fatigue. This finding adds to current literature, demonstrating that caregiver burden intensity is not only associated with caregiver psychological distress but also independently associated with objective measures of caregiving burden, highlighting the relevance of these 2 components in the experience of FCs . Our proposed model has good discriminatory capacity and has a high specificity, allowing the model to identify FCs with lower probability of high-intensity subjective burden in a high-risk population. To our knowledge, this study is the first to find these associations in an advanced cancer population in Latin America. In our study, most of FCs are female and first-degree relatives, similar to what has been described elsewhere . Prevalence of burden observed in this study is also consistent with previous global evidence showing that the proportion of FCs who reported high levels of subjective burden varied from 35% to 56% . These results confirm that this population share a common experience with FCs around the world. We also report that a large proportion of FCs experience a considerable objective burden of care, including an extended period taking care of the patient, taking care of their loved ones in a daily basis and with lengthy daily schedules, and most of them actually living with the patient. Interestingly, we find that objective burden is higher among FCs who did not have someone to share caregiving responsibilities with, and this association remains significant in the multivariate analysis. This finding is related with a report by Park and colleagues who observed in a Korean population that FCs of cancer patients who shared caring responsibilities were less likely to experience the negative aspects of caregiving . We also observe a nonsignificant trend in the univariate analysis, showing that providing care during a considerable number of hourssuggesting a high level of caregiver engagement -could also influence caregiving burden experience . The proportion of FCs reporting a considerable objective burden of care reflects that this is a homogeneous population, which may have challenged our ability to find other associations between high subjective burden of care and other objective burden variables. These results together suggest that it is likely that intense caregiving burden is underreported in this population, as only a third of FCs are categorized as experiencing high-intensity burden, although individual variables related to objective burden are much more frequent. Latinos have strong family relationships in which providing care to both healthy and sick relatives is considered a part of it. Reporting caring as burden could be seen as not loving their family member or could also being experienced as guilt . Studies on Chinese population also show the protective factor of filial piety against the level of subjective burden ). Another hypothesis could be that other factors besides objective burden could influence the experience of care. Literature from dementia patients suggests that the caregiving experience, whether it is perceived as a burden or not, is influenced not only by "objective" factors such as patient symptoms or the intensity of the caregiving demands. Caregiving was also influenced by more qualitative factors such as the quality of prior relations, the meaning attributed to caring, and the experience of reward in taking care of a loved one . Literature among FCs of cancer patients addressing this phenomenon should be studied in the future. Another concerning finding in this study is that most FCs have not had training in caregiving skills. This shows that FCs are disregarded by the health-care system even when they are a cardinal part in it. Besides experiencing objective burden, this population does not have support in improving their abilities to take care of their loved ones exposing them. Interventions in caregiving skills, social support, or respite care could be possible alternatives to support this vulnerable group . FCs with symptoms of anxiety and depression are more likely to report a high-intensity subjective burden of care. Similar findings were noted in several previous studies ; only one publication has reported this finding in people from Latin America . It is well known that cancer is a highly stressful event, which may constitute a traumatic stressor for many people including family members. Therefore, psychological problems in FCs of advanced cancer patients, such as depression and anxiety, could be increased due to high intensity of care needs and a dramatically increased use of formal services at EOL . Patient symptoms such as fatigue, drowsiness, depression, anxiety, and poor well-being and caregiver perception of those symptoms are also associated with high subjective caregiver burden. This is in line with findings from previous studies . In PC, it is common that patients experience various physical and psychological symptoms . Therefore, FCs who assume the task of interpreting and monitoring patient's status reported a considerable burden. High levels of burden is associated with FCs whose patients reported poor QOL. This finding contrasts with a German study by Krug and colleagues in which caregiving burden was not associated with a decrease in patient QOL . It is known that QOL of advanced cancer patients is directly related to the number of symptoms and the possibility of improving symptom control . It is possible to hypothesize that burden of care increases as FCs realize that regardless of the activities performed, none of them improves QOL of their patients during the EOL. Some authors indicate the importance of understanding reciprocal suffering in the caregiver-patient relationship . This supports the idea that all efforts of PC teams should focus on the dyad rather than the patient or caregiver separately. One novel aspect of this study is the proposal of a model to identify FCs with high burden. This model includes the presence of depression, anxiety, taking care of the patient alone, and caregiver perception of patient fatigue. The presence of any or more than one criterion in each caregiver increases their likelihood of experiencing high-intensity burden. As the model has a good specificity, it can be thought of as a diagnostic rather than a screening tool. All these findings are relevant for Latin American countries as caregiving is usually performed by family members who lack support from public institutions, from the community or other family members, and therefore is commonly underrecognized as a health problem . Highlighting this issue in the region could contribute to increasing awareness of its frequency and impact in this population to reveal its relevance as a health issue in the public discussion and promote the implementation of policies to prevent this experience before burden becomes critical. Limitations of this study must be noted. First, this study involves secondary data; therefore, the study was not powered to detect associations with specific variables. Of note, the unequal distribution of the sample sizes of the main outcome could have decreased the ability to detect other statistically significant differences. Regardless of this limitation, we were able to detect some difference between the groups, making these findings relevant. Second, the cross-sectional nature of this research does not allow us to suggest causality. However, the exploratory nature of this analysis allows us to generate new hypothesis for future research. Third, all patients recruited to this project were receiving PC in a single public hospital. Thus, our findings should not be generalizable to all Chilean or Latin American population. In summary, FCs of advanced cancer patients enrolled in a PC unit from a public hospital in Santiago de Chile experience high burden of care frequently, which is independently associated with caregiver anxiety and depression, lack of help with caregiving, an indicator of objective burden, and FCs' perception of patient fatigue. These findings suggest the need of psychosocial support to FCs to improve mental health outcomes and decrease caregiver burden. It also suggests that strategies should be implemented at the institutional level to better support FCs to prevent or decrease burden of care. --- Competing interests. None.

Pérez-Cruz PE (2023) . Objective burden, caregiver psychological distress, and patient religion and quality of life are associated with high-intensity burden of care among caregivers of advanced cancer patients in a Latino population. Palliative and Supportive Care.

Introduction Health inequities must be analyzed from the angles of critical epidemiology and intersectionality, in a simultaneous, totalizing and dialectical manner. Therefore, a joint effort must be made to appreciate the richness contained in the transversality of gender, social class, occupation, ethnicity and spatial position in the social determination of health. Power relations permeate the entire framework that determines inequities in society, in an intersectoral perspective, overflowing their effects on the health levels [1][2][3]. In the case of gender and ethnic differences in the productive insertion, it is necessary to take into account the qualification and discrimination levels, which are reflected in the design of positions, salaries and institutional hierarchies, against a patriarchal and racist society, determining the gender-imposed role choices. It is known that the discrimination factors in the world of work are greater in relation to gender than to ethnicity, as the latter suffers a more profound type of discrimination, related to education and qualification, which has its roots in social and power relations of the historically constructed slave society [4,5]. The ideal society for the capitalist system to function is the patriarchal society, with the white man exercising control over others, including nature [6,7]. Incidentally, from the point of view of socioenvironmental determination, the capitalist accumulation system is characterized by exhibiting an oppression, exploitation and expropriation model, with consequences for health. The right to health becomes increasingly frail, with the commodification and privatization of essential services, previously provided by the public sector, increasingly fraying the social fabric on which it is anchored [8][9][10]. Intersectionality, on the other hand, is based on the understanding that we are shaped by the interaction of distinct social positions, which occur in an environment and power structure context, such as laws, policies, governments, social institutions, religion and media. Through these processes, independent forms of privilege and oppression are created, under colonial-imperialism, racism and patriarchy [11]. These relationships are expressed from the very conception of the right to health and its respective implemented health policies, to health access and actions, favoring or hampering its promotion, prevention and recovery [12]. Moreover, the time period required for inequity to manifest itself in population health levels would be of five years, with a peak at seven years and decreasing after twelve years [13]. In the perspective of understanding how inequities germinate in the Brazilian socioenvironmental space, and that of the state of Sao Paulo, we start out from its socioeconomic background, which is marked by a dependent model of capitalism. Some of its characteristics are the distancing of the internal productive structure from the workers' collective needs, the workforce overexploitation and the premature wearing out of workers, with low wages and local taxes that are more advantageous to central economies [14]. Regarding the state of Sao Paulo, Brazil, which accounts for 31.93% of the Brazilian gross domestic product [15], its development model, with decentralized industrialization since the 1970s, has brought many benefits, but also many contradictions. We point out that the cities of Campinas and Ribeirão Preto benefited from industrial and agro-industrial development in a more equitable model, bringing well-being to the countryside, with smaller agglomerations than those surrounding the capital city. Thus, the model developed in the metropolis was quite harmful to its surroundings, which, despite achieving high success rates in education, failed to distribute its income in an adequate manner. Those regions that grew in a complementary way to the capital city had its advantages, as long as they were not too close, where the model acquired serious contradictions and generated dependencies [16], including health care. To analyze how the social determination of health is inscribed in the territory of the state of Sao Paulo, it is necessary to understand the configuration of the Brazilian Unified Health System in networks and regions, aiming to guarantee the principles of universality, integrality and equity. The Brazilian Health System is a dual system, with a public health system denominated SUS , free and universal, which is 32 years old, and coexists with the private sector in a complex dynamic, with 75% of its population depending solely on the public sector. Despite its principles of universality, integrality and equity, it struggles with reduced health financing and a rather insufficient proportion of public expenditure, less than half of Brazil's total health spending as a proportion of GDP of 8% [17]. The SUS, regardless of its chronic lack of funding, has greatly improved the population's health conditions, ensuring increased access to health services altogether and specifically to primary care [18]. This is due to the fact that it offers an important proximity to the local population with a great amount of capillarity, especially in its primary health care services. It has also greatly increased ambulatory and specialized procedures, although being constantly threatened by private-public provision arrangements, which try to shift its healthcare model and do not relieve the public system. These arrangements depict the articulation between three complexes: the medical-industrial, the medical-financial and that of support services, contributing to further increase inequities in funding, access and utilization of health services [17]. The SUS regionalization process has been going through different phases since its implementation, which took place rather late and slowly, but with considerable advances. It is important to emphasize that the current phase derives from the implementation of Ordinance n. 4.279/2010 and Decree 7.508/2011, with successive changes in network and region conceptions, until they reached the health care networks in negotiated and contracted regions. This pact occurs between the government levels and brings greater flexibility and gains due to scale, with resources bounded to thematic networks, extrapolating health regions and reconfiguring them, aiming to reduce disparities in the provision of health services, but also bringing about the need for finer adjustments between levels [19]. In 2011, the criteria and strategies for the construction of regionalized health care networks were gathered in the state of Sao Paulo, based on the sufficiency of primary, medium and part of high complexity care; population between 1 and 3.5 million, economy of scale and maintenance of the territory of previously constructed health regions and their assistance flows. They are characterized by their complex design, which combines homogeneous services in heterogeneous areas, considering thematic networks and the diversity of institutions and actors, in addition to conflicts between regions, fragmented in their equality or united in their differences, with major governance challenges [20]. Considering the different SUS network and region conceptions, we realize that the main socio-spatial and access inequities in health care were addressed; nevertheless, health levels inequities were completely disregarded. Therefore, the mismatches between efficiency, effectiveness and equity were thoroughly experienced during this process. Moreover, the relation between these concepts is complex and specifically for Brazil, few studies on local health efficiency have been carried out. Nearly two-thirds of the efficiency studies performed globally [21] were about productive, technical or scale efficiency in health services. Furthermore, these kinds of efficiency analyses with the frontier methods seek a more organizational view, whereas effectiveness and allocative efficiency stand on a programmatic level. Very few studies were based on health systems , and, to our knowledge, even fewer were developed on local health systems or on a systemic level, which includes health equity as a cross-sectional dimension. As examples of well-founded studies at the local level, we point out that of Sousa et al. [22], who presented efficiency scores about general services in Brazilian municipalities; Marinho [23], who analyzed the efficiency of the provision of health services in municipalities in Rio de Janeiro; and Souza et al. [24], who sought to assess the productive efficiency of the public hospital sector in the cities of São Paulo. Stochastic and non-stochastic efficiency frontier methodologies were used, combined with regression models, as well as bootstrap and jackknife methods, in order to reduce the effects of outliers. There are also studies focusing on primary health care , which attempted to differentiate the relative efficiency of health actions and health outcomes in Brazilian municipalities [25] and relate efficiency to the view of health professionals, in order to assess health promotion in selected municipalities in Minas Gerais [26]. In addition to the small number of Brazilian studies that specifically address health efficiency, in addition to simply testing the methodology or working particularly on productive, technical and scale efficiency, most of them address aspects more focused on health service outcomes and not health system outcomes at the local level. The aim of this article, therefore, is to assess the role of equity in health in determining societal health levels, in a local effectiveness and efficiency analysis of Brazil's SUS, among Sao Paulo state municipalities. Hence, we intend to strengthen the analysis of the association between social inequities and vulnerabilities and the effects experienced in health and in life, taking into account the particular organizational design of Sao Paulo state. --- Method In order to assess local health efficiency in a comprehensive equity-concerned framework, the following dimensions were considered: material and financial resources, products and services of health production and intersectoral variables. This selection allows evaluating the efficiency of input resources at health levels, with technical and allocation efficiencies combined, as well as productivity in health and effectiveness, associating health intermediate results to its final impacts [27]. The effect variables considered were life expectancy at birth and infant mortality , for all the statistical models. The variable selected to measure inequity was chosen in a intersectional perspective, associated with inequity by gender and ethnicity, from a socioeconomic and cultural point of view. Along these lines, other intersectoral variables tested were inequity by ethnicity in the proportion of vulnerability and unemployment. From the governance perspective, the municipality's transparency index was evaluated, according to an instrument of the Federal Prosecution Ministry . Unlike most international panels, there is no solid set of indicators in this area, much less at the municipal level. From the environmental point of view, variables related to basic sanitation were tested, such as water supply, waste disposal and the existence of sanitary sewage. The time period considered was ten years, with observations ranging from 2000 to 2010 for all municipalities, with data available for the studied variables. The divisions used were the RRAS and its respective Health Regions in the following locations: Great SP ; Santos and Registro; Sorocaba; Bauru; Marilia; Presidente Prudente; Araçatuba and São José do Rio Preto; Ribeirão Preto and surroundings; Piracicaba; Campinas and São João da Boa Vista and Taubaté. These divisions allowed grouping the municipalities according to their health care structure and the possibility of gains in scale, historical and cultural heritage, with a greater diversity than merely geographical divisions, better discriminating the differences between groups. The techniques applied were the Fixed Effects panel data model and the Data Envelopment Analysis in a dynamic and network slack-based model [28], in addition to a correlation analysis between methods. The chances of improvement in the final results and their impact on health are presented, such as the potential years of life gained and the reduction in IM rates, referenced by the municipalities that were benchmarks for efficiency. It is important to note that, while the FE model has a dual utility, of presenting an effectiveness analysis, in a temporal fashion, coupled with efficiency , the DEA, particularly the dynamic and network model used, allows for assessing efficiency, considering all stages of the production of health, in a dynamic time-driven manner. The FE model admits the following premises: each locality has its own characteristics that could influence the dependent variables; some aspects of the unit can bias or weaken the interpretive power of the variables and control for this effect is mandatory. The FE model controls the time-invariant attributes of the independent variables, so that it permits a net effect interpretation. The locality specific effect was obtained by the sum of the municipality fixed effects and its residuals, which apply to inefficiencies at its upper limit, softening the effect of unknown variables and errors in measurement [29]. Another relevant assumption is that these unique time-invariant attributes are specific to the municipalities and do not correlate among them. Stata SE 10.1 software was selected to perform the analysis of the fixed effects panel models. The following equation allowed for the complete models: Y it = β 0 + β 1 X 1, it , + • • • + β k X k,it + γ 2 ε 2 + • • • + γ n ε n + δ 2 T 2 +δ t T t + µ it where: -Y it is the dependent variable where i = unit and t = time; -X k,it represents the independent variables ; β k is the IV coefficient; µ it is the error term; ε n is the n unit; γ 2 is the unit coefficient; -T t is the time; δ t is the time-related coefficient. For each dependent variable, the bivariate association with the explanatory variables, in addition to the multivariate model-by dimension and for the complete set-was obtained by means of the FE method. Additional tests were performed: the Hausman test, which permits to contrast the FE with the random effects model, and the heteroscedasticity assessment of variance constancy . The next step was to obtain the specific effects for each municipality, as the sum of its fixed effects and residuals, as a post hoc analysis. The complete model includes the efficiency gains values, benchmarked by the most efficient municipalities. The main advantage of the network DEA model is its multiple stages analysis, which surmounts the usual restrictions of the static models and leads to a greater correspondence to actual systems [30]. Consequently, in order to be considered efficient, the decisionmaking unit , must be efficient in all of its production phases; moreover, this technique enables revealing inefficiencies in a non-radial mode. This method assumes intermediate products to be produced and consumed inside the DMU, whereas inputs and outputs are external to its structure. The network model offers efficiency indices calculated at each point, besides the overall efficiency indices. The MaxDEA 8 Ultra software was chosen for the network slack approach. The output-oriented model, with k stages, was considered, with the following equation: 1 τ * 0 = max Σ K k=1 W k 1 + 1 r k + ∑ h ∈ F k t k, h) + h0 z h0 ) Subject to: z o = Z λ k -s o + Z λ h = Z λ k s o + ≥ 0 where W k is the relative weight of each section, F k is the set of phases with connection points , ∑ K k=1 W k = 1, W k ≥ 0; s k+ are the product slack vectors, r k is the number of outputs at point k, t is the number of intermediate results in the connection between phases k and h, s o + slack vectors at the connections and z stands for the intermediate products. For LEB , the resource variables considered were average income and proportion of vulnerability and those related to inequity were measured by means of education and income differentials, by gender and ethnicity; as intermediate products, we selected breast cancer screening, the proportion of newborns whose mothers had at least seven prenatal visits and the proportion of Caesarean sections. We also tested intersectoral variables, such as aging, unemployment and illiteracy rates, as well as the proportion of adolescent mothers and water supply. In the case of IM , the same variables were tested, in addition to the proportion of children aged zero to five years out of school and people without electricity access. After analyzing the health impacts derived from the efficiency models through the potential years of life gained and the reduction in infant mortality rates, we proceeded in relating them to the levels of different aggregate variables, such as health and education levels, opportunities, living conditions and social vulnerability and equity. Further detailed analyses were performed with the visualization of São Paulo state maps, displaying the different levels of the effect variables, among regions and municipalities, as well as the health impacts obtained through both methods and the equity variables. Spearman's non-parametric correlations tests were performed to compare the techniques, regarding impact results for both dependent variables. --- Results --- The Statistical Models: The Effects on Health Levels The results obtained through the bivariate analysis of the FE panel model demonstrate that the financial resources had more significant results than the physical ones. The health production dimension, on the other hand, had little participation in determining the results for the set of municipalities. In order to decide which variables were to be tested for the distinct dimensions, as well as the complete set model, we selected the relevant variables from the bivariate analysis . The aggregate results in Table 2 depict that gender-ethnicity inequities in education, as well as income distribution, unemployment, illiteracy and aging rates, were significant for both effect variables in the intersectoral dimension, with the latter remaining in the final model of the LEB variable, together with the social vulnerability and environmental variables, such as the proportion of adolescent mothers. On the other hand, the IM variable included ethnicity and work-related income inequalities, in association with social vulnerability and intersectoral dimension variables, such as the proportion of children out of school. Both models reached high values of R 2 , close to 80%. A relevant finding related to the financial resources dimension is that the GDP per capita and the density of nurses proved to be determinants of IM, whereas only the vulnerability variables were important for LEB. Regarding health production, screening for breast and cervical cancer, in addition to the proportion of Caesarean sections and of newborns whose mothers had at least seven prenatal consultations, were decisive for both effect variables, but with a very low R 2 , of around 5%. In the environmental dimension, water supply and electricity access appear, respectively, as relevant variables for LEB and IM. Regarding governance, it is worth noting that the variable related to transparency did not remain in the final models. Among the dimensions, the intersectoral one showed the highest R 2 values, close to 80%, followed by physical and financial resources, close to 70%. We should emphasize that some variables were significant only at the bivariate analysis, not persisting in the final models, such as per capita health expenditures derived from local tax revenues, the proportion of GDP related to services, the Gini index and the distribution of income by quintiles, dependency ratio, proportion of the population dependent on the elderly, proportion of the population with at least one disability, variables related to the Municipal Human Development Index and its components, in addition to those related to social responsibility . For a complete view of all variables tested in the bivariate analysis, please consult the Supplementary Tables S1-S3. --- A First Glance at the Health Impacts Derived from the Models The final models equipped us with the health impacts and offered us a first glance at the potential years of life gained and the reduction in the infant mortality rates, across the regions. Figure 1, below, shows the potential years of life gained in LEB according to the regionalized health care networks . It can be observed that the distributions obtained according to the FE model were more rigorous and showed higher values than in the DEA model, including more localities displaying extreme values . It is noteworthy that the Mananciais region exhibits proximate distributions for both methods. Figure 2 then shows the potential reductions in the IM rates for the RRAS. Unlike LEB, the distributions showed higher values in the DEA model than in the FE model. The best results, according to the FE model for both effects were observed in Greater SP , in Registro and Santos and Taubaté . The worst ones are in the capital, regarding life expectancy and in Marilia, for infant mortality . This is due to an imbalance in the distribution of wealth and education in these places, with the worst inequity results, even with high wealth , or proportionally with less wealth, but also with an unequal distribution, especially in relation to education, reflected both in the high rates of illiteracy and in gender-ethnicity inequities . With the DEA model, the best results for life expectancy were found in Campinas , while the capital had the best results for the infant mortality rate, while the worst results in life expectancy were found for the Alto Tietê region-RRAS 2 -and the worst infant mortality rates were found in Sorocaba -RRAS 8 . wealth and education in these places, with the worst inequity results, even with high wealth , or proportionally with less wealth, but also with an unequal distribution, especially in relation to education, reflected both in the high rates of illiteracy and in gender-ethnicity inequities . With the DEA model, the best results for life expectancy were found in Campinas , while the capital had the best results for the infant mortality rate, while the worst results in life expectancy were found for the Alto Tietê region-RRAS 2 -and the worst infant mortality rates were found in Sorocaba -RRAS 8 . When the stages of health production in the DEA methodology were analyzed, there was a substantial reduction in efficiency , demonstrating that health care did not contribute to the final health results as expected. When considering the health production variables, a lot of efficiency is lost and, in this case, the best results are from Presidente Prudente in relation to LEB and from the capital for the IM rate , whereas the worst ones are in the capital, this time for LEB and Araçatuba, for the IM rate . The efficiency averages were generally higher for LEB, with smaller disparities than the IM rates. Considering the discrepancies in the efficiency indices between the effect variables, they ranged up to 40 p.p. between the two variables in some locations. Regarding the regions , Araçatuba and Ribeirão Preto and adjacent areas were the ones with the smallest differences, followed by Sorocaba and Bauru. At the opposite direction, Greater Sao Paulo had the biggest differences. --- Putting It all Together: Further Views and Synthesis After analyzing the differences between regions and its rankings on both health impacts and selected aggregate variables , we verified five distinct typologies for the regions. First of all, the least efficient locations are those that, although presenting better levels of health, living conditions and education, exhibit high social vulnerability, medium opportunities and large inequities in income and education by gender and ethnicity, such as the capital city of SP and part of its surroundings , demonstrating that health care did not contribute to the final health results as expected. When considering the health production variables, a lot of efficiency is lost and, in this case, the best results are from Presidente Prudente in relation to LEB and from the capital for the IM rate , whereas the worst ones are in the capital, this time for LEB and Araçatuba, for the IM rate . The efficiency averages were generally higher for LEB, with smaller disparities than the IM rates. Considering the discrepancies in the efficiency indices between the effect variables, they ranged up to 40 p.p. between the two variables in some locations. Regarding the regions , Araçatuba and Ribeirão Preto and adjacent areas were the ones with the smallest differences, followed by Sorocaba and Bauru. At the opposite direction, Greater Sao Paulo had the biggest differences. --- Putting It All Together: Further Views and Synthesis After analyzing the differences between regions and its rankings on both health impacts and selected aggregate variables , we verified five distinct typologies for the regions. First of all, the least efficient locations are those that, although presenting better levels of health, living conditions and education, exhibit high social vulnerability, medium opportunities and large inequities in income and education by gender and ethnicity, such as the capital city of SP and part of its surroundings . These regions, in comparison to the capital, have worse education levels and living conditions but higher equity levels , or worse social vulnerabilities and opportunities but higher equity and education levels . The central region of the state and the western fringe also showed great potential for improvement in efficiency; exhibiting worse levels of living and health conditions, but with less inequity of income and vulnerability and better opportunities, but with worse levels of education, with inequities regarding gender and ethnicity . On the contrary, the last typology includes the south vector, especially to the southeast , and the northwest vector, especially to the west , which show a better balance between these variables, as well as the region of Campinas and Ribeirão Preto . For a complete view of the impacts in the health levels, based on the efficiency models performed in all Health Regions and Regionalized Health Networks, in detail, please consult the Supplementary Figure S1. We gathered that in all RRAS, the municipalities that show the lowest efficiency rates and, therefore, the greatest potential for improvement, are those with the highest level of vulnerability or inequities, in addition to the existence of conflicts, toxic economic development models, workers' overexploitation and environmental disasters, showing an equivalence between the statistical methods employed. We can observe based on the constructed maps that the distributions of the potential years of life gained are inverse to the average LEB results ; that is, in the opposite direction to the expected one. The opposite happens to the distribution of the potential reduction in the IM rates and its average results . We gathered that in all RRAS, the municipalities that show the lowest efficiency rates and, therefore, the greatest potential for improvement, are those with the highest level of vulnerability or inequities, in addition to the existence of conflicts, toxic economic development models, workers' overexploitation and environmental disasters, showing an equivalence between the statistical methods employed. We can observe based on the constructed maps that the distributions of the potential years of life gained are inverse to the average LEB results ; that is, in the opposite direction to the expected one. The opposite happens to the distribution of the potential reduction in the IM rates and its average results . Most strikingly is the fact that the lower the inequities, the greater the efficiency ; as for the Theil index distributions, we may note a closer similarity to the DEA results . We also tested the correlations between the results of the applied methods : for the variable LEB, the results were only satisfactory, 0.532. For the IM rate, this correlation was significantly higher, reaching 0.803. Figure 3. Distribution map of potential years of life gained in municipalities in the state of SP, fixed effects. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 3. Distribution map of potential years of life gained in municipalities in the state of SP, fixed effects. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Source: created by the authors, based on the performed regression models and the efficiency analysis . Note: The above score results from the ranking among the RRAS . Equity variables derive from the distribution of general income , work and ethnicity and the distribution of education by gender and ethnicity , highlighting the worst regional distributions. Vulnerability variables refer to IPVS6 and the proportion of the population that receives < 1 4 MW. Education variables derive from the literacy rate; % of non-adolescent mothers and % of children aged 0-5 years attending school; opportunities refer to employment and aging; the ones related to living conditions refer to average per capita income and adequate sanitation. Paulo, DEA method. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . --- Figure 5. Distribution map of Life Expectancy, average results in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Paulo, DEA method. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . --- Figure 5. Distribution map of Life Expectancy, average results in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 6. Distribution map of the potential reduction in IM rates in the municipalities of the state of SP, fixed effects. Note: Choropleth maps, consisting of six divisions, using the following limitsminimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 7. Distribution map of the potential reduction in the IM rates in the municipalities of the state of SP, DEA method. Note: Choropleth maps, consisting of six divisions, using the following limitsminimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 6. Distribution map of the potential reduction in IM rates in the municipalities of the state of SP, fixed effects. Note: Choropleth maps, consisting of six divisions, using the following limitsminimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 6. Distribution map of the potential reduction in IM rates in the municipalities of the state of SP, fixed effects. Note: Choropleth maps, consisting of six divisions, using the following limitsminimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 7. Distribution map of the potential reduction in the IM rates in the municipalities of the state of SP, DEA method. Note: Choropleth maps, consisting of six divisions, using the following limitsminimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . . Distribution map of the potential reduction in the IM rates in the municipalities of the state of SP, DEA method. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . --- Figure 9. Distribution of gender-ethnicity educational inequity, in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Most strikingly is the fact that the lower the inequities, the greater the efficiency , as shown in the inequity maps of the level of education by gender and ethnicity and the overall and work income Theil index. The intersectional educational inequities exhibit a very close resemblance to the Fixed Effects impacts for both effects ; as for the Theil index distributions, we may note a closer similarity to the DEA results . Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th pe centile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, th number of municipalities, their mean and standard deviation are described. The hist grams contain bars proportional to the number of localities in each division . Figure 9. Distribution of gender-ethnicity educational inequity, in the municipalities of the state SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum valu 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each inte val, the number of municipalities, their mean and standard deviation are described. Th histograms contain bars proportional to the number of localities in each division of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 10. Distribution of inequity regarding overall income distribution , in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 11. Distribution of inequity regarding work income distribution in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . --- Discussion --- The Models and Techniques: What Do They Tell Us? Health equity, from a critical perspective, is essential in order to attain good final results for society. Whereas the balance between wealth and its equitable distribution undoubtedly influences health efficiency, its most relevant aspect lies within the tripartite equity, weaving the categories of social class, gender and ethnicity [1], especially in comparisons under the same general framework, such as the local health system analysis we performed. The municipalities with the best health results were not always the most efficient ones. This occurred exactly because of the gap regarding the variables related to equity, especially the difference in education between gender and ethnicity. This is a more structural variable than simple income differences [4], such as Theil's indexes tested, overall and work-related income. It is noteworthy that intersectional equity did not achieve the Figure 10. Distribution of inequity regarding overall income distribution , in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 10. Distribution of inequity regarding overall income distribution , in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . Figure 11. Distribution of inequity regarding work income distribution in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . --- Discussion --- The Models and Techniques: What Do They Tell Us? Health equity, from a critical perspective, is essential in order to attain good final results for society. Whereas the balance between wealth and its equitable distribution undoubtedly influences health efficiency, its most relevant aspect lies within the tripartite equity, weaving the categories of social class, gender and ethnicity [1], especially in comparisons under the same general framework, such as the local health system analysis we performed. The municipalities with the best health results were not always the most efficient ones. This occurred exactly because of the gap regarding the variables related to equity, especially the difference in education between gender and ethnicity. This is a more structural variable than simple income differences [4], such as Theil's indexes tested, overall and work-related income. It is noteworthy that intersectional equity did not achieve the Figure 11. Distribution of inequity regarding work income distribution in the municipalities of the state of SP. Note: Choropleth maps, consisting of six divisions, using the following limits-minimum value; 5th percentile; 25th, 50th and 75th percentiles; 95th percentile and maximum value. For each interval, the number of municipalities, their mean and standard deviation are described. The histograms contain bars proportional to the number of localities in each division . We also tested the correlations between the results of the applied methods : for the variable LEB, the results were only satisfactory, 0.532. For the IM rate, this correlation was significantly higher, reaching 0.803. --- Discussion --- The Models and Techniques: What Do They Tell Us? Health equity, from a critical perspective, is essential in order to attain good final results for society. Whereas the balance between wealth and its equitable distribution undoubtedly influences health efficiency, its most relevant aspect lies within the tripartite equity, weaving the categories of social class, gender and ethnicity [1], especially in comparisons under the same general framework, such as the local health system analysis we performed. The municipalities with the best health results were not always the most efficient ones. This occurred exactly because of the gap regarding the variables related to equity, especially the difference in education between gender and ethnicity. This is a more structural variable than simple income differences [4], such as Theil's indexes tested, overall and work-related income. It is noteworthy that intersectional equity did not achieve the same importance in our previous analysis of efficiency at the global level [31], which allows us to assume that the local level is the ideal locus for these differences to gain visibility. In our models, health care did not explain efficiency enough, which showed a high association with the intersectoral dimension: this is because municipalities are being compared within the same health system. Although exhibiting loco-regional differences, they were not differentiated in the model, with the healthcare variables tested. This may also be due to not assessing healthcare utilization according to the populations' needs, which would maybe unveil these differences on a local scale [32,33]. On another note, we did not find a relationship between financial resources and health levels in the overall models; on the contrary, they were strongly related to the dimension of health production or were only present in the dimension of resources for the IM variable . However, inequity and vulnerability were strongly related to health levels. In this sense, Biggs et al. [34] indicated that the positive association between material living conditions and health levels revealed itself only when reduction or stabilization of poverty and inequity were also present, interposed by LEB and IM, demonstrating they were effect modifier variables. The differences observed in the results were due to the fact that the FE method showed an imbalance in the distribution of wealth and education in the assessed locations, whereas in the DEA, the differences were due to the wealth and results already achieved in large cities, which are more valued by the method, even with high levels of inequity. Therefore, they should both be used, as they depict different complementary aspects, especially at the local level. --- Examples of Economic Development Models in Sao Paulo The state of Sao Paulo produced a unique invention in its decentralization and regionalization process, in the sense of integrating the concepts of network and region in a RRAS, promoting the integrality of health care units, with universality and equity at its base. The problem is that the territory brings inequities and social dynamics, which are not always incorporated into the planning or its selected delimitations. Furthermore, it involves multiple actors and institutions: the state, society and the market, with particular interests. Therefore, there are many extreme values in the analyzed distributions, as the RRAS were not conceived for their equitable homogeneity, but for geo-economic and political-administrative issues, in addition to sociocultural identities and the sharing of infrastructure, communication and logistics networks [19,35]. The diverse historical and economic development, as well as the predominant economic activity in the most efficient regions show great variations and we should concentrate and examine a couple of examples, in order to illustrate the results. It is above all important to highlight the contradictions found, such as: the promotion of arts, culture and ecological tourism in the region of Mananciais, coexisting with a high proportion of districts with very high vulnerability and a large proportion of the population that receives less than 1 4 of the minimum wage, housing shortage, deforestation and irregular settlements and rural regions; the eco-forest system activity in Registro and the diversified economic development centers in Taubaté, using medium-high technology; and the large offer of formal jobs in the Oil and Gas sector in Santos, but also surrounded by environmental conflicts, related to the expansion of the port area and the pre-salt exploration. The region of Franco da Rocha should also be underlined, as it has the highest equity and scored well in efficiency, close to Mananciais, mainly due to reaching both the lowest ethnicity income ratio and the Theil index related to work income. It is a region with tourism and secondary residences , extractivism and cellulose , but with high social vulnerability and many environmental disasters, such as floods and landslides and precarious infrastructure and access and with a historical and symbolic molding related to the Juquery Psychiatric Hospital . It is also important to emphasize that the Araçatuba region had the best result regarding the Gini and Theil indexes, as well as in vulnerability , followed by the Presidente Prudente region, which shows, however, lower efficiency results, mainly due to the high illiteracy rates. The Campinas and Ribeirão Preto regions showed intermediate efficiency results, considering the high wealth and medium distribution, with urban agglomerations resulting from their long and sustained growth and concentration of transport, logistics and economy of scale. They have also suffered some depletion of the capacity to radiate well-being, as originally planned by regional development policies. These contradictions between appearance and essence of the capitalist mode of production lead to the deterioration of the environment and manifest themselves in cognitive, social and economic ways [36]. --- The Typologies: On How Social Inequity and Vulnerability Interplay in the Context of Capitalism The different typologies observed in the state of Sao Paulo depict how the structural causes are important in determining the health levels. We verified a strong imbalance between health and education levels and living conditions on one side, and opportunities, vulnerabilities and social equity on the other. It is clear from our results that social sectors should be organized in such a way as to improve this balance, rather than having its design based solely on administrative proximities. We have found greater potentials for life expectancy improvements and infant mortality reductions exactly in those more developed localities that reached high average health levels, but based upon income and work inequities and social vulnerabilities or on those less developed countryside localities with lower health and education levels and living conditions, but with less social vulnerabilities and more opportunities. Our great concern is that these localities, although with less overall inequities, present themselves with more structural inequities, such as gender and ethnicity on education and income levels. It is crucial to understand how the concept of social vulnerability is inscribed in the dynamics of capital, with the dominance of fictitious capital and green economy, along with the large growth of the service sector, constraining the spatial circuits of socioeconomic production. According to critical geography [37], the superior circuit subsists on the inferior one , which submits for fear of falling back into the sphere of complete exclusion. As we have described, social vulnerability is all the more present in the localities with the greatest health levels and living conditions, though badly distributed, or the medium levels of these dimensions, but with a greater proximity to the central regions, especially the capital. In that sense, we can observe two different situations: being close to the capital and having at least the benefits of higher education levels, although not of income, and that of being depleted on education and income levels, with important overall and work income inequities, which is the worst scenario. At the same time, the socio-environmental relationship is weakened by the intensification of use and depletion of the soil and workers, exposed to pesticides and forced to abandon traditional and ecological forms of production in the countryside, to favor a brutal model of indifferent extractivism and the commodification of what was obtained naturally from the soil, in the past [38,39]. Likewise, the health sector commodification intensifies social vulnerability, as what was offered in the past to workers to improve quality of life, has been decreasing greatly [10], encompassing a slower growth on health levels and a poorer distribution of its benefits to society [40]. The pendular movement of the Brazilian internal bourgeoisie also helps us understand this dynamic of imperialist capital, occupying an intermediate position between the former national bourgeoisie and the buying bourgeoisie class, associated with imperial-ism. Their social position oscillates between dependence and contradiction with foreign capital, accepting the subordinate place in the international division of labor and always keeping their interests, above all, on the expanded reproduction of capital, without any socialization of risks, despite accepting to be dependent on the State and public funds [41]. The relation between social position and inequities found in our study were mainly due to ethnicity-oriented income inequities, overall and from work. Currently, the productive capital is an increasingly smaller part of the system, dominated by financial capital, mainly the fictitious one, which, by the hand of the market and the State, makes promises to investors through financial collateral arrangements and public debt bonds, expropriating the workers' future. According to Fontes [42], "the flight forward through State indebtedness, on a delusional scale, means the commitment of the States themselves in a direct manner, with the exacerbation of the future extraction of value". Thus, if currently the premature exhaustion of the workforce does not imply a decrease in the average life expectancy, the quality of life and health has dropped considerably, as well as the full consumption capacity, generating situations of social vulnerability [14]. Our results embrace this concept, as we have noted that the highest average results in life expectancy occur exactly in the most unequal localities, along with high levels of social vulnerability. Social vulnerability must be understood within its historical and social dimensions, as a deprivation of the power to act, to demand the guarantee of social rights and to take care of one's health, within a logic of relations of oppression, domination, stigmatization, manipulation and exclusion, with socioeconomic and civil aspects. Moreover, it is accompanied by an ideology of blaming the socially frail, without taking into account their capacity for resistance and change, cross-sectioned by gender, ethnicity and social class relations [12,43]. We have found that gender and ethnicity related inequities in educational levels and income inequities affect local health efficiency greatly. Within the logic of serving the financial capital and justifying fiscal adjustment measures, regardless of social vulnerability, an efficiency study was carried out by the World Bank [44], using the DEA methodology to evaluate the efficiency of Brazilian municipalities according to the levels of attention and the macroregions. The key finding, that PHC is efficient in terms of productivity but not performance, demonstrates the underutilization of its potential to improve equity. Moreover, it contends that the secondary and tertiary levels are less efficient, due to the small hospitals, which do not have an economy of scale, but are located in more remote regions, promoting equity in access. These considerations show the contradiction of the study that proposed a fair adjustment, with equity and efficiency regarding public spending. The analyses were not controlled by intersectoral and cross-sectional equity variables, and it was finally proposed to increase PHC productivity, with more procedures, reducing the costs with small hospitals, totally contrary to the sense of universal access and integrality, which go much beyond the procedures and the economy of scale. The lack of an equity adjusted model and of an effectiveness-oriented analysis, failed to produce a fair adjustment altogether. In contrast, in our study, both methods showed that the municipalities with the highest degrees of inequities , associated or not with social vulnerability exhibited the lowest efficiency indices, not attaining its full potential for health effects. We would like to point out that extreme poverty and selective social policies, particularly for the health and education sectors, have also been established as essential causal mechanisms in the association between social inequity and health levels [45], as well as livelihoods and structural, material and symbolic conditions, especially the educational level, acting independently, going far beyond the per capita income, at the local and global level [46]. Therefore, we must look for new ways to measure the final impact results on people's lives and health. Far from the usual measures of quality of life or happiness, we need new measurement tools that can apprehend the contradictions, contrasts, wearing out and, above all, the sinuous cross-sectional movements within the categories in which we are all stratified [11]. --- Study Limitations It was not possible to assess the governance variables, except for the MPF transparency index. For a future study, a proper way to do so would be to study the effectiveness of the action of municipal health councils in the monitoring and inspection of health actions, which would be a more objective way of evaluating governance and the prevention of corruption in the health area [47]. There are very few Brazilian studies on efficiency at the municipal level, and the few that have been carried out were related to efficiency in public management in general [22] or related to the technical efficiency of hospital health services [23,24] or primary health care [25,26]. What we proposed was to define the efficiency of local health systems, which was in part hindered by the fact that all municipalities belong to the same health system. On the other hand, due to local heterogeneities, regarding the intersectional aspects, it was possible to apprehend differences in social inequities and vulnerabilities. As much as the authors have tried to encompass the different dimensions of real life, we know that no method is capable of reconstituting the totality. Our effortin this study was to look through the openings, catching a glimpse of the gaps and potential of the methods used to unveil existing mechanisms and contradictions. As stated by Nietzsche, we wanted "to stir up what was previously considered motionless, to fragment what was thought to be united; to show the heterogeneity of what was imagined in conformity with itself" [48]. --- Conclusions In view of our findings, we demonstrated that structural issues are essential in the association between equity and efficiency and that intersectionality, along with its implications on health effectiveness, may be more comprehensively understood at the local level. Furthermore, the contradictions in the capital of the state of SP revealed that overcoming mortality in the first year of life does not guarantee living longer and better in this urban space, where wealth and vulnerability, opportunities and unemployment coexist. The cost to society is extremely high, perverse and cruel, considering the chasm between the small average increments in Life Expectancy, which only a minority will be able to enjoy, and the precarious living and health conditions of those who sustain such gains. This happens exactly because the logic of capital has extended itself to all social relations and dominates all aspects of life. These inequities are also reproduced inside the organizational arrangements of health actions and services in SP, as the expected equity was projected at the level of access to health and not the final results. This is an intersectoral aspect that should sensitize health managers, along with public local authorities in providing adequate local services and implementing public policies for improving living conditions, as well as tackling the existing social vulnerabilities and inequities, offering employment opportunities and adequate environmental conditions, in order to permit a thriving society. It cannot be stated, in any way, that the most efficient regions are the ones with the best living conditions, but that they are social spaces that use their resources in a more distributive way. Therefore, we can verify the importance of intersectional equity for achieving efficiency and effectiveness in local health systems, which is related to the choice of different political options of economic development models, radiating well-being comprehensively or concentrating it for only a privileged few. --- Supplementary Materials: The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/ijerph19052990/s1, Table S1: Results of the bivariate analysis, fixed effects model, for the variables life expectancy and infant mortality: resources, health and intersectoral dimensions. Sao Paulo Municipalities, 2000 and 2010. Description: All variables tested initially in the fixed effects bivariate analysis can be consulted in these tables, according to the physical and financial resources; the health production and the intersectoral dimension. Note that only some variables were directed to the initial multivariate models. Table S2: Results of the bivariate analysis, fixed effects model, for the variables life expectancy and infant mortality-intersectoral dimension. Sao Paulo Municipalities, 2000 and 2010. Table S3: Results of the bivariate analysis, fixed effects model, for the variables life expectancy and infant mortality-health production dimension. Sao Paulo Municipalities, 2000 and 2010. Figure S1: Potential years gained in life expectancy at birth and reduction in infant mortality rates, regionalized healthcare networks and health regions: comparison between methods . Description: This file depicts the number of potential years gained in life expectancy at birth and the potential reduction in infant mortality rates, calculated with both techniques used, permitting comparisons between municipalities, within health regions. --- Data Availability Statement: The datasets used during the current study are available from the corresponding author upon reasonable request. The consulted data sources are open to public access and can be reached at the following websites: IBGE-Brazilian Institute of Geography and Statistics, https://www.ibge.gov.br/estatisticas/sociais/populacao/ 9662-censo-demografico-2010.html?=&t=o-que-e; DATASUS-SUS Information Technology Department, https://datasus.saude.gov.br/informacoes-de-saude-tabnet/; SES/SP-Sao Paulo State Health Department, http://www.saude.sp.gov.br/ses/perfil/profissional-da-saude/informacoesde-saude-/; SEADE-State System Foundation of Data Analysis, https://www.seade.gov.br/listaprodutos/; MPF-Federal Prosecution Ministry, http://combateacorrupcao.mpf.mp.br/ranking; SIOPS-Public Health Budget Information System, http://siops-asp.datasus.gov.br/cgi/siops/ serhist/MUNICIPIO/indicadores.HTM; STN/MF-National Treasure Department/Ministry of Finance, https://www.gov.br/tesouronacional/pt-br; All data analyzed during this study are included in this published article .

Health equity is cross sectioned by the reproduction of social relations of gender, ethnicity and power. The purpose of this article is to assess how intersectional health equity determines societal health levels, in a local efficiency analysis within Brazil's Unified Health System (SUS), among Sao Paulo state municipalities. Fixed Panel Effects Model and Data Envelopment Analysis techniques were applied, according to resources, health production and intersectoral dimensions. The effect variables considered were expectation of life at birth and infant mortality rates, in 2000 and 2010, according to local health regions (HR) and regionalized healthcare networks (RRAS). Inequity was assessed both socioeconomically and culturally (income, education, ethnicity and gender). Both methods demonstrated that localities with higher inequities (income and education, gender and ethnicity oriented), associated or not to vulnerability (young and low-income families, in subnormal urban agglomerations), were the least efficient. Health production contributes too little to health levels, especially at the local level, which is highly correlated to the intersectoral dimension. Intersectional health equity, reinforced in its intertwining with ethnicity, gender and social position, is essential in order to achieve adequate societal health levels, beyond health access or sanitary and clinical efficacy.

Background There has been a reported, inextricable connection between people's behaviours and their environment. Therefore, macro and micro-ecological phenomena influence behaviours, including alcohol consumption among diverse groups and populations . Consequently, environmental and personal behaviours that influence alcohol consumption could be contextualized in terms of the social ecological model. Indeed and in the context of this study, the model accounts for multiple correlates associated with alcohol consumption among the youth. Urie Bronfenbrenner coined the ecological model in 1974 to explain the role of familial and other "social contacts" in child development . Since then, the model has been expanded and used by scholars from different disciplines in examining multitudes of behaviours among populations of interest. The model, for example, could be employed in examining social media use among the youth and alcohol consumption . For this paper, alcohol consumption means the use of beverages containing alcohol as an ingredient . Alcoholic beverages in this case were taken to mean Beers, Wines, and Spirits. Previous studies have used the social ecological model in examining decisions and behaviours of diverse groups of people. Hickey, Harrison, and Sumsion , for example, used the model in explaining career choices of nursing students. Other studies applied the model in examining alcohol consumption, although mainly among adult populations and without clear regard for the microsystems such as religion and gender as primary contexts for alcohol consumption. Two studies, for example, applied the model in examining alcohol consumption-related decision-making and in assessing the relationships of demographic and personality characteristics . Another study adopted the model in explaining harmful alcohol consumption in Delta State, Nigeria . The Gruenewald, Remer, and LaScala study that considered demographic characteristics, as the present study did, was unable to single out adolescents as a point of focus. Yet, adolescence as a developmental period is one stage most likely to be influenced by the human ecological systems into alcohol consumption and other maladaptive behaviours. Based on the ecological model, we asked: what are the sociodemographic correlates of consumption of alcoholic beverages among adolescents in public secondary schools in Uganda? As earlier typified, this paper anchors on the social ecological model to explore the prevalence and ecological correlates of alcohol consumption among adolescents. The social ecological model is reliable in explaining complex behaviours such as alcohol consumption. The paper considers a social ecological discourse as it manifests the various levels with which adolescents interact and potentially influence their drinking behaviours. For instance, the microsystem of the ecological model could explain variables such as gender, involvement in places of entertainment, use of social media, friendship dynamics, and level of studying against alcohol consumption. While measures such as brief interventions have been in place to address youth drinking, less is known about the application of contemporary theoretical frameworks in remedying alcohol use among the youth in schools in developing countries. Possibly, the social ecological model would serve as an addition to the available options for advocacy against youth drinking and better prioritize demographic antecedents in the prevention of alcohol consumption. The ecological spaces notwithstanding, alcohol consumption is identified as responsible for the estimated increase in the global disease burden . Consequently, alcohol consumption, especially among the youth, remains one of the key health concerns . Moreover, alcohol consumption is hazardous at the most formative stage of adolescence . Often, in the context of a developing country like Uganda, alcohol consumption has resulted in hazardous and negative outcomes, including increased road traffic injuries, erosion of socio-cultural norms, involvement in risky sexual behaviours, premature death, poor health, interpersonal violence, and self-harm . In the face of the negative outcomes of alcohol consumption among adolescents, there is no known study using the socio-ecological model to examine alcohol consumption among adolescents in Uganda. Moreover, as Kabwama et al. among the youth but only considered vulnerable groups like those living in slums and fish landing sites. Other studies were conducted among the general population. Notably, Abbo et al. considered demographic correlates of alcohol consumption among secondary school students. However, their study considered only two districts -Kampala and Gulu. Therefore, using the social ecological theory to explain the consumption of alcoholic beverages among the youth in public schools was necessary. The present study is anchored on a socio-ecological model to explore the prevalence and identify protective and risky demographic correlates of alcohol consumption among secondary school adolescents. The socio-ecological model posits that individual and environmental variables account for alcohol consumption among students. The model comprises five layers within which interaction occurs -the microsystem, mesosystem, exosystem, macrosystem, and chronosystem. The fifth layer may not be applicable in examining correlates of alcohol consumption with cross-sectional data. Therefore, this study is anchored on the first four layers of the ecological model. The concern here is that alcohol consumption among the youth is manifold to the extent of drawing from social and environmental influences. To that end, correlates of alcohol consumption among students mirror individual, interpersonal, institutional, communal, and societal echelons. Particularly, for the interaction between individual students, the first and second levels seem relevant in examining alcohol consumption among students. Issues of age, gender, religious affiliation and practices, and the way these antecedents interact with students' socio-economic and neighbourhood spaces contribute greatly to expounding alcohol consumption among students . Therefore, in the context of the socioecological model, this paper underscores students' age, gender, religious affiliation, and friendship, involvement in places of entertainment, use of social media, and form of students' classes as possible correlates of alcohol consumption among students. By and large, characteristics of students serve as a basis for adducing differences among alcohol consumers . Regarding prevalence, and as previously noted, alcohol is the leading substance of abuse among adolescents in Uganda. In fact, in a small-scale study, Abbo et al. found that the most common substance used among students in Kampala and Gulu districts was alcohol . The WHO Global School-based Student Health Survey reports that 12.8% of the students in Uganda had at least one alcoholic drink on one or more days during the past 30 days . However, the survey lacked pinpointing ecological correlates of consumption of the different types of alcohol. Other studies point to the prevalence of alcohol consumption as superseding the use of other psychoactive substances in schools among developed and developing countries. For instance, alcohol consumption is highly prevalent among students in the United States . In a study conducted by Fuhr, Fleischmann, Riley, Kann, & Poznyak , current alcohol consumption was highest compared to current and lifetime drug use. In their study regarding alcohol consumption and treatment-seeking behaviour among young people in Sydney, Australia, Lea, Reynolds, and De-Wit found that 83% of their participants consumed alcohol . Crooke et al. In addition to the prevalence reported above, students' characteristics form a significant component of protective or risk factors for alcohol consumption . Kabwama et al. identified that, regionally, Ugandans from the central and western regions were more likely to be medium to high drinkers compared to their counterparts in the eastern region. However, according to Tumwesigye, Kasirye, and Nansubuga , Qeios, CC-BY 4.0 • Article, December 4, 2023 differences in drinking contexts were mainly attributable to social interactions -especially among different social classes. In a study to review psychosocial risk factors for alcohol consumption, Donovan reports that only two studies examined age as a predictor of alcohol use initiation. In a comparable context, Rodham, Hawton, Evans, and Weatherall found clear gender differences in alcohol consumption among adolescents -more males than females reported drinking. The studies recorded above, however, were lacking in consideration of adolescents in secondary schools. Likewise, most studies in Africa and beyond only consider age and gender as the correlates influencing alcohol consumption among adolescents. Key and informative demographic areas like students' level of study and religious background are not accounted for by previous studies . Largely, religious inclination and faith tend to influence youths' decisions to consume or not consume alcohol . Church attendance in childhood is presumably protective against the early onset of alcohol consumption and the later development of alcohol-related problems . Moreover, evidence is available that youths who identify themselves as being strongly committed to particular faiths are less likely to consume alcohol . In the study to establish grade differences in alcohol consumption, Lakew et al. found significant findings, although the results were non-significant in multivariate models. Further evidence shows that weekly alcohol consumers in the US constituted about one-seventh of drinkers in the 9th grade but one-fourth in the 11th grade . In echo with Ahlström and Österberg , most studies regarding alcohol consumption among adolescents are situated in developed economies. As earlier recounted, most studies in Uganda adolescents in public schools in Uganda. This study was instituted to examine ecological phenomena after a considerable number of Ugandan-based reports underscored alcohol consumption for psychosocial challenges among adolescents in schools. The present paper considers a sample from four geographical regions, namely: Northern, Western, Central, and Eastern Uganda. Notably, Uganda is an amalgam of multi-tribal and multi-cultural societies. The present study premises on an understanding that each of the regions is a unique locality, with atypical socio-cultural settings. With that in mind, students in their respective regions show diversity in alcohol consumption in relation to demographic attributes. Diversity in students' backgrounds and school dynamics is the primary basis for our anticipation of the association between select socio-demographic correlates and alcohol consumption. The secondary school system in Uganda consists of three distinct categories. In the first category are schools founded by religious entities and aided by either the founding bodies or the Government on behalf of those entities. In the second category are schools founded and run by individual private investors. The third category, the schools regarded in the study as "public secondary schools," were purposely considered and drawn from Uganda's capital city, Kampala, and ten other major towns. The schools considered by the present study were owned and managed by the government. This category of schools was considered based on a number of their unique characteristics. For instance, the schools were historically established to provide affordable education to urban poor children. As such, they were located in the periphery of major towns across Uganda. Further, students in these schools were mainly non-residents. That implies that students in those schools constantly and freely interact with the rest of the society, where alcoholic beverages are mainly found. Most of the students involved in this study were adolescents, with an age range of 13 to 20. All students above the age of 20 were hence regarded as emerging adults. Although the mention of emerging adults for a study in schools sounds odd, clarification needs to be made that the status of most public schools in Uganda considers a universalised education system. The school system allows students beyond school age, mainly from poor families, to access free education. Therefore, finding students well above the age of 20 in Ugandan schools is not surprising. --- Design This was a cross -sectional study. A cross -sectional design enabled collection of large dataset at a single moment in time. Further, with this design, we were able to consider many attributes of students at ago. Quantitative techniques were used for data collection and analysis. Quantitative techniques were used to generate objective and more generalizable results. The technique of using quantitative tools and randomized processes removed bias from the dataset of the study and ensured reliable observations. Further, a quantitative approach enabled statistical generalization of our findings to the entire population of students in public schools. --- Measures Participants completed a self-administered questionnaire. The instrument was administered in classrooms or other convenient places within the schools. The instrument contained items to capture students' demographics, including region 2003) on conducting school surveys on drug abuse. Specifically, students were asked whether they had consumed each of the alcohol-related substances in the previous 12 months. For instance, students were asked: for the previous 12 months, how frequently have you taken beers ? The initial items regarding alcohol consumption were based on a Likert scale carrying five responses, namely: 1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = very often. Responses to each of the items were transformed into a binary scale: response category 1 was dummied to denote "No" or "never used," and the other categories of 2, 3, 4, and 5 were dummied to denote "Yes" or "ever used." That was done to generate a response pattern suitable for the computation of prevalence rates and to compare alcohol consumers and non-consumers. The items were written in simple language to improve interpretability among students from different classes and schools. Names of local brews of alcohol in different regions of Uganda were included in the questionnaire as synonyms for respective items, based on data provided by the National Care Centre. For instance, local names for spirits were given as enguli/waragi/kasese. Names of locally made alcohol were included to improve the validity of the responses generated. During the analyses, alcohol consumption items were dummied to consider students who consumed one or more types of alcohol -'polyalcohol consumption'. --- Sample Selection Part of the sample and sampling technique described in this paper is reported elsewhere . Nevertheless, the sampling strategy was thought out and coined after consideration of the distribution of public schools across the geographical space. To that end, the sample was obtained by first clustering schools within their respective regions. Thirteen schools were purposively and then proportionately sampled, three from each of the northern, western, and central regions. Four schools were sampled from the eastern region. Purposive sampling considered only co-educational, urban schools. Proportionate sampling was used to strike a balance between Kampala city, which had many schools , and other towns that had one school each. The sampled schools emerged from Kampala city and the following towns: Entebbe in the central region; Jinja, Mbale, Soroti, and Tororo in the eastern region; Gulu, Moyo, and Arua in the northern region; Fort Portal, Kabale, and Mbarara in the western region. The number of students in all schools was obtained using proportionate sampling. The overall sample was obtained using Leslie's method of sample size determination. Samples from their respective classes were obtained using simple random sampling -each student present in the classroom was given a number, and then the numbers were selected at random. A total of 1,982 participants were sampled to participate in answering the questionnaire. However, 1,819 returned the completed questionnaires, making a response rate of 91.8%. Data collection took place mainly in classrooms. However, in some circumstances, other places, e.g., school compounds and laboratories, were used to avoid the distraction of school activities. --- Inclusion and Exclusion Criteria All students in senior two and above present at the time of data collection were eligible for the study. Students absent from school at the point of data collection were excluded from the study. The study items asked about the experience of alcohol consumption within the previous 12 months of secondary school life. Therefore, senior one students were excluded from the study. --- Data Analysis Data were first entered into IBM Statistical Package for the Social Sciences , version 20.0, and then exported to STATA version 15.0 for analysis. Missing values were excluded using list-wise deletion. Descriptive data were summarized and categorized in terms of frequencies and weighted percentages to correct for sampling errors. The weighting of data was based on students' region of origin and age as a clustering variable. The prevalence of consumption of the different types of alcohol was explored using descriptive statistics. Percentages were used to report the prevalence of consumption of Beers, Wines, and Spirits. The statistical significance of the proportions of alcohol consumers was examined using chi-square p-values . Descriptive statistics of the study sample are presented in Table 1. Analyses were set at a 5% confidence interval. Associations of the students' socio-demographics with the consumption of Beers, Wines, and Spirits were explored using bivariable and multivariable logistic regressions. All covariates were entered into the multivariate model, as they were all plausible correlates of alcohol consumption. The models were adjusted for students' age and region of origin. Part of the technique and data reported in this paper have been previously considered elsewhere. --- Results This paper anchors on the socio-ecological model to expound on the prevalence and demographic correlates of consumption of alcohol among adolescents in public secondary schools. Bivariable and multivariable logistic regression Among the participants included in the analyses, the majority were males , had 2 or more friends , liked visiting places of entertainment , and were very religious . The overall prevalence of the consumption of beer was 27.93%. lower extent of religiousness (somewhat [AOR = 1.6, 95%CI: 1.27-2.12, p < 0.001] and not religious [AOR = 2.5, 95%CI: 1.25-4.99, p < .01]) was associated with a higher likelihood of beer consumption. Additionally, students who identified as loving places of entertainment were two-fold more involved in beer consumption . Regarding the consumption of wines, it was established that the overall prevalence of wine consumption was 37.56%. The independent socio-demographic determinants of wine consumption were religious affiliation, loving places of entertainment, and use of social media. Students of Roman Catholic religious affiliation had a higher likelihood of wine consumption compared to Muslims and Pentecostals . In addition, a lower extent of religiosity was associated with a higher likelihood of wine consumption . Additionally, students who loved being in places of entertainment were two-fold more involved in wine consumption . However, students who often used social media were 1.6 times more likely to be involved in wine consumption compared to those who did not . The prevalence of consumption of spirits was 18.08%. The socio-demographic correlates of consumption of spirits were gender, religious affiliation, religiosity, love of being in places of entertainment, and use of social media. The likelihood of consumption of spirits was 0.7 times lower among females compared to males . Compared to students from the Roman Catholic affiliation, there was a lower likelihood of consumption of spirits among students affiliated with other denominations . Moreover, a lower extent of religiousness was associated with a higher likelihood of consumption of spirits . Additionally, students who liked being in places of entertainment were more than two-fold more involved in the consumption of spirits . Regarding the use of social media, students who often used media were 1.6 times more likely to be involved in the consumption of spirits compared to those who did not . After excluding the non-consumers, it was found that students who consumed more than two types of alcohol were 85.38%. The socio-demographic correlates of polyalcohol type consumption were religious affiliation, religiousness, and use of social media. Compared to students from the Roman Catholic affiliation, there was a higher likelihood of polyalcohol type consumption among other religions . Moreover, a lower religiousness was associated with a lower likelihood of polyalcohol type consumption (Somewhat, AOR = 0.7, 95% CI: 0.47-0.91, p < .05; Not religious, AOR = 0.5, 95% CI: 0.16-1.30). Additionally, students who often used social media were less likely to be involved in polyalcohol type consumption . --- Discussion The aim of this paper is to use the socio-ecological model to expound on the prevalence and socio-demographic correlates of alcohol consumption among school adolescents. Percentages and logistic regressions were used in achieving the study objective. In the results, consumption of wines and beers was higher compared to the use of spirits. The findings may not be surprising, as the students considered in this study were largely in urban and day schools. Moreover, alcohol is readily available to Ugandan youth, both in local brews and industrially . Following the abundance of different types of alcohol, the WHO GSHS survey among students in Uganda approximates that 12.8% of the students had at least one alcoholic drink on one or more days during the past 30 days . Thus, the rate was expected to be a little higher in a study conducted a decade later. Probably, the result that consumption of alcoholic beverages was high could imply that students get access to highdensity alcohol outlets in their localities, which sell both regulated and unregulated beverages. Production of locally made alcohol in Uganda is practically not regulated, as many youths turn to alcohol consumption. It has previously been reported that many homesteads ferment and distil local brands from the abundant fruits . The variations in religious affiliation and students' alcohol consumption come after a fair body of literature relating religion and alcohol consumption among the youth. For instance, previous studies show that religious inclination and particular faiths tend to influence youths' decisions to consume or not consume alcohol . Accordingly, studies show that attendance at church during childhood was protective against early onset of alcohol consumption. Church attendance further protects the youths against later development of alcohol-related problems . Consequently, youths who self-identified as having strong commitment to particular faiths were evidently less likely to consume alcohol . Alternatively, students could be accessing alcohol through cultural rituals and ceremonies. Consumption of church wine, for example, is well ritualized among Christian faithful, and often, alcohol is integrated into religious ceremonies . Notably, the findings could be located in the socio-ecological theory of alcohol use. According to the theory, individual students' behaviours interact with the institutions where the adolescents belong . Churches and their ritualized ceremonies may not be the exception. All the same, the present study's findings on the prevalence of alcohol consumption are supported by similar studies elsewhere. Accordingly, alcohol is the most consumed substance among adolescents in developing countries , and in highly developed countries . In the neighbourhood of Uganda -Kenya, Othieno & Ofulla support the present study's results -reporting that alcohol consumption among students was most prevalent. Similar studies predict that alcohol consumption among adolescents is higher than the consumption of other drugs . The results regarding socio-demographic correlates of alcohol consumption were significant at both the individual and institutional ecological levels. Adjusted logistic regression models show significant gender differences in the consumption of beers and spirits, but not in the consumption of wines. In addition, males had higher odds of consuming beers and spirits. Gender differences in alcohol consumption have been reported previously. Rodham et al. found that more males than females reported drinking. Hahn et al. also found significant gender differences in current hazardous and non-hazardous drinking. Male students were more likely than females to report drinking, although only by a relatively small margin . Kabwama et al. found that in comparison with their female counterparts, males were more likely to be medium and high alcohol consumers. The findings regarding gender could be explained based on socioecological theory. At the nucleus of the socioecological model, students' micro-characteristics, including gender, define differences between males and females and between individuals of a particular gender as well. Moreover, the model seems to account for the way the microsystem nurtures different genders, hence the difference in the consumption of alcoholic beverages. However, the present study's findings contradict those of Wu et al. in their study to establish correlates of protective motivation theory to adolescents' drug use intention. Nevertheless, the present study's results affirm previous studies in revealing that being male was a risk factor for alcohol consumption . The female gender, on the other hand, was protective against alcohol consumption . Relatedly, Manyike et al. found that male students were about six times more likely to use psychoactive substances than females. In fact, Manyike and colleagues pointed out that the male gender and living in hostels were associated with alcohol consumption. The present study, however, significantly differs from the preceding report, as we did not consider living in a hostel as a risk or protective factor. The differentials in gender could be attributable to the first level of the ecological model. For instance, differential parenting, interpersonal, and institutional norms might nurture drinking more in males than in females. Further differentials in significant findings were found in the exploration of religious affiliation and religiousness with regard to alcohol consumption. In terms of the social ecological model of alcohol consumption, religion, as an institution and part of the mesosystem, predicts or protects students against alcohol consumption. It explains the interaction between the innermost of a student and the factors in the surroundings related to alcohol consumption. On the other hand, religiousness is reflected in the "inner self" of the students and represents core values that protect against or promote alcohol consumption. Institutional ecological factors compare with Vantamay . The study found that students in Muslim and Pentecostal dominions were less likely to consume beers, wines, and spirits than their Catholic and Anglican counterparts. Roman Catholics, in particular, had higher odds of alcohol consumption than any other religion. The result that Roman Catholics were more likely to consume alcohol than other religions conforms to common practices and previous literature. Practically, some religions, such as Pentecostals, unequivocally loathe the consumption of alcohol among their faithful. To the end of the Islamic faith, the consumption of alcohol is strictly taboo. Islam is generally considered to have strong proscriptive norms against the consumption of all types of alcohol . The Roman Catholic Church, on the other hand, neither condemns nor discourages alcohol consumption among the faithful . That could be the reason why, compared to other religions, more students who identified with the dominion were more likely to consume alcohol than students could. Indeed, evidence shows that youth who prescribe to the Roman Catholic dominion are at a greater risk of falling victim to alcohol abuse and associated problems . On the other hand, belonging to the Muslim dominion is protective against alcohol consumption . Furthermore, Stafström and Agardh , in their study to assess socio-economic determinants of alcohol consumption among Ugandan university students, found that being a Muslim was negatively associated with alcohol consumption. However, Stafström and Agardh made a rare observation that male Muslims were at a significant risk of engaging in monthly heavy episodic drinking, an observation the present study was unable to adduce. Loving to be in places of entertainment and using social media significantly predicted alcohol consumption. In terms of the socio-ecological model, the two correlates explained alcohol consumption at the level of interaction between the students and the exosystemic environment. Indeed, activity in places of entertainment could be accompanied by alcohol consumption and other social behaviours. Therefore, it is likely that those adolescents who love such places could be drinkers as well. Moreover, students who go to places of entertainment have high chances of meeting their peers who influence them towards drinking. In addition, it could be possible that students who use social media interface with alcoholrelated messages that stimulate students' drinking, as several studies have suggested. Generally, the socio-ecological model explicates the significant study results in terms of the variables in the immediate and extant student environment. --- Limitations Like many other surveys, the present study does not go without setbacks. In the first instance, the study relies on selfreported experiences from students. We recommend that future studies use more detailed measures of alcohol consumption among students in public schools, such as quantities of consumed types of alcohol and frequency of alcohol For the present study, some of the dynamics of the socio-ecological model, such as familial influence were not given attention, due to the nature of the dataset. Hitherto the influence of the family dynamics, such as family type, family structure, psychosocial family environment and family socio-economic status could be predictive of alcohol consumption among young people. Further in using the socio-ecological model for this study, the influence of peers and groups were partly studied. The frequency of meetings with friends for example and consumption of peers could have been significantly associated. We recommend that future studies explore such factors in sufficient detail. --- Conclusions The social ecological theory could account for the correlates of alcohol consumption among students. Individual studentlevel factors and institutional factors expound on alcohol consumption among the students. Specifically, gender, religion, religiousness, loving to be in places of entertainment, and use of social media significantly predicted alcohol consumption among students. Gender-specific and religious-related interventions could mitigate alcohol consumption among students. --- Implications Significant study findings on the consumption of different types of alcohol bear educational and adolescent mental health implications. The results may demand benchmarking ecologically specific advocacy against alcohol consumption in schools. In comparison with the socio-ecological model, the study results imply that the alcohol industry could include not only the producers of alcohol but also a large network of distributors, wholesalers, bars, and advertisers . Therefore, interventions for in-school youth drinking may need to be developed by benchmarking with and involving institutions at different levels of the ecological model, such as religious institutions, healthcare services, media, and village councils. Moreover, "gendered models" could be explored to have some gender-specific messages that bring out the negative consequences of youth drinking. Further, the gender-specific messages could focus on the differential effects of drinking among girls and boys. --- Statements and Declarations --- National Council ratified institutional approval for Science and Technology, under number SS 3423, and the office of the President of the Republic of Uganda . At data collection, students' consent was obtained using the approved Institutional Review Committee consent form version number 13. For students under the age of 18, their respective school Head Teachers provided consent on behalf of their parents. --- Competing Interests We declare no competing interests regarding the authorship of this research and the content reported herein. --- Authors' Contributions AR conceived the study idea, collected and analysed the data, and wrote the manuscript for publication. GK guided the writing of the concept, data collection and analysis. She participated in the writing of the manuscript. AM participated in writing the discussion of results and reviewed the final manuscript.

Introduction: Consumption of alcohol among the youth could be attributable to socio-demographic characteristics. This paper anchors on the socio-ecological model to expound on the prevalence and socio-demographic correlates of alcohol consumption among adolescents in public secondary schools. Specifically, the model was used to explore gender, religious affiliation, form or class of study, social media use, friendships, and involvement in places of entertainment as possible predictors of alcohol consumption.We employed a cross-sectional survey with quantitative methods. The sample comprised 1819 participants, yielding a 91.8% response rate. Males were relatively more numerous (59.3%), and the mean age was 17.3 (SD = 1.9). Bivariate and multivariate logistic regressions were employed to deduce the association of selected demographics with the consumption of beer, wine, and spirits.The prevalence of alcohol consumption was generally high. Multivariate logistic regression showed a significant gender difference in the consumption of beer and spirits. Females had lower odds of consuming beer and spirits. Students in the Muslim and Pentecostal dominions were less likely to consume beer, wine, and spirits than their Roman Catholic and Anglican counterparts. Students in the Roman Catholic dominion had higher odds of consuming any type of alcohol compared to other religions. Loving to be in places of entertainment and the use of social media significantly predicted the consumption of beer, wine, and spirits.At the multivariate level, some socio-ecological factors could account for differential alcohol consumption among the students. Individual student-level factors such as gender and the institutional factor of religion could explain alcohol consumption among the students. Specifically, gender and religion were significantly associated with alcohol consumption. It is recommended that ecological differences and "gendered models" are considered as part of the interventions for in-school youth drinking.

Introduction Suicide is a significant global public health problem, with nearly one million suicide deaths reported worldwide annually , and is the second leading cause of death among adolescents and young adults aged between 15 and 29 years . A similar study noted that actual suicide attempts have become more prevalent among young people and are the main signals of further suicidal risk . While suicide is also a national concern in China , there is a dearth of culturally-relevant research, particularly in assessment and intervention. For years, suicide prevention programs have been difficult to formulate as no single risk factor could predict suicide with great accuracy . It pertains even to common proposed risk factors such as suicidal ideation, which still could not consistently or independently predict suicide behaviour . Suicide behavior has been included in the classification systems of mental disorders, specifically the Diagnostic and statistical manual of mental disorders , as a psychiatric compilation that requires "further study." A diagnosis of Suicide Behaviour Disorder would require meeting all the following five diagnostic criteria: within the last 24 months, the individual has attempted suicide on at least one instance; the act does not meet criteria for non-suicidal self-injury ; the diagnosis does not apply to suicidal ideation or preparatory acts; the act was not carried out during a state of delirium or confusion; and The act was motivated by purely political or religious objective. Notably, this proposed diagnosis entails the importance of the individual's intent in defining suicidal behaviour and the individual's expectation that the sequence or set of actions could potentially lead to their own death. Thus, it also differentiates from another "non-suicidal self-injury." Additionally, Kendler et al. highlighted potential antecedent risk factors or criteria , concurrent criteria --- Suicide Risk Assessment As part of the suicide risk assessment, suicidal ideation, and suicide attempts are two significant factors. Suicidal ideation refers to thoughts and desires to end one's life. This ranges from relatively passive ideation to active ideation . Past research in community settings showed that youth typically reported suicidal ideation at a moderate frequency, with intensity ranging between mild to moderate frequency . A suicide attempt is an action motivated to end one's life . A classical three-step theory of suicide asserts the role of pain in understanding suicide . It theorizes that the combination of pain and hopelessness is vital for developing suicide ideation, which a lack of social connectedness would aggravate. This theory construes suicidal ideation and behavior as distinct. Research indicated that frequent, intense, and chronic suicidal ideation is related to subsequent suicide attempts . Due to this intertwined relationship, suicidal intent and suicidal ideation are two main assessment areas in psychometric instruments for suicide risk assessment. It is essential to review some risk factors pertaining to suicide. Such risk was found to be greater in males than females, similar to the general suicide cases . Another prominent finding was that the level of increased risk was related to the history of suicide attempts, and more so when there was a family's psychiatric history . Further, clinical depression symptoms were salient risk factors, especially for more severe psychopathology, a sense of hopelessness, and suicidal ideation tendencies. Likewise, suicide with co-existing disorders was associated with higher risk, including substance misuse for specific alcohol and drugs, anxiety, and personality disorder . Notably, suicidal ideation and prevalence increase sharply during the teenage years . Such suicidal ideation persists even after youth's hospitalization . Over one-third of adolescents who reported suicidal ideation they eventually attempted suicide . Another research showed that young adults with suicidal ideation are estimated to be 12 times more likely to attempt suicide by the age of 30 . It is notable that the majority of teenagers with suicidal ideation would eventually attempt suicide within 1-2 years of such suicidal ideation onset , and they are commonly characterized by specific clinical issues, particularly depression or dysthymia . Other studies have also documented that suicides cases between 9-8 years and have become more and more common by 15-19 years . These findings pointed out the role of social and emotional processing in the development of suicidal thoughts, which could lead to suicide behavior . Indeed, the role of suicide intent on eventual suicide is more significant than previous attempts or a sense of hopelessness . Thus, it has been recommended for the measurement of suicide intent be included in clinical practices for suicide. At the same time, clinical depression appears to be a key precursor to suicide. It is, therefore, essential to elucidate the relationship between major depressive disorder and suicide. Further, such development warrants the urgency and pertinence of developing effective assessment, and intervention. --- Asian culture and collectivism A review of risk factors for young adults' suicidality highlighted that psychiatric or mental disorders coupled with a prognosis of suicidal behavior and suicide are significant predictors of suicide behavior and mortality by suicide . It also further argued about the role of social and interpersonal factors in understanding and predicting suicidal behavior. Most research on suicide risk assessment adopts an individualistic and deterministic view of human psychology and behaviour. Nevertheless, Bronfenbrenner's ecological model posited the role of 10.54392/ajir2333 multiple ecological contexts in shaping an individual's well-being, and indeed, evidence has suggested the importance of the biopsychological model in accounting and conceptualizing the dynamic nature of suicide behavior . Interpersonal Theory of Suicide outlined the suicidal risk as a combination of frustration or lack of social connection and a sense of low selfworth and perceived burdensome. This further suggested that suicide entails a relational and social element In this paper, the focus would be on risk assessment in the context of Asian society, particularly in China. This is an area of interest as there has been a high suicide ideation rate and incidences among Chinese in recent years . Recently, there is a sharp increase in report cases of depression and suicide in Asian population, particularly in overseas Chinese societies like Singapore, which have seen fast industrial and economic development . The quest to assess and prevent suicide have not been effective, particularly among youth and children as they are not proactive or less vocal in reporting their suicidal risk, hence their parents and guardian often overlook the potential risk to their children. Thus, it is essential to adopt a culturally-informed and relevant approach in formulating assessment instruments and in understanding suicide. Youth face the developmental task of developing their identity through individuation and independence from their family . Such emotional autonomy was found to be related to depressive symptomatology . Unlike Westerners, Asians strive for integration instead of individuation. Therefore, social approval and concern over interpersonal relationships would be key areas in influencing depressive symptoms and suicidal risk. In Chinese societies influenced by Confucian Heritage Culture, students face societal pressure to excel academically. Cross-cultural research suggested that Western youth have more interest in pursuing individuation and romantic relationship as compared to Singaporean adolescents . The high value in social-oriented achievement such as academic competence and cognitive skills related to academic achievement would be significant in shaping Chinese's mental well-being. Hence, the development of a culturally relevant instrument for mental welling and suicide would take into account the manifestation and phenomenological experiences which are shaped by adolescents' developmental and culture tasks . During adolescence, the individual is facing the challenge of developing his unique identity through individuation and becoming independent of his family . Chou also found that depressive symptomatology was associated with 2 aspects of emotional autonomy, i.e., individuation and de-idealization of parents. In a collectivist Asian society where the emphasis is on integration rather than individuation, we questioned if identity formation would become a challenge to Asian adolescents and lead to depression. On the other hand, since others are of high importance in the self-construct of collectivist Asians, we speculated that concern over selfother relationships might be a critical concomitant of depression for Asian adolescents. Adolescents in Asia, especially in the Confucian Heritage Cultural communities such as Japan, Taiwan, Hong Kong, and Singapore, also face tremendous pressure for academic achievement. A study comparing stress and coping in Singaporean and American adolescents found that academic pressure was the most frequently experienced stressor for Singaporean adolescents, in contrast to American adolescents, who were more concerned over romantic relationships and individuation from parents .We, therefore, proposed that concerns over academic competence and the cognitive skills related to academic success or failure might be significant for Singaporean adolescents. Depression is a condition whose manifestations and phenomenological experiences are intimately formed by the culture and the developmental tasks faced by adolescents . Having outlined the significance of a cultural-relevant perspective, it is essential to examine how sociocultural influences the manifestation of depression symptoms, behavior, and potential suicidal development. Major depression is a psychological disorder with impairments in cognitive, emotional, and neurobiological domains. Several etiological models indicated that an amalgamation of developmental, psychosocial, neurobiological, and genetic factors leads to Major Depressive Disorder . Across cultures, key symptoms of major depression are persistent low mood, a sharp reduction in energy, and interest, intense feelings of worthlessness, hopelessness, and some reported excessive guilt. These symptoms are observed cross-culturally . However, subjective experiences and symptom presentation can vary across cultures and this could pose a challenge in assessing depression in non-western cultural groups . It is postulated that the relationship between culture and depression is mediated by individual's selfconstrual . The collectivistic nature of Chinese communities entails relatively more interdependent self-construal and their "idiom of distress" were found to contain more symptoms regarding social aspects of the self . In such culture, social contexts are deemed as an integrative part of self-construct . Indeed, the values and belief systems of a culture influence individuals' goals and motivational efforts . Thus, their psychological state would be influenced by interpersonal and social processes. For instance, the perception of a lack of parental support and peer acceptance are found to be predictive of depressive mood among Hong Kong Chinese adolescents . So, it is meaningful to incorporate interpersonal elements of depression as these are culturally sensitive and relevant to depressive symptomatology. However, these constructs are often absent in most assessments developed in the West. Other socio-cultural research found that Asian tend to place less emphasis on affective symptoms; instead, they tend to present somatized complaints . Chang found that Asian Americans demonstrated higher salience for psychosomatic symptoms as compared to ethnic Americans. Likewise, East Asian and Asian American reported similar psychosomatic depressive symptoms but less affective or emotional symptoms. Other relevant sociocultural research suggested that guilt and shame appear to influence Chinese suicidal tendencies. Several scholars have begun to highlight the salience of shame among Asian Americans due to its presence in several Asian languages and parenting techniques , and higher levels of shame experiences compared to Caucasians . The collectivistic nature of Asian also influences their high need for social approval and desire to fulfill socially prescribed duties, hence leading to a sense of shame when they are unable to meet social expectation . Wong et al. conceptualized shame as an interpersonal experience, which comprises two dimensions: external shame , and family shame . Research showed that external and family shame was positively correlated with depression and suicidal ideation but negatively correlated with self-esteem . Self-conscious moral emotions such as guilt and shame have been found to be particularly salient during Major Depressive Disorder . Meta-analysis studies showed that those who reported high levels of shame were less effective in communicating their suicidal intent and often could not be understood when they seek help through indirect means . Studies in community settings and college students showed that shame was positively associated with suicide ideation . Similarly, excessive, persistent, and inappropriate sense of guilt is considered as a clinical symptom of MDD, particularly for melancholic subtype . A recent meta-analysis showed that younger adults with current major depression reported higher levels of guilt as compared to older adults . Another research indicated that a sense of guilt was characterized by female MDD patients who had a history of suicide attempts . Past research also revealed that patients with current MDD reported significantly high levels of guilt . --- Development of a Cultural-Relevant Assessment It is important to review the current suicide risk assessment scales in past research. Baek et al. noted that self-reporting is the common method to identify symptoms related to suicide risk. This is a common approach to screening suicide risk groups, and interviews would be carried out to assess the severity of suicidal ideation. Such structured interview tool aims to minimize the subjectivity of experts' judgment. Other researchers have investigated the factors predictive of suicidal behavior and found that major depression, impulsiveness, life events, and sociodemographic factors . Thus, it is essential to include major depressive disorder, particularly culturally relevant factors, in the development of suicide assessment instruments. Indeed, there is a lack of consensus over diagnostic criteria, an absence of culturally appropriate norms, and a dearth of cultural validity in the assessment . Recent research examined the validity and reliability of a Chinese language suicide screening questionnaire-observer rating assessment for children and youth . However, this research largely considered the linguistic equivalence of assessment scale items in Chinese culture and did not integrate socio-cultural relevant constructs such as major depressive symptoms, interpersonal and psychosomatic constructs which had been found to be a precursor to suicide, and predictive of suicide. Perhaps such inclusion would bolster the diagnostic capacity and improve the preventative effort as it reflects a shared Asian cultural emphasis. The aim of this theoretical paper is to develop a cultural-relevant suicide assessment scale with sound psychometric properties and incremental validity over previous instruments developed in the West. Incremental validity refers to the extent a scale confers predictive validity over existing scales . Kate et al. and other research typically included Beck's inventory of depression and hopelessness with suicide risk assessment. We argue that this might not be appropriate as these did not sufficiently consider the cultural experience and values of Asians, such as concern over interpersonal relationships, psychosomatic manifestation, emphasis on socially approved success such as achievement, and developmental concern for social integration instead of individuation. Other research which attempted to adopt Western Scales in the past was mainly concerned with linguistic equivalence and translational issues but failed to take into account salient cultural-sensitive and relevant nuances, which would no doubt affect the effectiveness of the assessment. --- Measures The first part of the questionnaire would encompass the Chinese Suicide Intent Scale , which has been validated in Chinese society . The study adapted and extracted 7 statement groups each assessing various aspects of suicidal ideation. Each statement group consists of three sentences that describe different intensities of suicidal ideation, representing a three-point scale . The prospects are instructed to select the specific statement of each group that is most applicable to them with higher values indicating a greater risk of suicide. We do not distinguish different degrees of suicidal risk nor set a cut-off criterion as even very low total scores can be associated with significant risks of suicide. These items would serve as a screening instrument for suicidal ideation. This scale would cover three factors: precautions ; planning ; and seriousness for high variance, and such high construct validity would provide the support that C-SIS has sound psychometric properties. Thus, it is a qualified and appropriate measure for assessing suicidal behavior in the Chinese population. Unlike the previous studies done by Gau et al. and Zhang and Jia , this study did not draw depressive symptoms items from Beck Depression Inventory. Instead, the study would include salient cultural factors from Singapore Depression Scale and the Asian Adolescent Depression Scale . For the Asian Depression Scale, this author has drawn two socio-psychological constructs as follows: Loss of Meaning of Life ; and Affective-Somatic Symptoms . From the Asian Adolescent Depression scale, this author has also drawn the following: Cognitive Inefficiency ; Negative Self-evaluation . Chang and Koh 's assessment of the psychometric properties showed that these constructs provide a more accurate assessment and more effectively capture the cultural experience of Asians . Participants are asked to rate each item on the extent to which they generally feel on a five-point scale , with higher values indicating a higher level of depressive symptoms. In this study, the Asian Suicide Risk Assessment comprises items from the Chinese Suicide Intent Scale and Asian Depression Scale, which fulfill the author's quest to develop a cultural-relevant questionnaire for his suicide risk assessment. Both scale items have been validated within the Asian and Chinese cultural settings and showed sound psychometric properties for assessment purposes. As reiterated, suicide and depression are sociopsychological phenomena that manifest within a culture. Beyond only striving for translation accuracy and linguistic equivalence, this study bolsters the clinical utility by incorporating culturally-specific and relevant constructs, particularly: interpersonal and social perception toward self and life purpose; psycho-somatization; and cognitive efficiency. Indeed, such a scale is vital and relevant in capturing the socio-cultural suicidal and depressive experience. Integrating cultural-relevant depression assessment constructs, it would bolster the predictive power of the instrument in capturing episodes of depressive thoughts, which would inevitably lead to a sense of despair and hopelessness, and eventually suicide in most instances. Thus, it also confers further clinical utility in the aspect of earlier suicide detection and prevention. --- Asian Suicide Risk Assessment Scale Instruction: Participants are to choose a particular statement out of 3 choices in each group that is most applicable to them. Scoring Scheme: For items 1 to 7, each item consists of three sentences that describe different intensities of suicidal ideation, representing a 3-point Likert rating scale . The higher the score the higher likelihood of suicidal tendency. --- I. Objective Circumstances Related to Suicide Attempt --- II. Asian Depression Symptoms Instruction: This section assesses depressive symptoms in adolescents, and higher scores in respective depressive categories indicate the severity of the depressive-suicidal risk. Scoring Scheme: Participants are asked to rate each item on the extent to which they generally feel on a 5point Likert rating scale . The maximum score is 90 with a cutoff score at 45. The higher the score the more depressive a person is with a higher indication of depressive-suicidal risk. --- No --- Conclusion The study adopted a cultural-relevant approach to developing an Asian Suicide Risk Assessment instrument. It considers the role of socio-cultural influence in shaping the manifestation and development of suicidal and depressive symptoms. By drawing from instruments that have been validated within Asian culture, this study aims to formulate a culturally relevant scale that appropriately captures the cultural nuances, thereby exhibiting greater clinical utility and incremental validity over present instruments. Generally speaking, Asians are less expressive and often take a more collectivistic stand, this author proposed and included culturally salient factors such as affectivesomatic symptoms, and interpersonal and social-oriented evaluation, which were previously lacking in previous suicide risk assessment items. In addition, it included a developmentally salient factor that aptly characterizes young Asians' industrious nature and emphasis on achievement in career and academics. With these, the authors believe that it would be a versatile instrument to test for suicidal-depressive risks within Asian culture.

Suicide is a serious social and psychological issue that has a devastating socio-economic impact globally. However, it remains elusive as mental health professionals grapple to formulate effective assessment and intervention strategies. Particularly, there is a dearth of cultural-relevant suicide risk assessment scales as most instruments were developed in Western culture. Even with translation and linguistic equivalence, present suicide risk assessment scales do not encompass culturally salient and relevant psychological constructs. This study adopted a socio-cultural approach to develop a suicide risk assessment with sound psychometric properties and also to capture the cultural-specific symptomatology of suicide as well as depressive Asians.

Background Addressing gender inequality is recognized as essential to health and sustainable development. Gender inequality and early marriage are obstacles to women's life chances as they impact negatively on education, and lead to early child-bearing and increased risk of maternal and child morbidity and mortality [1]. Adverse consequences persist across the woman's life-course and into the next generation, perpetuating cycles of poverty and ill-health among the poorest. In India, marriage before age 18 is legally banned. Widespread efforts by both government and non-government organisations to curtail early marriage are helped by strong economic growth and increased education. Indeed, the latest National Family Health Survey in 2015 reports significant progress in delaying marriage and improving levels of education. In urban Maharashtra, the proportion of women age 20-24 years who married before age 18 dropped from 29 to 18% in 10 years. The overall proportion of women with 10+ years of education increased from 31% to 42, and is at 52% in urban areas [2]. For marginalised slum communities, conditions are less favourable with other structural inequalities compounding gender inequality. Gender norms are powerful pervasive beliefs about gender-based social roles and practices that are deeply embedded in social structures. Norms are produced by patriarchal power-relations and maintained, in part by self-surveillance as girls follow internalised gender scripts. In India, gender norms produce outcomes that disadvantage girls and women. Norms reinforce women's caregiving and reproductive roles and limit their access to public space. Gender-related scripts were found more significant than either economic rationales or women's empowerment in explaining variations in age at marriage across India [3]. While empowerment theories have explored women's subordination within the household, social institutions, and the state, they have paid insufficient attention to the symbolic aspects of gender [3]. According to the "performance theory" of gender, girls learn to perform gender roles and adopt gender identities that 'regulate' social interactions and limit options including the freedom to move and be visible in public space [4][5][6]. It shapes their choices in ways that continuously reproduce gendered pattern of behaviour in day-to-day social interactions. It is the visible display of gender that allows neighbours and communities to police women's actions. The anticipation of social sanctions or rewards, with the need for belonging and approval from the group, is one of the key motivators for compliance [7]. Once a girl reaches menarche in India, parents get concerned about demonstrating her 'good' virtue, an essential aspect for finding a good matrimonial match [3]. Good virtue requires modesty, a deferential demeanour, proficiency in household chores and above all sexual purity. Early marriage becomes part and parcel of the symbolic display of segregation, modesty, and chastity. The supremacy of virginity means unmarried girls are in need of both restraint and protection, limiting their access to public spaces [3]. Gendered power dynamics are embedded in space, organised into the "masculine" public domain, and the "feminine" private sphere [8]. Popular discourse associates women's safety with the modesty of her clothing, with burkhas and salwar kameez designed to hide the female body from public view. As custodians of family honour, girls are socialised to fear not only potential violence in public spaces but also the threat of public censure that will impact her 'reputation' [5]. The fear of sexual harassment maintains male privilege, diminishes women's feelings of safety and belonging in public places and restricts their freedom of movement [9]. Fear and social control significantly limit girls' individual agency to access public space, a structural barrier in any intervention aiming to increase female education and participation as citizens in society. Any emancipatory change among adolescent girls thus requires concurrent social change. Gender constructions can be challenged and redefined when performance of gendered identity transgresses established norms [10]. Where individual agency is largely constrained by structural factors, social change starts at the level of social practices: via changes in day-to-day social relations that individuals and communities cultivate [11]. There is very little detailed description and analyses of the subtle changes that occur when women contest discriminatory norms in gender programmes and this paper addresses this gap using research data collected in the context of an intervention that encourages the inclusion of young women and girls in public spaces. --- Parivartan Change at Play is a sports-based programme among adolescent girls age 12-16, implemented in a slum community in Mumbai. Young women were recruited from within the slum community to serve as "mentors" to younger girls. They were trained to lead reflection sessions on gender and to coach kabaddi, a contact team sport. They then delivered a carefully structured programme of life skills and gender training to younger girls, interspersed with weekly games of kabaddi. Concepts from social norms theory [7,12] were used to shape the content and implementation of the programme. To perform their responsibilities, mentors needed to challenge mobility restrictions and negotiate their visibility in public space. In this paper, we focus on the change process among mentors, noting how the programme enhanced their agency to strategize and negotiate greater freedom and visibility in their community. We emphasize changes in day-to-day social interactions at home and in public spaces. --- Methods --- Study setting and design The Parivartan programme was located in four plots at the periphery of Shivaji Nagar, one of Mumbai's largest urban slums. The community consists predominantly of Muslim migrant families mainly from Uttar Pradesh working in the unorganized sector and living in substandard housing with poor water supply and sanitation. The wards included in this study are near a dumping ground and some lanes are seen as unsafe because drug users frequently loiter there. Various NGOs have been implementing a range of health and development projects including a sports-based programme for boys. Increasingly community development programmes work at both the individual and community level. Men in the communities are mobilised mainly via the Imams in the mosques and women via Mahila mandals, which are small groups of neighbours residing in the same lanes. Public spaces are dominated by men and after menarche, girls' mobility and visibility are restricted, as is their interaction with boys. Burkhas or salwar kameez with headscarf are the requisite dress code outside the home. Apnalaya, a grass-roots NGO with longstanding presence and credibility in the community, implemented the intervention. The research was implemented by the International Centre for Research on Women , in collaboration with the STRIVE research consortium. We adopted a prospective qualitative research design to study the interaction between the intervention and the changing context within which it was implemented [13]. Case studies were done with 10 mentors and 15 girls during the implementation phase, preceded by participatory research among girls, mentors, mothers and fathers at the design stage. Written consent to participate was obtained from all research participants. --- Sampling Mentors for the intervention were recruited from within the slum, with eligibility based on age and education , as identified by Apnalaya . Out of 40 applicants, 15 young women were selected as mentors after three rounds of personal interviews to establish their interest in sports, level of aspiration, their commitment towards the programme and their position on the rights of women and girls. They were coached on kabaddi, mentorship and leadership skills and trained in a Gender and Gender Equality curriculum during the initial 5-day residential programme. There were 4 more 2-day workshops on using the intervention tools with their group of athletes. All mentors were responsible for conducting two sessions per week with their group of female athletes. The full programme consisted of a well-structured curriculum encouraging reflection on gender expectations and myths, human rights and life skills delivered over 15 months. The tools designed for these sessions consisted of 21 Card Sessions presenting topics and 19 Group Education Sessions with role plays and games to facilitate practice and reflection on issues introduced the previous week. Mentors received a monthly stipend of INR 3000 . Implementation challenges were discussed during weekly meetings with Apnalaya staff, who were available throughout the project to help mentors problem solve. Project staff placed special emphasis on helping mentors ensure their personal safety and that of their athletes. --- Data collection By the time the implementation of programme started, five mentors had dropped out , and the data used for this analysis draws exclusively on 2 rounds of face-to-face indepth interviews with the 10 remaining mentors. The interview guides were developed based on literature on gender practices in India and understanding of the community, based on formative research. Guides for the second round were personalised with follow-up of particular issues of interest arising in the first round, while keeping style of interviewing and issues covered consistent. Interviews were shaped around a semi-structured interview guide with open-ended questions on: gains, achievements, difficulties and challenges encountered as Parivartan mentors; safety and security; commitment to and outcomes associated with their mentor roles; freedom to move around in the community and relaxation of restrictions; perceptions of changes in themselves and in the relationships with parents and caretakers; and changes in those whose opinion the mentor's valued in terms of their own behaviour . All interviews were done by the first author at the ICRW field office, a comfortable and relaxing environment which enabled confidentiality, at a time convenient to them. Interviews were digitally recorded, transcribed and translated verbatim. --- Analysis We combined thematic and narrative analyses [14]. The transcripts were reviewed and themes discussed continuously during data collection by the authors. We followed a step-wise procedure of familiarising ourselves with the data, identifying a thematic framework and developing a coding frame, using Atlas.ti for data management. We also developed spreadsheets to explore commonalities and differences across mentors, while ensuring that the context and integrity of each narrative was maintained across both data rounds. We looked for patterns in how mentors negotiated space and exerted agency paying attention to the interactional context, acknowledging that narrative identities are shaped and co-constructed between mentor and interviewer [14]. Interpretation was influenced by insights gained during observations in the community and during regular meetings with mentors. For this paper we investigate the theme of mobility, identifying how mentors negotiated the relaxation of mobility and visibility restrictions, both at home and in the community. We explore the extent to which the Parivartan programme gave them the skills and opportunities to do so, and how their personal history and circumstances may have impacted the trajectory of their transformation. We also examine the various strategies mentors developed as a group to contest norms and the factors contributing to break-downs and set-backs of achieved freedoms. --- Results --- Profile of mentors Table 1 gives the profile of the 15 mentors who enrolled as mentors and started the residential training. This is a select sample of young women, welleducated compared to their contemporaries in the slum, with several pursuing a university degree. Mentor 1 and 5 were the only ones who had dropped out before finishing 12th class. Mobility restrictions had stopped mentor 4 from attending mainstream school after 10th class, but she studied from home and sat 12th class exams, though unfortunately failed. Mentors 10 and 14 studied at university level from home. Only mentor 11 was married at the time of recruitment, and lived with her in-laws. Most other mentors lived with both parents, except for mentor 2 whose parents had both died, and mentor 10 who lost her father. All families had previous contact with Apnalaya, some as active members of self-help groups, while others had been beneficiaries of schemes, including scholarships for children's education. Mentors expressed different motives for becoming mentorsfor some it was additional family income, for others it represented an opportunity to learn and come out of the house. Mentors 11 to 15 dropped out before the implementation started and were not interviewed for the case studies. After the first day of the intensive training, M11's family decided they could not deal with the logistics of caring for her small baby. The time commitment required to recruit athletes far exceeded what M14 and M15 could accommodate given their study and work commitments. Two sisters M12 and M13 had to withdraw as they went to live in their native village. --- Variations and changes in mobility restrictions In Shivaji Nagar, parents restrict the movement of young women through 'male' public spaces, and their behaviour is closely policed by neighbours and relatives. Any deviation from expected patterns raises suspicion about relations with men or boys, and is interpreted by neighbours as a marker of bad parenting. The severity of mobility restrictions depends on the purpose of the outing, the time of day and the distance a girl travels. Going to school or work are considered 'valid' reasons, but leisure time with friends or acquaintances is not. At night when it is dark and during the heat of the afternoon when streets are relatively deserted, are times seen as especially unsafe. The immediate neighbourhood is considered safer than places further away like markets and public transport, which are associated with men and boys. Measures to protect a woman's safety in public include sending an escort with her, mostly an older relative, though a younger brother is also acceptable. The extent of mobility restrictions varied among mentors before and during the programme. We summarize variation in restrictions for moving to various places, by depicting whether she needed an escort at all times, during unsafe times in afternoon and evening, only after dark or not at all . The graphic below visualises the variation in mobility restrictions before respondents began as mentors, and 18 months later. It demonstrates clearly that mentors were able to negotiate permission to move more freely on their own, both to pursue programme-related activities and beyond. Despite progress, limitations remained. Mobility restrictions were re-imposed upon those mentors who dropped out of the programme during implementation. Various demands came with the role of mentor, with the need to move around in the community the most prominent one. We analyse the programme's expectations and the challenges mentors encountered at sequential stages of training and implementation. --- Initial residential gender training At the start of the programme a 5-day residential training on gender equality, life skills and rights was held in a location outside the community. Staying away from home overnight predictably raised suspicion as expressed by one of the mentors: "I was not sure if I would be allowed to be out for this training as it was for 5 days and we had to stay there. You know the people here talk so much about girls. If a girl is not seen in the house for one night they come asking, 'Where is your daughter? She is not seen.' They have nothing to do with it yet they will come and ask the mother or at least gossip with other women in the area. This is bad…. with this fear of bad name parents don't send their daughter out in the night to stay somewhere else." . This strong community policing of women's movement made negotiating mentors' attendance difficult. Nevertheless, for nine of the 15 young women invited to the training, Apnalaya's credibility as a respected grassroots organisation engendered sufficient trust. For the other six mentors Apnalaya staff were involved in several levels of negotiation to persuade parents to let their daughter participate. M6's mother was supportive but insisted that Apnalaya staff sought permission from the father and the elder brother. This took multiple home visits up to the last day before the training when the elder brother was available. A long conversation was interrupted by the arrival of a visitor, at which point the brother suddenly agreed and signed the consent form. Later that evening he forbade his sister to go as he had only agreed to avoid a discussion in front of visitors. However, M6 quietly left the house early in the morning while others were asleep, letting only her mother know. This resulted in an aggressive response from the father and elder brother banning the mother and younger brother from the home for three days. Upon her return home after the training, they did not speak to her for several days, yet M6 moved on to the next step in the programme: recruitment of young girls. Spending 5 days and 4 nights together in a nonrestrictive environment provided a safe space for the young women to discuss and question mobility and visibility restrictions imposed on them, while practicing negotiation skills to push boundaries. Another major outcome of the residential training was the building of strong personal bonds between the mentors, a powerful resource of social support for the recruitment and implementation stages of the programme. --- Recruitment process of young girls into the Parivartan programme A lot of the narratives on how mentors managed to push boundaries refer back to this period. The recruitment of athletes involved obtaining consent from families, a process that took much longer than anticipated. Mentors had to visit the families of the girls' multiple times, initially accompanied by Apnalaya staff but later by themselves. Apart from contravening prevailing mobility norms, these visits encroached on time spent on household chores -both required negotiation at home. While some parents asked their daughter to quit the programme as time commitments far exceeded what had been communicated to them, the mentors stood their ground. As mentors felt safer to move through the community in little groups, they coordinated visiting the families together. Eventually, the inconvenience of organising times resulted in them going on their own, sometimes unbeknownst to the parents. Losing the safety of the group did feel uncomfortable and gave cause for anxiety. They feared both harassment by men and boys, and being seen by acquaintances and neighbours in areas where they are not expected to come on their own. All 10 mentors reported being confronted with these issues, but all came through adopting their own strategies. To avoid harassment by men, mentors approached their destinations through different roads or by-lanes when alone. "Actually, the first time I went to XX without another mentor, I was also very scared. The entire area XX you will only see men around. And to go through this crowd initially was a big challenge we had. So we would get out through the internal lanes because we did not want to go through them. This is how it worked for us for 2-3 months but now we can easily tell the men to move and we make our way through the crowd even when alone." . --- Fig. 1 Variations and changes in mobility restrictions Several mentors reflected on the constant negotiation with parents to counteract the effect of neighbours commenting on their movements through the community. Trust developed gradually through communication as the parents came to understand that the role as mentor demanded this level of mobility. Neighbours remained keen to police her movements, requiring further negotiations during the actual implementation of Parivartan. --- Sports and reflective sessions with the athletes As the actual programme started, mentors accompanied girls from their homes and dropped them back after each session. Sessions ran in the afternoon when streets and alleys are relatively deserted, and her visible presence lead parents, neighbours and relatives to request timings that seemed more appropriate or the company of an escort. Instead of compromising, mentors took it as a challenge to overcome these barriers. The fearless attitude displayed by some mentors catalysed others to resist interference too. Many mentors acknowledged the power of sharing both the challenges and solutions from fellow mentors, leading to increased confidence as a group and as individuals. Framing the greater mobility and visible presence in the community as a 'duty' of being a mentor and a requisite for doing 'good work' was the main strategy used in negotiating with parents and in silencing neighbours. "Whenever I am late at the sessions or the meetings that Apnalaya has for us in this programme, the women around my house come and ask my mother, 'where is she? It is so late? When will she come? She should not be out of the house for such long hours.' That is when my mother tells them straight in their face, 'she is out doing some good work and I am proud of my daughter. We trust her.' When my mother says this they keep quiet for a moment, but the next time I am late they come and ask again, but my mother stands by me. I am happy that she understands my role as a mentor." . Reaching the school grounds where the sports sessions were held required a 45 min walk through markets and passing bus stops-all places crowded by men and boys. Mentors again coordinated with fellow mentors to travel together to accompany groups of athletes. While they reported incidents of teasing, name-calling or stalking, mentors and their athletes developed the ability to handle the harassment with increasing confidence. Mentors perceived their increased confidence as the main personal benefit from their association with Parivartan and this boosted their commitment to the programme. As they examined the previously imposed restrictions on their mobility, they felt convinced that change was desirable and justified. From this position, it was easier to negotiate parents' support to fulfil their mentor responsibilities. --- Further training programmes outside the community Eight months into the intervention, the programme needed the mentors to attend three non-residential trainings, each lasting 2 days and one 2-day residential training conducted outside the community. This required them to travel independently using public transport and coming home late in the evening. For mentors M1, M4, M5 and M6 this was the first time they travelled out of the community without a family member accompanying them. Yet the company of other mentors provided them with confidence and readiness to handle any harassment they might encounter. --- Hopes, strategies Parents have clearly been pivotal in supporting their daughter to take on the role of mentor. Mentors attributed their parents' support to the way they had strategically shared some of the content on gender and rights included in the reflection sessions for athletes: "I discuss the topics that are in the module with my mother… but not everything together. I give her small small doses. This will help her understand what I am working towards and also know where my thinking is coming from. I have to see her mood and then go ahead talking to her… if I talk everything to her at the same time and it becomes an overdose then she can ask me to shut up." . The process of building trust was clearly a gradual one, navigated with care and predominantly via the mother. As social customs restrict direct interaction between young women and older men in the household, it was the mother who negotiated with her husband and sons. Yet five mentors did report changes in direct communication with their father and all with their elder brothers to negotiate pushing boundaries. Several mentors narrated their father rebuffing neighbours, and justifying her participation in the programme and movement through the community. "… like if I would go out he would be worried and keep calling me. But now he knows that I know what to do when, so he is not much worried. Even if someone asks him what I am doing out for so long, he answers them appropriately" [M5, RND 02]. It seems that demonstrating her communication and negotiation skills within the family, and sharing her achievements as a mentor, has given her parents confidence in her ability to deal with situations outside. This opening for dialogue, with the trust it inspired, gave mentors the capability to negotiate mobility beyond her Parivartan duties, to pursue education but also for leisure time. Prior to Parivartan, mobility restrictions had caused three mentors to drop out of mainstream education. Yet, with increased confidence and parental trust, M1 and M5 began attending night school outside the community; this required them to access public transport and travel back home in the dark, on their own. Mentors M8 and M9 negotiated leisure time with their friends going beyond the slum boundary, taking pride in commuting independently, something inconceivable before the programme. They navigated this change partly by first obtaining permission to spend leisure time with the mentor group, an intermediary step that made it easier to gain permission from parents. --- Fears and failures Mentors recounted their agency in effectively enrolling parents' support for their duties as mentors and beyond, yet there was hesitation too. They did not take their current freedoms for granted and fears of 'falling back' were prevalent, with mobility seen as conditional on not making mistakes. Sharing their opinion with parents, demanding justice or asking to be involved in any decision that concerns her, was still seen as a potential 'step too far'. "I am scared that if I say something or ask for some permission, she [mother] could say "no there is no need for you to go out of the house anymore." I fear that she will stop me from doing this as well. She will say, "you don't go out at all," and I will have to be in the house all the more. And that day she got angry with me and said, "don't go to school and don't go anywhere… just don't get out of the house. There is no need for you to go out." She was saying this." . Once mentors had started moving independently, they became frustrated when they needed a 'valid' reason to go out, or when only permitted out if escorted by a male relative. Ready and willing to negotiate, they clearly needed to be cautious and strategic in pushing boundaries gradually. Even when mentors felt they could appropriately respond to neighbours who might question their mobility, they still feared neighbours' power to influence their parents. 'Suspicion' about sexual chastity and its impact on family honour could easily raise its head and undo the hard-won trust they had built. There was also concern about incidents in the community re-awakening doubts about how unsafe the environment really is, and how others may incite parents to re-instate normative restrictions. Mentor 2, an orphan who lived with her grandmother saw her freedom reigned in when her uncle, who is her guardian, returned from the Middle East where he had been exposed to more orthodox religious ideas. Having described her relative freedom in the first round of interview, in the second she describes how his views had changed: "….. he is come for the past one month and now everything in the house has changed. I have to be careful about the time I spend out of the house, the cloths I wear… he is insisting on every woman and girl in the house wearing a burkha. … He was not like this before, when grandmother spoke to him about me joining the programme he readily agreed and never had a problem with my clothing. But now since he is back, he is behaving as if he has lost his mind.". For M2, increased restrictions on clothing and the amount of time spent outside the house had become reality. During the first round of interviews all mentors had spoken of their wish and resolve to postpone marriage until after the end of the Parivartan programme. By the second round, 6 months later, two mentors had dropped out because of marriage or engagement . The decision to quit had been imposed by the families they were getting married into. Before their engagement they achieved freedoms equal to those of other mentors. As the group of mentors had become a new important reference group, they were acutely aware of what they had come to see as a 'right' now being revoked. The failure of their attempts to negotiate, which had been effective with parents previously, left them clearly exasperated: "he rules they have, I am unable to follow them and also to understand why they are saying this… They often say, 'That's why I say girls should not go out so much…. when they get outside air then they don't like to stay at home'." . Her personal history is important to consider both during and before the programme. Mentor 6 was the one who disobeyed her elder brother about attending the residential training. Initially she and her parents had faced a lot of questions from neighbours about her movements. Yet everyone had become more supportive of her duties serving younger girls in Parivartan. This ultimately brought more respect to Mentor 6 and her family, with neighbours now approaching her for advice on education and schooling. In the first round of interview, Mentor 6's level of agency was impressive. The start of marriage negotiations had actually predated Parivartan. She had already broken off one engagement as it meant moving back to her village which she refused. She narrated how she had successfully negotiated with her new fiancé to postpone her marriage until after Parivartan as he lived about 20 km away, which would preclude her continuation. Unfortunately, her fiancé's mother became ill and insisted that her son get married at the earliest. This was a shock to the mentor, and again she negotiated with her fiancé to travel home every weekend in order to continue her association with the programme. But once she got married and went to live with her in-laws, she was not allowed out, and she was required to wear a burkha even in front of her male inlaws. Her husband assured her that everything would be fine later but patience was called for in these early days of marriage as opposing his mother's wishes would send the wrong message. She never did get permission to go back home on weekends and thus quit as a mentor. She reported enjoying the times she had on her own with her husband, trusting him and understanding the pressure he is under from his family. For mentor 4, the renewed restrictions were imposed in her own home. Her story illustrates how her parents seemed 'pressured' to do a U-turn and start conforming back to normative expectations of confining women to household chores, and away from public visibility. M4 described the changes in her mother and fiancé's behavior towards her, after her future mother-in-law had come to stay with her family, and had been unimpressed with the freedom she was afforded. Her fiancé started exerting control on her while she was still leading kabaddi sessions as a mentor, checking her whereabouts by phoning both her and her mother. "On Sundays I used to go late, roam around and then go to the market, but he would call me often and start yelling at me. "How much time are you taking? So much time is being spent at work. In half an hour you should be at home and you are roaming around till late. And mother is working alone at home." Then they coax my mother too. So when I would return home, my mother would also yell at me "What is it about you, go early, come back early." Otherwise I will not let you go. If you are going, then come back early." . Mentor 4 had perceived her father struggling with the apparent demands and attitudes of her future in-laws. She observed him expressing doubts to his wife, who rebuked him with "everything is new, let it go now and see what happens later". Her father had become quiet and her mother seemingly tried to create a conducive environment in preparation for marriage. Again, personal history seems important in illuminating her parents' conflicted situation as they had concerns about her mental fragility and health impacting on her marriageability. She was once kissed by a male childhood friend, which upset her to the extent she took pills to end her life. The risk of breaking off an engagement and the gossip it would create in the community, further decreases the prospects of marriage. Receiving no support and only silence from her parents, the mentor finally gave into the demands of the in-laws and her fiancé to discontinue with the programme. Once she quit, she was confined to the house and lost all contact with the other mentors. --- Discussion This qualitative case study situated in a Mumbai slum demonstrates how a carefully structured sports mentoring programme, conceptualized to contest restrictive visibility norms for girls and women in public spaces, allowed mentors to effectively negotiate a 'respectable' presence outside the home for themselves and the participating girls. The Parivartan programme relied heavily on the mobility and visibility of mentors for its success and charted out a comprehensive strategy that supported their collective and individual agency and promoted proactive family engagement. Not compromising on the women's ability to negotiate their own movements and reputation proved instrumental in the 'transformative' nature of this intervention. The mentors themselves negotiated freedoms both in and outside their homes. They changed the nature of key day-to-day social interactions, whether it was with mothers, fathers and brothers, neighbours, parents of their groups of athletes, or men on the streets. We must reiterate that mentors were purposively selected as 'positive deviants' , educated and still unmarried in their early 20s, from families previously involved in development initiatives or self-help groups with Apnalaya, a respected organisation in the community. Since social norms set limits to bargaining, and to what can be bargained over [15], opportunities for shifts in gender relations were maximized by involving families supportive of their daughters' aspirations. Our data suggests that elevated levels of aspirations on the part of mentors and their mothers was a strong driver of the bargaining in favour of mobility within and beyond the family. Contesting restricted norms involved gradual negotiation, initially drawing on 'valid reasons' to gain permission to perform necessary tasks or 'duties' as mentors. Careful bargaining was needed to navigate the complex shift from an identity constructed around predominately domestic duties towards a new identity of a mobile young woman working towards a cause, visible to neighbours and community. The bargaining power to change gender dynamics at home and in the community are linked [15]. The most critical enablers at home were the mothers with whom mentors shared discussion topics on gender inequality and gender justice, always strategic about what and when to share. This process was characterised by both cooperation and conflict; the more mentors questioned and challenged issues of inequality, the less they were willing to accept constraints on their mobility and freedom. In line with traditional gender conduct, mothers initially negotiated on their behalf with the male members of the family, yet mentors also started communicating directly with elder brothers and fathers. This demonstration of individual agency in itself seems to have contributed to the mentor winning parental trust in her ability to be safe in public spaces. The family was thus enrolled in the co-production of a new identity [16] as a respectable young woman doing 'good work' with younger members of the community. Parents were active players by not giving into social sanctions of neighbours and relatives. As the programme unfolded, the mentors developed into a strong support group for each other, influencing and inspiring each other to stretch boundaries, gaining confidence each time they witnessed each other's successes. The programme created opportunities for collective action, increasing mentors' ability to think and relate in a collectivized manner. They formed a new reference group for each other in terms of what was possible and acceptable. Our data corroborate the finding that collective bargaining and action are central to both questioning and contesting gender relations [15]. Mentors contested mobility restrictions taking risks as a group, with collective agency an important step towards greater individual agency in day-to-day social interactions [11]. First, they sensibly used strategies for protection: moving in groups, taking inside alleys to avoid crowds of men on the main streets when going on their own. In other words, they modified their behaviour to avoid unwanted male attention in order to resist exclusion from public space. While this strategy risked reproducing the norms that reduce their claim to safe access [17], the skills gained from the gender training enabled them to go further. Mentors rebuked men and boys on the street and came to no harm. They managed, gradually, to achieve the right to 'take risks' and put their right to access public spaces above their desire for protection, diminishing the perpetuation of patriarchal power [6]. Most mentors went beyond negotiating mobility for performing duties and achieved more leisure time away from home. Notable in our data was how conversations steered away from reputational risks. The discourse of sexual safety was side stepped in both the narratives and in the intervention. In fact, the mentors' presence in public spaces became de-sexualised. Instead of losing respectability by being visible in the community, they gained social standing through their new identity as mentor, performing a valued community service in association with a reputable and trusted social development organisation. This observation may have important implications for other interventions that aim to increase education and delay marriage. By dwelling too much on marriageability, programmes may unwittingly reinforce concerns about sexual safety rather than defusing them. All mentors expressed anxiety about potential curtailment of their freedom, and insecurity about what will happen once the programme ends. Importantly, bargaining power to leave the home all but evaporated for the two mentors who dropped out. Confronted with more gender-retrogressive in-laws, their parents' support also waned. While they seemed to come from less progressive families in the first place, we cannot tell how the other mentors will fare once the marriage process starts. Mobility restrictions did increase again for the mentor whose uncle and guardian migrated back from the Middle East. Identity and 'cultural' politics appeared to take center stage at the cost of women and girls symbolically representing cultural exclusiveness. Limitations to this study include a potential desirability bias in mentors' accounts, even when they felt free to express concerns about their future. We also cannot know how the mentors' income increased their bargaining power within the family and what will happen when it falls away, but we will explore this once the third round of data, collected a year after the end of the programme, are available. We cannot disregard influences from secular change and other development initiatives. Indeed, previous efforts addressing gender inequality no doubt contributed to the mentor families' readiness for change, in the same way this sports programme inspires and prepares other families for future change opportunities. The ultimate target of Parivartan are the girls participating in the sessions, and documenting the changes among them was beyond the scope of this paper. However, a first step was establishing that mentors drawn from within the slum community were able to implement the programme and provide new role models. Despite visible change in these young women's presence in public spaces, it seems too early to claim that these mentors have set a new standard by having adopted new roles and responsibilities [12]. Yet the symbolic aspects of performing gender came under strong scrutiny and the positive reception so far gives hope for greater participation of young women as citizens in times of ongoing social and economic change. --- Conclusion In a Mumbai slum where fear and social control significantly limit young women's access to public space, the day-to-day social interactions of mentors implementing a sports-based programme changed in significant ways. The mentor role created opportunities for collective action, increasing mentors' ability to think and relate in a collectivized manner and taking risks free from overbearing paternalistic protection. This paper makes a significant contribution because gender norms continue to act as structural barriers to many public health programs and rob generations of young women to participate as citizens in society. It provides important insights into addressing embedded social norms that perpetuate gender discriminatory practices and the social patterning of health inequalities. --- --- Abbreviations ICRW: International Center for Research on Women; IIPS: International Institute of Population Sciences; NGO: Non-Government Organisation Authors' contributions RVK, LH, and MD made substantial contributions to conception and design of the programme. RVK, LH, MD and MC contributed to the research methodology. SB collected the data. SB, MC and MD analysed and interpreted the data. BC gave detailed input on social norms. SB and MC drafted the manuscript. All authors critically reviewed and approved the final manuscript. --- --- --- Competing interests The authors declare no competing interests. ---

Background: Harmful gender norms are known structural barriers to many public health and development interventions involving adolescent girls. In India, restrictions on girls' liberty to move freely in public spaces contribute to school dropout and early marriage, and negatively affect girls' health and wellbeing, from adolescence into adulthood. We report on mechanisms of change among female mentors 18 to 24 years old who contested discriminatory norms while implementing a sports-based programme for adolescent girls in a Mumbai slum. Methods: We adopted a prospective qualitative research design. Our analysis is based on case studies derived from two rounds of face to face, in -depth interviews with 10 young women recruited to serve as mentors for the project's young female athletes. We combined both thematic and narrative analysis. Results: The programme created opportunities for collective action, increasing mentors' ability to think and relate in a collectivized manner, and challenged the traditional female identity constructed for young women, which centres on domestic duties. The mentors themselves negotiated freedoms both in and outside their homes, which required careful and strategic bargaining. They changed the nature of key day-to-day social interactions with parents and brothers, as well as with neighbours, parents of their groups of athletes and men on the streets. They formed a new reference group for each other in terms of what was possible and acceptable. Demonstrating greater negotiation skills within the family helped win parents' trust in the mentor's ability to be safe in public spaces. Parents became active supporters by not giving into social sanctions of neighbours and relatives thus co-producing a new identity for their daughters as respectable young women doing 'good work'. They effectively side stepped reputational risk with their presence in public spaces becoming de-sexualised. Conclusions: Mentors contested mobility restrictions by taking risks as a group first, with collective agency an important step towards greater individual agency. This research provides important insights into addressing embedded social norms that perpetuate gender discriminatory practices and the social patterning of health inequalities.

Introduction The Australian population is ageing fast, with a predicted increase in the old age dependency ratio from 21 per cent in 2011 to 38-42 per cent in 2050 [1]. The rapid population ageing in Australia will lead to shortages of labour force as well as increases in government expenditure on age pensions, health and aged care services, as stated in the Australian Government's Intergenerational Report 2010 [2,3]. Maintaining labour force participation at mature ages is considered to be the most constructive strategy for addressing all the challenges of an ageing society as working longer can not only increase productivity and tax revenue, but also assist individuals to build resources for their own retirement income as well as reduce the government's potential liability [2,4]. However, mature age workers (aged [45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64] in Australia were found to leave employment well before pension age, and have relatively lower level of workforce participation, when compared to both domestic younger working age groups and same age groups in other countries of the Organization for Economic Co-operation and Development (OECD] [5,6]. Though the labour force participation among mature age Australians has increased substantially from 67 per cent in 2001 to 74 per cent in 2012, mainly due to the increase in females' participation in part time jobs according to OECD Statistics [5], it was still lower than that in the United States and Canada, and much lower than that in New Zealand. Australian mature-age men saw a downward trend in participation rates that dropped from 85% in the 1960s to a low of 60% in the 1980s and 1990s, before recovering to 72% in 2011 [6]. Mature age workers were also found to be disproportionately represented among the long-term and very long term unemployed in Australia [5,7,8]. The increasing health life expectancies in last two or three decades makes labour force participation at late life more feasible, especially for those working in less physically demanding jobs. Further understanding of how ageing impacted on sustainable work ability and why workers left their paid work at later life early before the age pension age are extremely important for workforce planning and ageing well in an ageing society. The literature review shows that labour force participation and early retirement are complex and multidimensional [9][10][11][12][13]. Extensive attention in previous studies has been paid to individual factors from labour supply side, such as the impacts of ill health [14], financial consideration [15], joint labour supply and family care needs [16], as well as institutional factors, such as universal medical insurance, eligibility for superannuation, age pensions and income tax system [17] etc., while less studies focus on factors from labour demand side, such as employment history, work conditions, and job satisfaction [15,18,19]. Gender difference is also cognizant in literature. For instance, men are more likely to consider financial aspects, while women are more likely to consider work-life balance, such as the work and caring responsibilities and the joint retirement decision with their spouses [20]. First of all, poor health, chonic diseases, caring responsibilities, workplace inflexibility, age discrimination, without non-school qualifications and lack of trainings are found to be the major barriers to the continuous employment or reemployment of mature age workers [8,14,16]. Secondly, older people working in manual occupations are more likely to get injured or disabled, or have difficulty to meet high physical requirement when age arise, hence they are more likely to be retrenched at mature age while less likely to be reemployed in other occupations [8,21]. Thirdly, job dissatisfaction and long term unemployment are found to have strong discouraging effects on labour force participation at mature age [22,23]. Lastly, the Australian system, including the more favourable access to superannuation and age/disability pensions as well as the universal health insurance, is characterised by incentives to retire early, which might contribute to the relatively younger expected ages of retirement in Australia when compared to United States though both countries have comparable life expectancies and healthy life expectancies [17]. As there is no longer a mandatory retirement age in Australia and some other developed countries, retirement can be either voluntary or involuntary aligned with factors influencing leaving. There are several studies in Australia looking at the individual characteristics associated with voluntary and involuntary not working [5,24]. Significant difference was found among the voluntarily and involuntarily not working groups in terms of individual/household characteristics, labour market experiences and wellbeing at mature ages [5]. In addition, 'involuntary' retirement is associated with a marked decline across of economic well-being measured by financial hardship, and life dissatisfaction, while there is no decline in economic welfare at anticipated early retirement [4,25,26]. Nevertheless, to our best knowledge, there is no study in Australia so far looking into the common and different factors predicting voluntary and involuntary workforce transitions at mature ages. This study aims to fill in this research gap by using the nationally representative longitudinal data drawn from the Household, Incomes and Labour Dynamics in Australia survey 2002-2011 for Australians aged 45-64. The results can serve as evidence to inform researchers, policy makers and industrial actions to promote workforce longevity hence to better prepare for an ageing society. One theory and two conceptual approaches are adapted for our study to provide a useful framework to guide us to select important factors which might predict voluntary and involuntary workforce transitions at mature ages. The theory of 'cumulative advantage' suggests that inequalities across the life course underlie the increasing gulf between the well-off and the disadvantages in later life [27,28]. Consequently, preventing people from accumulating lifelong disadvantages in health, education and employment since their earlier life stages could help to delay the onset of chronic diseases and reduce involuntary workforce transitions at mature age [29]. The ecological model of aging [30] focuses on the "fit" between individual's changing capacities, demands and preferences, with consequences for staying or leaving their current living environment. We modified this "fit" approach from living environment to working decision. A flexible and ageing friendly workplace could help the mature age workers to meet their changing health, financial status and preferences hence stayed at work longer. The second conceptual approach is the "elderly migration" model [31], in which "push", "pull", and "contextual" factors are utilized to predict older people's decision concerning their life arrangements. The push and pull factor analysis has also been used for workforce transitions by Shultz et al. [11], in which push factors are perceived as negative considerations while pull factors as positive considerations for early retirement. The aims of this study are to explore: How lifelong advantages and disadvantages could influence voluntary and involuntary workforce transitions at mature ages? How the changing health capacity and changing preference to work more or less hours could influence voluntary and involuntary workforce transitions at mature ages? How the pull and push factors could influence voluntary and involuntary workforce transitions at mature ages? --- Materials and Methods --- Data This study utilizes the nationally representative Household Income and Labour Dynamics in Australia survey data of waves 2 to 11 . The HILDA follows the same individuals yearly since 2011 and collect comprehensive information by asking respondents questions on socio-demographics, labour force participation, employment history, current working conditions, job satisfaction, income, housing and wellbeing, etc. [32,33]. --- Key Measures We follow the same way in Gong and McNamara [5] and Gong and Kendig [4] to define voluntary and involuntary workforce transitions. Mature ages are defined as "aged 45 to 64 years" given that relatively few people remain in the workforce beyond age 64. Working includes both part time and full time paid work; not working includes being unemployed or not in labour force during the week before the survey. Those self-employed are excluded from this study as they have been found in literature to be very different from other workers in terms of working conditions and behaviours [34] Voluntarily or involuntarily not working at each year was defined according to individual's responses to four questions: whether people want a job; if wanting a job, whether they are looking for a job; if not looking for a job, what are the main reasons; and what are the main activities when they are not working. Voluntarily not working is defined when people report that they are not in the labour force, and do not want a job; not in the labour force and might want a job, but they are not looking for one because of 'does not need to work/no time/prefers to look after children/not interested'; or not in the labour force, do not report whether or not they want a job, and their main activity is one of 'retired/voluntarily inactive/study/travel/holiday/leisure/doing voluntary job'. Involuntarily not working includes people who report that they are, unemployed; not in the labour force but want a job; not in the labour force and want a job, but they are not looking for one because of own illness, injury or disability/childcare reason/health of someone else/too young or too old'; or not in the labour force and do not report whether they want a job, and their main activity is one of 'home duties/childcare/own illness, injury or disability/caring for ill or disabled person'. We then define voluntary and involuntary workforce transitions as from working in one year to voluntarily or involuntarily not working in the subsequent year. We have also identified whether people had ever returned to paid work after the transitions until the last recorded HILDA wave used for this study. --- Methodology The logistic and multinominal logistic models are utilized to investigate what factors jointly predicting not working, voluntary or involuntary workforce transitions among Australians aged 45-64 [35,36]. The dependent variables in the regression models are transitions from working at one year to not working, voluntarily or involuntarily not working when compared to those staying at work at the subsequent year. Our methodology recognizes that people at mature ages could leave the workforce for a time and then returned to paid work. We count each transition from working in one year to not working in the subsequent year as an independent transition, while the change from one job to another is counted as no transition group "stayed at work". For example, if an individual worked in one year, left work in the subsequent year, and returned to work before or until the last wave , we counted as one transition. If an individual worked in one year, left work, returned to work and left work again before or until the last wave, we counted as two transitions. The preliminary data check on HILDA survey 2002-2011 indicates that among 1241 workforce transitions in 10 years, 942 occurred on different respondents in different years with one transition per person, 260 occurred on 130 respondents with two transitions per person, and 39 happened on 13 respondents with three transitions per person. Around two thirds of these transitions were associated with not returning to paid work, while the other one third was associated with returning to paid work before last wave . As each individual might have zero, one, two or three transitions over ten years, there might be concern on the autocorrelation and dependence of the residuals in our regression model due to the use of pooled data of same participants from the longitudinal survey. We have implemented ways to decrease this potential bias. Firstly, every transition is treated as an independent one in our regression model with changing age, family structure, financial situation and work conditions though gender and education might be stable over time. Secondly, we use the survey data as cross-sectional one by restricting all workers aged 45-64 in each of the 10 years so that the respondents aged 45 were different in different years; Thirdly, we use the cross-sectional weights in HILDA survey which were adjusted yearly to make sure the survey data to be nationally representative in each of the years. Lastly, we have controlled for as much as the individual characteristics and taken into account the reasons for leaving paid work and main activities after workforce transitions in defining voluntary and involuntary work force transitions. Consequently, we expect the impact of the autocorrelation and dependence of the residuals on our modelling estimations to be small. Nonetheless, we estimate predictors and advise caution in any attempt to interpret our results in terms of causality [4]. As there is no large cross-sectional survey data in Australia with information on workforce transitions for older workers aged 45-64, our strategy of using pooled data drawn from different waves of existing longitudinal data could increase the number of transitions and hence be able to estimate the transition models that would not be possible by using any single year data with small sample size. This approach is not only feasible, time-and cost-efficient but also permits the study of transitions occurred in a longer period than was assessed within any single investigation. All the analyses are conducted by STATA 15.1 . --- Selected Predictors According to the theory of 'cumulative advantage', ecological model of aging, and the "elderly migration" model as discussed above, we use, the proportion of paid and unemployed years, tenure in current occupation, and the highest educational attainment from HILDA survey data to reflect lifelong advantages and disadvantage; whether paying mortgage or whether having a child or dependent student to reflect financial status; aging and long term health conditions to reflect changing health capacity and preference to more or less work hours to reflect changing preferences; long term health conditions, job dissatisfaction, fixed term and casual contracts, high local unemployment rate, working as labourers as push factors, while no mortgage, partnership, partner's working status and income, working as professional staff or in public sector as pull factors. Part time work can be push or pull factor depending on individuals. The multiple factors associated with work force participation at later life found in the empirical studies include physical and mental health, educational attainment, tax-transfer, expected retirement income and health insurance systems, social and employer's attitudes to ageing, caring responsibility, work flexibility, access to retraining and support services, occupations and other job characteristics [7,[12][13][14][15][16][17]22,23]. The predictors controlled for in our final regression models are: individual and household characteristics, including age, age square term, gender, partnership, number of children under age 15, number of dependent students aged 15-24; life-long advantages/disadvantages, including educational attainment, tenure in current occupation, ratios of paid and unemployed years after graduation; financial factors, including whether paying mortgage or not, partner's working status and income; work conditions, including working in public or private sector, employment type , occupations , contract type ; Changing capacity and preference, including long term health conditions, preference of work hours ; job dissatisfaction on various job aspects ; and state average unemployment rate at the same year when workforce transitions occurred. Job satisfaction/dissatisfaction is measured by a group of questions in HILDA asking individuals "How satisfied are you with your job on a scale of 0 to 10 ?" In this study, we used the job dissatisfaction with four job aspects . We generate a dummy variable each aspect of job satisfaction: dissatisfied if with a response from 0 to 5 and satisfied if with a response from 6 to 10. The scale is used as a threshold for being satisfied or not in this study as 60 out of score 100 is socially perceived as a threshold of being satisfied or not during school evaluation. In addition, the distribution of job satisfaction shows that the proportion of respondents with a satisfaction level lower than score 6 was ranging from 10% to 20% in HILDA 2011, which is more close to the proportion of leaving paid work when compared to the proportion with a satisfaction level lower than the mean or the median . Long term health condition is measured by asking respondents "Does anyone here have any long-term health condition, disability or impairment, as shown in the showcard , any disfigurement or deformity, any mental illness which requires help or supervision, shortness of breath or difficulty breathing, chronic or recurring pain, long term effects as a result of a head injury, stroke or other brain damage, a long-term condition or ailment which is still restrictive even though it is being treated, any other long-term condition such as arthritis, asthma, heart disease, Alzheimer's, dementia, etc. For comparison purpose, we have adjusted income data into 2009 price by indexing them using the average of monthly Australia national Consumer Price Index for each year. The annual unemployment rate by state WAS generated by the average of ABS monthly unemployment rates [37]. We use whether people are still paying their mortgage as a proxy for their financial status, as wealth data is only available in every four years in HILDA. --- Results --- Incidence of Workforce Transitions As shown in the first part of Table 1, the ten-year pooled data yields approximately 1241 work force transitions from working at one year to not working in the subsequent year: voluntarily not working , or involuntarily not working , when compared to staying at work . As shown in the second part of Table 2, there are: 490 voluntary transitions without returning back to work till last wave ; 136 voluntary transitions returning back to work until last wave; 282 involuntary transitions without returning back to work till last wave; and 274 involuntary transitions returning back to work until last wave. After voluntary not working, only one fifth returned back to work, while after involuntarily not working, around half returned back to work. This is mainly due to financial pressure after leaving their jobs [4,38]. Figure 1 provides the age profiles of voluntary and involuntary workforce transitions from one year to the subsequent year occurred within the survey period of 2002-2011. It shows that at age 45, people start to exit their jobs slowly and gradually, either voluntarily or involuntarily, with a relatively higher proportion of involuntary workforce transitions than that of voluntary workforce transitions. Since age 53, the voluntary workforce transitions increase much more rapidly while the proportion of involuntary workforce transitions are relatively constant; and voluntary workforce transitions starts to overwhelm involuntary workforce transitions. For instance, the proportions of voluntary and involuntary workforce transitions are 1. 27 Figure 1 provides the age profiles of voluntary and involuntary workforce transitions from one year to the subsequent year occurred within the survey period of 2002-2011. It shows that at age 45, people start to exit their jobs slowly and gradually, either voluntarily or involuntarily, with a relatively higher proportion of involuntary workforce transitions than that of voluntary workforce transitions. Since age 53, the voluntary workforce transitions increase much more rapidly while the proportion of involuntary workforce transitions are relatively constant; and voluntary workforce transitions starts to overwhelm involuntary workforce transitions. For instance, the proportions of voluntary and involuntary workforce transitions are 1.27 per cent and 2.31 per cent at age 45 years, 3.13 per cent and 2.71 per cent at age 53 years, and 18.84 per cent and 5.31 per cent at age 64 years. --- Individual Characteristics and Work Conditions --- Individual Characteristics and Work Conditions Table 2 presents the individual characteristics and work conditions associated with workforce transitions which are used in the final regression model. It shows that the total number of workforce transitions from working to not working is 16,811, in which, 15,701 were staying at work, 563 voluntarily not working, 492 involuntarily not working, 55 were not working but 'unable to be determined' as voluntary or involuntary one. When transitions occurred, the average age of workers in our study was 52.23 years. About 51 per cent of them were males, 76 per cent currently had a partner while 24 per cent did not have a partner . On average, there were 0.31 children and 0.34 dependent students per household. About 38 per cent of mature age workers had a degree/diploma, 25 per cent with a certificate, 10 per cent with year 12 completion and 27 per cent finishing year 11 or below. The proportion with any long-term health condition was about 21 per cent. Regarding working or not at mature ages, the most important financial concerns are whether still paying mortgage, eligibility to superannuation, whether partner is working or not and by how much income [39,40]. In our study, 44 per cent of mature age workers were still paying their mortgages, 32 percent of them were eligible for superannuation and only 0.31 percent of mature age workers did not have any superannuation . Among those with a partner, 80 per cent of their partners were working, and the average annual income of working partners was AU$74, 230 at 2009 price. When transitions occurred, the average tenure in current occupation was 14.37 years. After graduation, on average, 87 per cent of years after graduation were paid years and 2 per cent were unemployed years. 35 percent of respondents were working in public sector and more than two thirds were working full time and 27 per cent working part time. About 38 per cent were managers and professionals, 11 per cent were technicians; 34 per cent were workers, sales, clericals or administrative staff; and 17 per cent were operators/drivers/labourers. The majority had a permanent or ongoing contract, 9 per cent had fixed term contract, 15 per cent were working on a casual base, and very few were on other contract types. More than half of people preferred to work the same hours as they currently did, about one third would like to work less hours, and only one tenth preferred to work more hours. About one fifth of workers were dissatisfied with their jobs, in which 19 per cent, 13 per cent, 11 per cent and 18 per cent were dissatisfied with their job payment, job security, work itself and working hours, respectively. The state average unemployment rate is 5.2 per cent across all years. We use whether paying mortgage to represent financial status as we found that there is no significant difference among outright owners and renters regarding their probability of workforce transitions. The owners have home ownership and relatively higher wealth but the renters are more likely to receive government rent allowance once they are not working. --- Regression Results We have run three multivariate regression models: Model 1 is the logistic model on the transitions from working to not working; Model 2 is the multinominal logistic model on the transitions from working to voluntarily or involuntarily not working; and Model 3 on the transitions from working to voluntarily not working till last wave, voluntarily not working and back to work, involuntarily not working till last wave, or involuntarily not working and back to work. The three models all used workers staying at work from one year to the subsequent year as their reference group. The estimated coefficients and significant levels of all predictors from the three models are reported in Table 3 for comparison The first column of numbers reports estimated coefficients from Model 1, the second and fifth columns present estimates from Model 2, and other columns from Model 3. Table 3 shows that: age squared term significantly predicts voluntarily not working and not going back to work, while it is associated with less likelihood to voluntarily leave paid work and going back to work. Age is insignificant to involuntarily not working . Males are more likely to voluntarily not working and going back to work. Currently without a partner decreased voluntarily not working , but it increased involuntarily not working and going back to work. The number of dependent students decreased voluntarily not working and not going back to work, as well as decreased involuntarily not working and going back to work. Education is insignificant to all the work force transitions . Long-term health conditions significantly increased both voluntarily and involuntarily not working . Besides health, finance is also a very important factor in explaining work force transitions at later life. We found that, still paying mortgage decreased voluntarily not working , but it was insignificant to involuntary not working. Having a partner who is working decreased voluntarily not working , and it decreased involuntarily not working and not going back to work. Partner's income only slightly increased voluntary not working , and also slightly increased involuntarily leaving paid work and going back to work. Both work conditions and job dissatisfaction predicted voluntary and involuntary not working at later life, but in different ways: Tenure, as defined as years in current occupation, increased voluntary not working, while decreased involuntary not working. Proportion of paid years decreased both voluntary and involuntary not working, while proportion of unemployed years significantly increased involuntarily not working . Working in public sector significantly decreased involuntary not working . Working part time increased voluntary not working , as well as increased involuntarily not working and not going back to work). Workers/sales/clericals/administrative staff/drivers/labours were more likely to voluntarily not working and not going back to work, while less likely to voluntarily leave paid work and going back to work. Fixed term contract significantly predicts involuntary not working , while casual work predicts both voluntary and involuntary not working . Preference to work less hours significantly predicts voluntary not working , and increased involuntary not working and going back to work, while preference to work more hours predicts less voluntary not working while increased involuntarily not working and going back to work. Dissatisfaction on job security and work itself predicts involuntary not working ; while dissatisfaction on work hours predicts voluntary not working and not going back to work. In order to better understand how different factors could drive voluntary and involuntary work exits at later life, we compared the signs of estimated coefficients of predictors from the regression Model 2 . It demonstrates that the factors driving voluntary and involuntary workforce transitions at mature ages are very different in Australia excepting that both long term health conditions and preference to work less hours increased while having a working partner and proportion of paid years decreased both voluntary and involuntary work force transitions. Besides these four common factors, the voluntary workforce transitions were jointly driven by individual and household characteristics, financial concern, employment history and current work conditions; while involuntary workforce transitions were mainly driven by vulnerable employment history and current work conditions . --- Discussion --- Summary of Findings Findings in our study indicate that the working proportion decreases slightly since age 45 and then goes down rapidly after age 50, especially after age 55. The majority of mature age workers moved from working to voluntarily not working and only a few to involuntarily not working. Before age 53, the proportion of involuntary workforce transitions is slightly higher than that of voluntary workforce transitions. While after age 53, voluntary workforce transitions increase rapidly and start to overwhelm involuntary workforce transitions. The positive age effect on voluntary workforce transitions, especially after age 53 years, is likely to be associated with the rising opportunities to be eligible to use income from superannuation or receive a disability pension [41]. Once other factors have been controlled for, the age effect is insignificant for involuntary workforce transitions, indicating that the observed slight increase in involuntary workforce transitions with age in Figure 1 is unlikely to relate to age itself. It is found that there are four common factors which had significant impacts on both voluntary and involuntary work force transitions. In which, proportion of paid years played the most important role, followed by long term health conditions, having a partner who is working, and prefer to work less. Both historical and current employment statuses have significant impacts on workforce transitions and this is consistent to the accumulated life-long advantage and disadvantage theory used for labour market [27,42]. The longer the tenure in current occupations, the less likelihood to exit paid work involuntarily while the higher probability to exit paid work voluntarily. The higher the proportion of paid years after graduation, the lower likelihood of not working either voluntarily or involuntarily at later life, while the higher the proportion of unemployed years, the higher probability of involuntary not working at later life. Having long term health conditions has a similar and strong power in predicting both voluntary , and involuntary workforce transitions . This reflects the fact that long term health condition is a major reason for mature age workers to leave paid work, as well as a barrier for them to go back to work. This could be explained that mature age workers with long term health conditions might value their free time more and are more likely to be eligible for government disability pension hence have a higher probability to leave their paid work voluntarily. On the other hand, workers with long term health conditions are less demanded by their employers hence their probability of involuntarily not working is higher. Family structure, partnership and paying mortgage also have significant impacts on workforce transitions at mature ages. Unsurprisingly, home buyers still paying mortgage are less likely to exit paid work voluntarily. Workers, currently without a partner, are less likely to exit paid work voluntarily and are more likely to go back to work after involuntary workforce transitions, reflecting their high independence in both time and finance. Workers with a partner who is working are less likely to voluntarily exit paid work, reflecting the complementarities of joint arrangement of work and leisure time between partners at later life. Partner's income had a significant, positive but small impact on voluntary workforce transitions. Workers with dependent students are less likely to exit paid work voluntarily, but once they exit their paid work involuntarily, they are less likely to come back to work, reflecting that they have strong incentives to stay at work to support their dependent students but face strong barriers to go back to work at mature ages. There were also strong incentives among mature age workers to adjust their working hours when age arises, and there is room to improve workforce participation by hours for those who were under employed. When compared to those who prefer to work same hours, prefer to work less hours significantly predicts both voluntary and involuntary not working; dissatisfaction on working hours increased voluntary not working, while prefer to work more decreased voluntary not working. Part time, casual work, and prefer to work less hours might be a signal for a pathway to retirement for those workers who were financially prepared [43]. While for workers with an overwhelming workload, work hours need to be adjusted down according to their changing health, capacity and preference. The estimated coefficients of other predictors are mostly under our expectations and in line with existing literature. For instance, workers who were dissatisfied with their job security or work itself, working under fixed term or casual contracts were more likely to leave paid work involuntarily while working in public sectors predicts a lower probability of involuntary workforce transitions. Non-professional staff had a lower likelihood to go back to work after voluntary not working. The general insignificance of education levels on workforce transitions at mature ages might simply reflect the combination of income and substitution effects as mentioned by human capital theory. On the one hand, the income effect predicts that higher educated people with higher earnings are more likely to be able to afford to enjoy free time by exiting their paid work earlier before the age pension age. On the other hand, the substitution effect states that higher educated people might stay in paid work longer due to a higher opportunity cost driven by their higher wages or better employment conditions [8,44]. --- Policy Implications In order to remove the barriers that many older workers are facing to carry on working, the OCED called on the Australian authorities to take further actions to enhance the public awareness and effectiveness of age discrimination legislation, to prevent social securities as incentives to early retirement and to strengthen older workers' employability [6]. It is found that in New Zealand from 1992 to 2001, increasing age pensions age from 60 to 65 for both men and women, and allowing people to stay at paid work while receiving age pensions have effectively increased labour force participation at mature and older ages [6]. The OECD has concerns that in Australia, the possibilities to draw superannuation benefits unconditionally as a lump-sum at an early age, to use disability pension as a pathway to early retirement, and to reduce income from age pensions while receiving income from paid work might contribute to the decrease of labour force participation at mature ages, which have not been well examined. The existing policies and current efforts to increase workforce participation at later life in Australia include improving education and training, assisting attachment to labour market, enhancing long term campaign with age stereotypes and age discrimination, financially encouraging employers to hire workers aged 50 and plus, providing substantial superannuation tax incentives after age 60, as well as to increase progressively the preservation age for superannuation from 55 to 60 and age pension eligible age from 65 now to 67 and further to 70 [2,21,45]. The current policies aiming to increase age eligibility for superannuation and age pensions are expected to delay some voluntarily not working with financial consideration but not for others without financial consideration. The implications of our findings suggest that in order to facilitate longer workforce participation and enhance productivity and well-being at later life, different government policies and employment practices should be engaged to address the major causes of voluntary and involuntary workforce transitions at mature ages. Promoting mature age workers' health, employability, work flexibility and friendly work environment, as well as providing rational and secure pathways before full retirement could help older workers to meet their changing health and family needs, hence stay in paid work longer [4,[46][47][48]. A central and new challenge for an ageing society is to enable continued workforce participation at later life by preventing or ameliorating chronic diseases or disabilities when age arises for workers in their 50s or 60s [49]. The 'health first' and "fitness" approaches, and life-long accumulative disadvantage theory, should be taken in consideration in making further policies to tackle the health-related or vulnerable worklessness for mature aged workers in Australia. For voluntarily not working at later life, the 'health first' and "fitness" approaches suggest that the fundamental policies and employment practices are health promotion over life span, age-friendly workplaces, work flexibility to meet changing preference etc. The "health first" approach targets the root cause of worklessness through preventing, improving and managing chronic diseases at mature ages hence refining workers' health capacity and employability [50]. Health promotion can reduce both local worklessness and health inequalities but need joint efforts among clinical groups, work program providers work organizations and local authorities [4,51]. In Europe where some of countries have already taken important steps to tackle the challenge of ageing population, health promotion activities in workplace for ageing workers have recently been promoted as a new approach to improve occupational and populational health [51]. Besides the historic approach that takes into account occupational risks, technical and medical expertise, and ergonomic adaptions in the work environment, this new approach promotes healthy habits which may delay the onset of diseases or help to manage the chronic diseases. A great effort has been made to increase the motivation of older workers to move to healthier habits, as older workers are more reluctant to make changes than younger workers. The existing health interventions in Australia have mainly occurred in communities for promoting physical activities and in primary care centers for disease prevention, as well as in health and aged care institutions for managing disabilities and chronic diseases, the health promotion activities in workplace are still inadequate. Australia shares the same obstacle for health promotion programs as in Europe on how to ensure continuity of funding and effectiveness after the end of the intervention programs. With the extended life expectancy, many people in their 50s and 60s are expected to work with some form of mild chronic diseases or disabilities. It has been found that working longer hours than what is feasible is harmful to health, indicating that the standard full time work might no longer be the best fit for many older people with long term health conditions [49,52,53]. The "fitness" approach encourages the employers and employees to discuss and negotiate work hours, hourly wage, and other work arrangement after reaching certain ages according to the changes in both labour supply and demand sides hence to achieve a new agreement which could be beneficial to both employers and employees. Our analysis supports this by evidence that almost one third of mature age workers had indicated their willingness to reduce working hours at later life. The alternative options could be secured part time or casual employment as a pathway to full retirement when health and energy declined at mature ages. For involuntarily not working at later life, the life course approach suggests the implementation of policies in equalizing lifelong opportunities for health, education, training, retraining, employment assistance, can help to promote lifelong health, work capacities and continuous labour force participation for those with vulnerabilities, such as those without non-school qualifications or trainings. Job insecurity is the most emerging issue to be addressed for those involuntarily not working. In last two or three decades there has been continuous shift away from secure to insecure jobs and from standard full time contracts to non-standard arrangements in Australia and many other developed countries [29,49] These changes are mainly driven by the economic restructure and technical change resulting a shift of economy from manufacturing sectors to service sectors [29,49]. It has been found that during this shift, older workers are often forced into precarious employment with the consequent cycle of fewer job opportunities, little training and lack of income security, exposure to discrimination, harassment and workplace bullying, non-portability of leave entitlements, as well as a reduced capacity to exercise autonomy in how the work is done, resulting damage to health and wellbeing [29,49,54] The new policy making will also need to take into account the changes in role model and work culture during the new economy, as these changes are likely to increase the demand for secure part time jobs at mature ages. On the labour force supply side, our analysis shows that the current generation of mature age workers are baby boomers who are still working under the male breadwinner female caregiver model, pursuing the norm of "good jobs" as secure and full time jobs, working as long as possible except for married females who participated in labour force flexibly to balance work and care needs [29,49,[55][56][57]. While for the new generations, the working model is changing significantly where people spend more years on formal education and trainings in early life in order to better survive in the new knowledge-based economy, with males working mostly full time but spending more time with children and reducing work effort in response to health change in later life, while females reducing working hours instead of fully withdrawing from work force for caring responsibilities [49]. On the labour force demand side, the employer and recruiter perspectives are also changing in terms of what they want from mature age workers. For instance, the notion of employability has changed from "reliability, punctuality and the ability to accept direction" to "resourcefulness, adaptability and flexibility", the requirement for formal qualification has grown, the low-skilled jobs have been reduced and casualization of the workforce is increasing in an uncertain economy [29]. Current efforts in Australia, to increase job security of part time or casual work, include extra loading in earnings, wage subsidy, and protection against unfair dismissal etc. [49]. Further investigation needs to be done on how to increase the options of more secure part-time, fix-termed or casual employment and other forms of more tenuous engagement in a new economy of services. Retraining programs with focus on broader skills and employability for workers who have lower level of qualifications and fewer training opportunities in a declining industry or occupation could assist transition from one industry to another hence to ensure lifelong continuous labour force participation [8]. As discussed, the strategy of using pooled data drawn from different waves of existing longitudinal data allows us to estimate the workforce transitions at mature ages that would not be possible by using any single year data with small sample size. Nonetheless, we estimate predictors and advise caution in any attempt to interpret our results in terms of causality [4]. Other limitations of this study include the utilization of one-digit occupational group to identify whether the work is physically demanding, and the use of job dissatisfaction to identify potential psychosocial risk factors in the workplace. For future research, more detailed occupational categories in HILDA can be used to identify possible impacts of hazardous work and impairing work on work force transitions. In addition, work-related stress [58] and workplace psychological harassment [59] are recognized world-wide as major challenges to workers' mental health problems and other stress-related disorders, which are known to be among the leading causes of early retirement from work, high absence rates, overall health impairment [58,59]. Larger cross-sectional and longitudinal survey for mature age and older workers are necessary for further estimations. --- Conclusions Encouraging mature age workers to work as long as possible is a long-term strategy in Australia and many other countries to address the policy challenges associated with ageing population. The issue in the current labour market is that mature age workers are facing long-term unemployment or underemployment while employers increasingly claim labour force shortages [29]. This calls for a deep understanding of what mature age workers need and face, what policies can address informed by a life-course perspective and a move away from the focus on individuals to the attitudes of society and employers to older people, including job security, promotion of healthy life styles, ageing friendly workplace and work flexibility [8,29,49,51]. Our research indicates that many mature age Australians want to work longer, and continuous paid employment could help older workers to work longer at later life, but how to best facilitate the retirement transitions when health deteriorates and how to keep older workers to work decently, safely and appropriately will be the challenges for government, industry and society as a whole to overcome.

The fast population ageing has generated and will continue to generate large social, economic and health challenges in the 21th century in Australia, and many other developed and developing countries. Population ageing is projected to lead to workforce shortages, welfare dependency, fiscal unsustainability, and a higher burden of chronic diseases on health care system. Promoting health and sustainable work capacity among mature age and older workers hence becomes the most important and critical way to address all these challenges. This paper used the pooled data from the longitudinal Household, Incomes and Labour Dynamics in Australia (HILDA) survey 2002-2011 data to investigate common and different factors predicting voluntary or involuntary workforce transitions among workers aged 45 to 64. Long term health conditions and preference to work less hours increased while having a working partner and proportion of paid years decreased both voluntary and involuntary work force transitions. Besides these four common factors, the voluntary and involuntary workforce transitions had very different underlying mechanisms. Our findings suggest that government policies aimed at promoting workforce participation at later life should be directed specifically to life-long health promotion and continuous employment as well as different factors driving voluntary and involuntary workforce transitions, such as life-long training, healthy lifestyles, work flexibility, ageing friendly workplace, and job security.

INTRODUCTION Childhood obesity rates are particularly alarming in Europe however, the problem varies across regions, with higher prevalence in southern countries such as Portugal . A plateau or decreased in overall prevalence of childhood obesity has been suggested in many developed countries . A surveillance study carried on Portuguese children, reported a decreased in overweight and obesity rates between 2008 and 2019 . Unfortunately, this optimistic picture may not be true for all children. In the USA, Skinner et al found that the obesity rates did not decreased for any age group and continued upward among socioeconomically disadvantage subgroups between 1999 and 2016. In high-income or industrialized populations, obesity tends to be more frequent among those classified with a low socioeconomic position ; the inverse is true in low-and middle-income countries . Also, low-SEP children may experience a greater increase in overweight risk during macroeconomic downturns, resulting in widening inequalities by social disadvantage in the face of economic crises . The latest economic recession that started in 2008 and affected many European countries has hit hard Portugal . However, few studies have looked for the impact of the economic crisis in the childhood obesity rates and inequalities. Currently, the Portuguese economy is suffering with the impact of the COVID-19 pandemic which is exerting a radical and abrupt effect on the country's gross domestic product and unemployment rates. This context reinforces the need to have up to date information on levels and trends of overweight/obesity to quantify its health effects and to prompt decision-makers to prioritize action and evaluate where progress is, or is not, being made. The present study aimed to describe the prevalence of childhood obesity in Coimbra between 2002 and 2016, and observe how childhood overweight and obesity was associated with SEP in each observation period. --- METHODS --- Sample population and methodology The present study uses population-based data from multiple projects of the Research Centre for Anthropology and Health of the University of Coimbra, Portugal. CIAS has focused on the study of childhood obesity and related determinants and has carried a number of national surveys and crosssectional studies in schools during the last two decades . Data from the district of Coimbra Primary schools were randomly selected from the list of public and private schools in the district and all the children were invited to participate. Questionnaires were delivered in the schools, sent home with the child and completed by the children's caregivers. The basis of the instrument was similar for all the studies and details can be found elsewhere . The protocol for all studies was in accordance with the International Ethical Guidelines Involving Human Subjects and was approved by the Portuguese Data Protection Authority and the Portuguese Ministry of Education. Parents were fully informed about all study procedures; informed written consent was obtained from the parents; children's consent was obtained prior to the anthropometric measurements. Children were included in this study if they were between 6 to 10 years old, had complete information on height and weight and were given parental consent. --- Anthropometry Height and weight were measured in schools by researchers who had been trained in standard anthropometric methods and using calibrated equipment . Where possible, the same anthropometric equipment was used in all the studies. Body mass index was calculated and the cut-off points from the International Obesity Task Force were used to classify children's nutritional status . --- Socioeconomic position SEP, a proxy variable of the socioeconomic inequalities, was defined by the parents' education level, which considered the highest level of education from mother or father. In mono-parental families, the parental education was based on the children's principal guardian. The variable was scored based upon the Portuguese Educational system and grouped into three categories: low , medium and high . This has been done in previous studies in the Portuguese context since the country does not have an official measure for SEP . --- Sport activity and television viewing Parents reported their children's physical activity and television viewing. The same question was used in 5 studies: "Does your child practice any regular and organized physical activity outside school hours? If yes, how many minutes per weekdays, Saturdays and Sundays?". The total minutes per week were calculated by adding the answers for all days of the week. Parents also reported the time their children spent watching TV during Saturdays and the total minutes/day were classified as a categorical variable according to the recommendations of the American Academy of Pediatrics , such as, less than 2 hours/day and 2 or more hours/day. Data from 2011 were excluded since the criteria used to define active children and the time watching TV was not the same as in the other studies. --- Statistical analysis The prevalence of overweight and obesity among 6 to 10 years old children from Coimbra was examined in five different time periods : 2002, 2009, 2011, 2013, and 2016. The percentage and confidence interval for overweight, obesity, and overweight was calculated separately for boys and girls. A chi-square test was run to test the differences between sample characteristics across the years. The data was divided according to the SEP and the percentage of overweight was calculated for the five time periods in order to observe the socioeconomic impact on children's nutritional status. Finally, a logistic regression was used to examine the association between SEP and children's overweight and obesity, in the different time periods. Odds ratio , 95% confidence interval and p-values were reported. All analyses were conducted using SPSS v.23; statistical significance was set at 5%. --- RESULTS The mean age of the 7192 children analyzed was 8.14 and 3610 were girls. Children's SEP, PA and TV viewing were statistically different across time periods . Overall, between 2002 and 2016, there was an increase in the adoption of PA behaviors and more children spent 2 or more hours/day watching TV on Saturdays. Independently of the sex, most children were from a higher-SEP, particularly from 2009 onwards. Prevalence of both overweight and obesity was higher among girls than among boys. Among girls, the prevalence of obesity was higher in 2002 and lower in 2009 . In boys, the lowest prevalence of obesity was found in 2011 and the highest was registered in 2002 . The lowest prevalence of morbid obesity in boys was found in 2009 . From 2002 to 2016, the decline in overweight and obesity was higher among girls than boys . Figure 2 shows that the prevalence of overweight, including obesity, between 2002 and 2016, was continuously higher among children of lower-and medium-SEP, and lower among high-SEP children. A pattern of decline was observed across the years in children from higher-SEP but the inverse was found for medium-and low-SEP children . The differences in children's overweight, including obesity, between SEP groups increased from 5.9% in 2002 to 14.7% in 2016. Table 3 shows crude and adjusted associations between parental SEP and children's overweight and obesity. Low-SEP was associated with increased odds of overweight and obesity but the association was attenuated after adjustment for children's sex, PA and TV viewing. The association between SEP and childhood obesity was weaker in This can be considered a positive change and may reflect a trend also reported in other developed countries . The literature has supported the notion that in countries facing the childhood obesity epidemic over several years, the plateau can be partly attributed to the initiated public health programs focused on the lifestyle of children . In the last years, the Portuguese government implemented several actions including the creation of a sugar tax on sweetened beverages that led to an 11% reduction of total energy intake through sweetened beverages consumption by the population . Results from the present study are in line with those reported in other Portuguese studies and in others countries such as Greece, reflecting a trend for decrease prevalence of childhood obesity during the economic crisis from 2009 to 2012 . Temporary economic slowdowns may lead to an increase in parental engagement in health promoting activities when working hour's decrease or a decrease in total caloric intake when households face extreme hardship . However, increasing levels of childhood obesity were observed in times of economic slowdowns in countries such as Ireland . These discrepancies indicate that changes might differ for overweight and obese children according to their age and the context they live in and the role of cultural characteristics in each country. Moreover, the suggested decrease may not be shared equally across all the socioeconomic groups. We found that while the prevalence of overweight and obesity is declining among children from higher-SEP, the inverse is seen for their counterparts of lower-SEP. Between 2002 and 2016, socioeconomically disadvantaged children were more overweight or obese than their counterparts of higher-SEP and the magnitude of that inequality grew within those years, which is in line with previous studies . Growing disparities in socioeconomic health inequalities during the last years were reported for English school-aged children and preschool children from the USA . While the peak of the recession is over, financial situation have not returned to the levels seen prior to the crisis, potentially contributing to the continue widening socio-economic disparities found in the present study. The 2008 economic recession, due to deterioration of socioeconomic and living conditions had a major contribution to the widening of inequalities in childhood obesity according to SEP. From 2011 to 2013, Portugal lost approximately 7% of the GDP and the recession period was characterized by rising deficits and high unemployment rate . Since 2008, the percentage of households with children that have been unable to buy meat or fish every second day has more than doubled during the economic crisis in countries such as Estonia, Greece, Italy and Portugal , and data from the Portuguese National Health Surveys revealed that the consumption of soup, fish and meat significantly decreased between 2005 and 2014 . The economic crisis may have reinforced the socioeconomic disparities in obesity related behaviors previously reported for Portuguese children, namely that children from lower-SEP had higher odds of consuming saturated and fat diets and less probability of participating in extracurricular sport activities . This study has several strengths. First, to our knowledge, it is the first to examine changes in the prevalence of overweight and obesity in Portuguese children according to the SEP throughout the last decade, including the years of the economic crisis; second, the measures were objectively collected using trained researchers and standardized methods, thus reducing the risk of misclassification of weight status; and third, the study's large sample size provided robust data to study different socioeconomic levels. However, these were cross-sectional studies based on different independent samples which does not allow to suggest the causality and 'period effects' could not be rule out. Furthermore, while the socioeconomic disparities in obesity widened over the time period that included the recession, it is not possible to conclude that the recession caused this tendency. More studies are needed regarding the direct impact of the recession on individuals' households in the above-mentioned period and also in the post COVID-19 era. In conclusion, childhood obesity remains a challenge for public health and there is a need to promote more daily PA and less sedentary time since we showed that those behaviors may attenuate the association between SEP and overweight or obesity. Reducing inequalities may require a proportionate universal approach, where the receipt of an intervention is proportionate to the degree of disadvantage, such that more children in deprived groups would receive programs to prevent obesity. --- AUTHOR DISCLOSURE STATEMENT The authors declare that there are no competing financial interests.

Aim: To observe the trends of overweight and obesity among Portuguese children from 2002 to 2016, before and during the years of the economic crisis, and compare these trends according to family's socioeconomic position (SEP). Methods: Prevalence rates were calculated using data from six studies providing comparable estimates from 2002, 2009, 2011, 2013 and 2016 for children aged 6-10-years living in the Portuguese Midlands (n=7192; 50.2% girls). Height and weight were objectively measured; children and family characteristics were collected by standard questionnaires. A logistic regression was used to test the association between variables. Results: Between 2002 and 2016, there was a decrease in the prevalence of overweight and obesity, which reached a statistical significance for girls. The prevalence of overweight, including obesity, was high (low-SEP=30.5%; high-SEP=20.5%) and a widening of socioeconomic inequalities was found. Socioeconomically disadvantaged children had more than 2 times the odds of having obesity than children from higher-SEP, even after adjusting for sex, physical activity and screen-time. Conclusion: While a decrease in overall rates of overweight and obesity was observed from 2002 to 2016, the social inequalities have been widened which suggest the need for public efforts to promote healthy weight at a population level, especially in lower socioeconomic classes.

Background Transgender women in San Francisco carry a large population-specific burden of HIV, with almost half estimated to be living with HIV as of 2020 [1]. Trans women in San Francisco have lower engagement in HIV care than other groups despite the availability of genderaffirming trans health clinics, HIV care experts, and universal health care access [2][3][4]. Trends in San Francisco are mirrored throughout the US. In a study of trans women receiving HIV care services throughout the country, fewer trans women had durable viral suppression than other populations living with HIV [3]. Viral suppression among trans women is 10% lower than in people living with HIV in San Francisco overall. COVID-19 has likely affected trans women's viral suppression and HIV care engagement. As of March 2021, viral load tests, which are a marker of HIV care engagement, were down by 6% in San Francisco [2]. HIV care engagement and viral suppression are lower among trans women due to a myriad of factors rooted --- Open Access *Correspondence: [email protected] 1 San Francisco Department of Public Health, San Francisco, USA Full list of author information is available at the end of the article in discrimination toward trans women that leads to disproportionately high housing instability, food insecurity, criminalization, and violence [2,4,5]. Stressors from these experiences are associated with elevated mental distress and substance use, which impact HIV care engagement and outcomes [6,7]. Many trans women living with HIV have trauma due to healthcare discrimination and may have high levels of anxiety, mistrust of providers, and fear of re-traumatization, which present barriers to initiating mental health and substance use services [8][9][10][11]. One of the many reasons for high rates of substance use among trans women is to cope with the effects of physical assault and intimate partner violence, which is a known barrier to adherence for those living with HIV [12,13]. There is a considerable unmet need for substance use and mental health services for trans women living with HIV who access care in the public system [14]. And yet there is little data that exists on the barriers to substance use services and mental health support for trans women living with HIV. Our team conducted a qualitative study of the barriers to MHSU services, among trans women living with HIV. We aimed to engage providers and trans women to assess determinants that could be addressed in an intervention to improve mental health and substance use linkage for trans women living with HIV. --- Methods The study included a convenience sample of providers and trans women living with HIV. We recruited providers for trans women living with HIV from eight organizations in San Francisco. Health care providers included a cisgender physician and cisgender nurses who specialized in HIV and gender-affirming care. Cisgender is a term used to describe people whose gender identity aligns with their assigned sex at birth. Mental health care providers consisted of licensed clinical social workers. Social service providers were trans and non-trans identified substance use program managers, case managers, and outreach workers. We also recruited trans women living with HIV who were not providers . We hosted one focus group of staff from a gender-affirming HIV care clinic and conducted in-depth interviews with trans and non-trans-identified providers and trans women living with HIV. Focus groups and in-depth interviews were conducted from February 2021 through May 2021 using semistructured interview guides. Examples of focus group questions centered on exploration . For trans women living with HIV, examples of the interview questions centered on access . Interviews were conducted over Zoom due to COVID safety protocols. All interviews were recorded and transcribed verbatim. Participants provided verbal informed consent. All methods were carried out in accordance with relevant guidelines and regulations. The study was approved by the Institutional Review Board at University of California, San Francisco . --- Data analysis To identify, analyze and report themes found in the data, we used an iterative approach in which thematic analysis was employed [15]. Due to the scarcity of studies regarding MHSU services for trans women, we used an inductive approach in which we derived categories and themes directly from the data. Coding was conducted in Dedoose with one co-author and senior author . Once coding was completed, we held weekly meetings which were attended by all authors. We began the process with data reduction, identified themes, deliberated on the conclusions, chose illustrative quotes, and wrote and edited the manuscript. Any concerns or conflicts were discussed on an iterative basis, and consensus was reached among the authors. --- Results A total of 15 participants were interviewed. Professional roles and job titles are listed in Table 1. We found two main themes and three subthemes . Barriers and facilitators to accessing MHSU services for trans women were discussed. --- Main theme: Lost trust in the system A main theme identified was that patients and providers had lost trust in the system's ability to best meet trans women's needs for MHSU services. Providers explained that access to publicly available MHSU services was mostly facilitated through referrals from primary medical care providers. Although trans women could initiate engagement in services on their own, most trans women living with HIV were linked to MHSU services via their HIV specialist and gender-affirming primary care providers. MHSU service barriers were linked to barriers to medical care, and medical care was a key access point to obtaining publicly available MHSU services for trans women living with HIV in San Francisco. --- Subtheme: suboptimal engagement to MHSU services due to the referral system A recurring system barrier was the referral system for MHSU services. Participants explained that MHSU referrals were primarily facilitated by medical providers in their gender-affirming primary medical care setting. Trans women reported that it took multiple medical clinic visits to receive an MHSU referral. When referrals were made, the onus of follow-up to initiate a new service was the responsibility of trans women living with HIV. Lack of follow-up put the responsibility of initiating MHSU services on the patient, which lowered the chance of follow-through to initiation. Providers reported that service initiation was a laborious process, as there were multiple steps in the intake process before people would see a counselor. --- I do think there actually is a wide disparity in terms of how intake is done, and this is another problem, actually, because primary care clinics need to be aware of how each clinic might operate a little bit differently, which is kind of a crazy thing to ask them to know . Additionally, providers at the medical clinic were not aware of what intake processes were in place, so they did not prepare nor support patients through the intake process. --- Subtheme: suboptimal engagement to MHSU services due to structural barriers Providers and trans women living with HIV described structural barriers to medical, substance, and mental health care. Safety, clinic reputation, language, clinic hours, and lack of trans-specific clinics and trainings may have impacted visit engagement and access to MHSU services. Providers discussed that some medical and social services had relocated to unsafe neighborhoods in San Francisco. Clinic location was especially important for those who were in recovery or struggling with substance use. Social service provider D stated, It's right there in a drug-infested area…… People are harassed because when I used to go there, I'd come out of the doctor's office, 'You got these kind of pills or those kind of pills?' It's like, 'Sweetie, come on. Leave me alone. ' Visit attendance among those in recovery and struggling with reducing substance use may have been impacted by having to access medical care in locations where active drug selling was regularly occurring. Providers also speculated that a clinic's reputation may determine if and where trans women would seek treatment. Providers reported that when it is known that a clinic provided poor health care to the trans community, it impacted engagement with the MHSU services. Structural barriers related to language capacity and hours in which services were offered were also important barriers. Some providers discussed that there were not enough Spanish speakers in MHSU services, which created access barriers for mono-lingual Latina trans community members. Other providers discussed that there were no after-hours MHSU services known to them. Furthermore, some clinics and programs that offered MHSU services, struggled with providing trans-competent care, Providers also said they did not receive medical, mental health, or substance use training on how to provide gender-affirming services and learned about the needs of trans women living with HIV on the job. Providers mentioned that even when they were trained on the job, many other people in the clinic, from security to benefits specialists, did not have training on gender-affirming care. This was a concern as providers reported that there is no routine oversight or monitoring of the quality of services trans people in the system receive. --- Subtheme: suboptimal engagement to MHSU services due to constant changes within the existing system Another important subtheme was that constant changes in what was offered in the public system created distrust and barriers to engaging in services. One participant reported that a side effect of innovations in services and changing city priorities was a lack of consistency that left some key populations, including trans women, behind. Social service provider A stated, The truth is, in San Francisco, a lot of people have lost trust in the system because we've had so many different programs and we've been so innovative in trying to find the right fit for the community that a lot of people got stepped on and left out in the process. Constant changes in treatment programs had a negative impact on community members' interest in MHSU services. Changes at the clinic level created instability that reduced patient satisfaction. It is worth noting that some substance use services struggled to meet the needs of trans women living with HIV. Providers discussed that other barriers were shortened treatment times in substance use programs from 6-months of detox and inpatient rehabilitation to 30, 60, and 90 days. Decreasing the days of treatment was seen as less efficacious for substance use recovery abstinence outcomes and may impact post-treatment care of their patients. People who completed their treatment in 3 months often returned to the same neighborhood. --- …then, the panic comes in when the treatment is over of where am I going? I'm going right back to the same neighborhood where I was at. It's like nothing's going to change. … Something needs to happen where you start making a way for people to not live in that area, if possible … Maybe they need more housing programs . Providers reported that trans women recovering from substance use needed long-term stable housing to increase their chances of recovery. --- Main theme: anti-trans and mental health stigma Participants reported that they observed and experienced anti-trans discrimination in the San Francisco public healthcare system. Social service trans-identified provider C recalled a waiting room in a clinic where the provider overheard a staff member deadnaming a trans client. --- She was calling the patient by their male name. And then when I was talking to her, the patient, was like, 'I don't care. ' But I know they care. I know in the back of their head they care. They just don't have the energy to fight every single day. Because of the tether between medical care and other services via the referral system, healthcare avoidance from discrimination had a direct impact on MHSU access. The vicarious trauma providers experienced from serving the trans community may also lessen trans provider's interest in pushing for referrals. An important barrier to engaging in mental health services specifically was the stigma associated with engaging in therapy. One trans woman living with HIV said, "I think people have this notion that if you say, 'Oh, I see a therapist' that means you're cray cray. " Mental health provider A said, Related to that is I think there's the issue of stigma at a mental health clinic and seeking out mental health services as a trans person that is just really…I think it's a really big barrier... The issue of mental health stigma hinders engagement to MHSU service among a community already burdened with multiple stigmas due to their gender identity and/ or race. --- Facilitators and recommendations Providers recommended that a peer navigator could be hired to facilitate access to MHSU services through the fractured public health system and help rebuild trust in the system. Furthermore, a support group may reduce the heightened social isolation trans women experience due to COVID-19. Providers suggested that peer support groups would be helpful for people in recovery from addiction. "I think it would be good to have a group with maybe, I would think maybe once or twice a month to have guest speakers that share their experience of how life was for them . " Trans health care needs, such as any gender-affirming procedures were seen as a facilitator in seeking mental health services. In San Francisco, residents' genderaffirming procedures are covered if they are eligible for Medi-Cal or Healthy San Francisco, the city's health access program. --- I think that there's a way in which I think the surgery thing and the mental substance use actually runs very much in parallel, and that could be an incentive for someone to agree to uptake a navigator because this is a person who's going to help you meet the requirements that you need to get your electrolysis to get your surgery . While other providers agreed, there was discussion of the impact on the client's comfort level and the necessity of overcoming that discomfort in order to engage in gender-affirming surgeries. Finally, our providers highlighted the importance of making connections between life stressors, mental health, and substance use as knowledge that could promote interest and engagement in MHSU services. One HIV care specialist stated, ...I think that one of the things I see as a need is that for the particularly trans women clients that we have, the amount of substance use is really high. And not surprisingly, we see people who are socioeconomically disadvantaged, traumatized, etc. So, a lot more people are going to use to cope. Lack of knowledge about the root causes of their mental distress or substance use may influence their engagement or lack of engagement to MHSU services. Increasing this knowledge through peer navigation, support groups and self-advocacy may potentially increase MHSU engagement. --- Discussion We found substantial structural and systems barriers that may contribute to unmet MHSU needs for trans women living with HIV in our city. Our medical services are intricately connected to MHSU services through the referral system, thus barriers that impact the medical services, in turn, impact access to MHSU services. One of the most common findings was that linkages between referrals and services were broken. Participants reported that referrals for MHSU services were often made without follow-up to ensure services were initiated. Providers in the medical setting neither had the time nor the resources to ensure referrals converted to services initiation. This is consistent with another study finding that lack of follow-up on referrals, in addition to complex referral systems and compartmentalization of specialty services, were barriers to health care utilization among trans women living with HIV in Canada [16]. Another system barrier was the availability of ancillary services that were needed to support recovery from substance use and promote mental health. For example, even after trans women were linked to substance use treatment services and completed a program, many faced unstable housing that often resulted in relapse as a way to cope with unmet basic needs. Stable housing has been identified as a crucial pillar to recovery [17]. The need for services to provide access to housing, opportunities for jobs, and safety, are likely needed before trans women living with HIV can be expected to initiate and use MHSU services. Barriers to services also existed because of the constant changes in the system of services. Participants described how innovations in services, relocation of clinics, staff changes, and other clinic operation changes resulted in confusion about what services were currently available. Consistent with past literature, safety concerns related to their medical clinic's location and the clinic's patient population were a deterrent to accessing care [18]. The lack of knowledge and misinformation underscores the need for better communication between different clinics and providers in the public health system. Past studies indicate that organizational changes such as staff turnover and management reorganization were associated with poor patient outcomes and a decrease in the effectiveness of treatment among patients with personality disorders [19]. However, when health providers are involved in these changes, and these changes are communicated, successful organizational change can occur and continuity of care for patients can be achieved [20,21]. We also identified barriers that may impact trans women's willingness, motivation, and readiness to participate in MHSU services. Providers discussed how poor mental health hindered their client's ability to engage in their MHSU services. Trans women living with HIV may lack knowledge about the root causes of their mental distress or substance use and the services offered to address these issues. Other studies support that people may lack insight into how daily stressors can impact their mental health and their need to engage in mental health services [22,23]. Anti-trans stigma within the system and fear of mental health stigma were also important barriers to MHSU service. Fear of discrimination due to gender identity and HIV stigma have led to delays in health and health care among trans women [9]. Mental health stigma, another stigma that trans women living with HIV in our study expressed, is a main barrier to seeking mental health services among trans people [24]. Several limitations of this study should be noted. This study was conducted with trans women, trans-identified providers, and cisgender providers in the public health systems. However, there were only a small number of trans women interviewed. This study relies primarily on the views of trans-identified and cisgender providers. Providers from a private health system or those in acute care settings may provide different perspectives and experiences in the referral process for trans women living with HIV. Furthermore, as San Francisco offers universal health care, these findings may not apply to other geographical areas. We also note that due to isolation, uncertainty, and in the context of the pandemic, an increase in poor mental health puts a strain on an already loaded mental health system [25]. Barriers may likely have increased, and new barriers may result from a shortage of staff and other resources. --- Recommendations Interventions are needed to mitigate the systems, stigma, and structural barriers trans women living with HIV face in initiating and engaging in MHSU services. Perhaps the most important intervention needed is the development of a coordinated MHSU linkage system that helps address concerns and facilitates access for trans women living with HIV to engage in mental health and substance use services. Participants reported that peer navigation may help facilitate linkages and help address barriers. Navigation services have been successful in engaging trans women in HIV care [26]. Navigation services, and particularly peer navigators who identify as trans and work in the public health system have been shown to improve HIV care engagement and outcomes and may provide the needed bridge for trans women to link to MHSU services through the fostering of trust, the similarities in background between peer and participant and accessibility of peer navigators [26][27][28][29]. Not only can peer navigators offer support through referrals to ancillary support programs, but they can educate, provide feedback, and motivational interventions to teach about the connection between social and daily stressors with mental health and substance use and may create motivation to engage in MHSU services [28,29]. Peer navigators need institutional support in which gender-affirming trainings for staff are tracked and supervised and a professional support system that has a process to discuss opportunities to decrease stigma and discrimination in the workplace and with the trans community. Monitoring to ensure quality services are being offered may be supportive of the work of navigators. Having peer navigators and more staff and health care providers who are from the trans community may help address quality concerns and mitigate anti-trans stigma still existing in the public health system while empowering trans women living with HIV and providing the impetus to engage in MHSU services. Increasing the number of trans-identified health care providers needs a substantial increase in education and employment opportunities for the trans community. We recommend that additional funds and resources be allocated to increase the number of trans people in the public health workforce. --- Conclusions Health care providers identified several barriers to mental health and substance use service for trans women living with HIV in San Francisco: the referral system, location of clinic, clinic hours, clinic reputation, lack of trans-specific clinics and programs, changes within the public health system and anti-trans and mental health stigma. These findings suggest that there is a need on multiple fronts to help trans women utilize mental health and substance use services. A peer navigator may help trans women navigate the health care system and link them to mental health and substance use services. --- --- --- --- --- Competing interests The authors report no real or perceived vested interest related to this article that could be construed as a conflict of interest. ---

Background: Little is known about the barriers to mental health and substance use services for trans women living with HIV. We conducted a qualitative study with trans women living with HIV and providers to explore barriers to mental health and substance use services in San Francisco.We conducted focus group discussions and key informant interviews with a total of 15 medical, mental health, substance use, and social service providers and trans women living with HIV. We identified, analyzed, and reported themes using thematic analysis and derived themes directly from the data. Results: Our study participants identified two main themes and three subthemes. One main theme is that trans women and providers have lost trust in the system due to (a) lack of a linkage system between referrals and services, (b) structural barriers such as service location, language capacity, clinic hours, and (c) constant changes in services available. Another main theme is anti-trans and mental health stigma.Interventions to coordinate linkage from medical to mental health and substance use (MHSU) services are urgently needed to facilitate the utilization of MHSU services. Other interventions to improve quality monitoring and system improvement, and to address multiple stigmas broadly in society are needed to improve unmet MHSU service needs among trans women living with HIV in San Francisco.

INTRODUCTION Every individual must pass through the stages of development in the span of his life. The stages of development of human life start from childhood, adolescence, early adulthood to old age. At each stage of development, individuals have their developmental tasks that should be passed well according to their age . Early adult individuals are expected to be able to adapt to new patterns of life development and are also expected to be able to play new roles, desires, attitudes, and values. In early adulthood, individuals have great opportunities to explore themselves, but on the other hand, they will also face great challenges . Hurlock explains that early adulthood starts from the age of 18 to 40 years. However, according to Arnett , this exploratory phase is experienced by early adult individuals with an age range of 18-29 years which is known as emerging adulthood. Things that are explored by early adult individuals and usually become problems are related to career/work, peer relations, education, and life partners . The amount of exploration that individuals do in early adulthood causes instability in themselves. There are so many changes that they want to make and feel when exploring themselves . The various changes experienced by individuals in early adulthood are not all positive. There are various kinds of negative feelings that also often arise in their minds. Not all individuals can go through and overcome the changes and challenges that occur in this phase of emerging adulthood. Arnett says that this phase of emerging adulthood is a phase filled with a lot of instability. The forms of crises that commonly occur in emerging adulthood include feelings of anxiety, doubts about their abilities, isolation, not understanding what their desires and goals are in life, confusion about making the right decisions, and fear of failure in the future The crisis phenomenon that occurs in individuals in the emerging adulthood phase is often known as the quarter-life crisis . The quarter-life crisis was first coined by Robbins and Wilner as a crisis that occurs due to an individual's unpreparedness to transition from adolescence to adulthood. There are 7 dimensions of the quarter-life crisis according to Hassler , namely: feelings of doubt and doubt in making a decision; Feeling hopeless because they always find failure to achieve an achievement; Having a negative self-assessment for things that happen that are not in line with expectations; Feeling trapped in a difficult situation because they have to carry out what has already been chosen Feeling anxious about things that will happen in the future; Feeling depressed when faced with the fact that they have to live independently; Feeling worried about interpersonal relationships because they have not been able to meet expectations, demands, and standards in the surrounding environment. These negative feelings if not handled properly will result in emotional crises ranging from stress, depression to other psychological disorders. Some individuals experiencing a quarter-life crisis tend to feel panicked, insecure, depressed, and useless . Many questions and demands arise because of the prevailing norms and culture, for example, Indonesia with a collectivistic culture that tends to demand to get married and continue their offspring, have a career or job, and have good social relations. The survey conducted by Robinson and Wrig on 1023 early adult individuals in the United Kingdom showed that as many as 70% of individuals aged 30 years experienced many crises when they were in their 20s. The same thing was also found in which showed that around 86% of individuals experienced a quarter-life crisis. In a situation where the individual is experiencing a quarter-life crisis phase in his life, the world's current condition is being hit by the Covid-19 pandemic. A disaster that in an instant changed the situation and condition of the entire world. Where there are many emergency rules and policies issued by the government to limit the activities and movement of all human beings. This situation certainly has a considerable impact on each group in various ways. Individuals who usually interact and communicate by meeting physically are no longer a priority during the Covid-19 pandemic. Then, the impact of the Covid-19 pandemic for early adults is increasing unemployment because fewer job vacancies are opened. This is reinforced by the Big Data analysis presented by the Central Statistics Agency , which explains that job vacancies have decreased as a result of the Covid-19 pandemic . Unemployment is not limited to individuals who have not worked or are looking for work. Individuals who work but are less productive can also be included in the unemployment category . The economic impact also makes many companies unable to operate normally, increasing the number of unemployed . This can be seen from the statement from the Minister of National Development Planning / Head of Bappenas Suharso Monoarfa, who explained that the number of unemployed in Indonesia had increased to 3.7 million people due to the Covid-19 pandemic . These economic problems cause considerable pressure for individuals . Stress due to a mismatch between expectations and reality in work and social relations is often found as the thing that triggers the emergence of a quarter-life crisis in early adulthood . The pandemic has impacted the mental health of young adults . Given the many changes experienced by early adulthood individuals and coupled with the Covid-19 pandemic, social support from those closest to them becomes very important . Social support can be defined as practical emotional and informational assistance from significant others, such as family members, friends, or co-workers, or people who are always there when needed . In the current state of the Covid-19 pandemic, with everything mostly done from home, individuals will be more intense in meeting their families who live under the same roof. Family is the closest person to each individual. Where the nuclear family consists of parents and children or husband and wife. Meanwhile, the extended family consists of a wider network, namely there are several generations in it such as grandmothers, grandfathers, uncles, aunts, and cousins . Family functioning is an interaction between family members to achieve functions and goals in a family . Goleman states that a family that functions optimally has closeness and openness between each of its members. Research by Retnowati et al shows that the closeness of each family member is one of the factors supporting understanding and expressing emotions in individuals. Therefore, this study aims to see the correlation between family functioning and the quarter-life crisis in early adulthood during the Covid-19 pandemic. --- RESEARCH METHOD The subjects involved in this study were 123 individuals. The sampling technique used in this research is purposive sampling in the form of accidental sampling. Where subjects who can be involved in research are those who fit the criteria set by the researcher . The population in this study were early adult individuals ranging in age from 18 to 29 years, adjusted to the criteria for early adulthood who tend to experience a quarter-life crisis . This study uses a correlational quantitative approach. Correlational quantitative research is a measurement of the correlation between 2 or more variables . There are two variables studied in this study, namely family functioning and a quarter-life crisis. This research instrument uses the McMaster Family Assessment Device scale and the Quarter Life Crisis Quiz scale with a Likert scale model containing 5 alternative answers . The Likert scale is a scale that puts response categories at points along a psychological continuum . The McMaster Family Assessment Device scale proposed by Epstein, Bishop, and Levin contains 38 items adapted and modified with aspects that exist on the scale, namely problem solving, communication, roles, ability to react, affective involvement, and behavior control. The Quarter-Life Crisis scale developed by Hassler which was later adapted and modified by Agustin amounted to 25 items with aspects of indecision in making decisions, hopelessness, negative self-assessment, trapped in difficult situations, feelings of anxiety, depression. to feelings of worry about interpersonal relationships that are being and will be built. This questionnaire contains statements about how individuals perceive the uncertainty of the situation around them including the emotions they feel from themselves, namely career achievement, interpersonal relationships, education, and financial stability. The research instrument was prepared using a google form and distributed through social media. Data collection was carried out for approximately 2 weeks starting from October 4, 2021. The data that has been collected is then scored and analyzed descriptively from each variable. Before carrying out the correlation test, a normality test and linearity test were carried out using the statistical analysis program Jeffreys's Amazing Statistics Program version 14.1. Based on the results of the validity test of adaptation and modification of the family functioning scale and quarter-life crisis, the different power values for each item on a scale are greater than 0.1 without any item being dropped. While the results of the reliability test of the family functioning scale show the reliability value of the alpha value of 0.963 which indicates the reliability of this scale is very high. The quarter-life crisis scale has an alpha reliability value of 0.967 which is also very high. The data analysis technique in this study uses non-parametric statistics, namely the Spearman-rho correlation test because the data is not normally distributed. --- RESULT AND DISCUSSION --- Result The results of the assumption test for normality showed that the distribution of the data was not normally distributed at 0.001 . While the linearity test showed a significance value of 0.066 , which means it can be said to be linear. The results of the Spearman Rho correlation test show a value of 0.012 with a correlation coefficient of -0.226 which means that there is a significant correlation in a negative direction between family functioning and the quarter-life crisis in early adulthood during the Covid-19 pandemic. Where if the functioning of the family is high, then the quarter-life crisis in early adulthood is low. On the other hand, if the functioning of the family is low, the quarter-life crisis in early adulthood is low. This is in line with the research of Cheung, et al. which explains that good family functioning can improve individual well-being and reduce early adult individual anxiety related to social relations. The results of score categorization on the family functioning variable showed that there were 2 subjects in the high category, 120 subjects in the medium category, and 1 subject in the low category. While the categorization of scores on the quarter-life crisis variable shows 37 subjects are in the high category, 59 subjects are in the medium category and 27 people are in the low category. Based on the analysis of demographic data, the distribution of subjects based on gender was obtained, as follows: Table 3 shows that the number of female subjects was more than male subjects, namely 86 subjects and 37 people . Demographic data based on marital status can be explained as follows: --- Details of the level of family functioning and quarter-life crisis based on categorization can be seen further in table 2 Table 4 shows 109 subjects are not yet married, and 14 subjects are married. Demographic data based on employment status can be explained as follows: Table 6 shows that 87 subjects lived with their parents/family, 11 subjects lived with their partners, 4 subjects lived with siblings, and 21 subjects lives alone . --- Discussion The results of this study showed that more than 70% of the subjects involved in the study were in a moderate to high quarter-life crisis phase. This condition is considered a bad thing because the impact experienced and felt by early adult individuals when they were unable to get through the crisis they experienced was quite severe. Early adult individuals who are caught in the crisis will feel useless, increasingly doubting their abilities, fearing failure to face the future, and not being confident in their life plans and goals . In line with the research demographic data, Dickerson states that women tend to experience more quarter-life crises than men because the demands on women are not only about getting married and taking care of the family but also being able to work and have good financial conditions. stable, and build social relations. Women in Asia, especially Indonesia, are still required to get married before the age of 30 because of the collectivistic culture . In this study, more subjects were unmarried than married. This is related to the quarterlife crisis which states that two things are usually the focus of individuals when entering early adulthood, the first is a career and the second is related to love . Employmentrelated demographic data is that more early adult individuals in this study were unemployed than employed. This can be one of the factors that cause individuals to experience a quarter-life crisis. Research from Basis found that one aspect that can improve the quality of life of early adult individuals is work. Early adult individuals usually desire to have a career before marriage or to continue their education to a higher level. However, sometimes in reality there are still many early adult individuals who do not have the desired job or that is by their educational background. In addition, dissatisfaction with the work being undertaken can also cause individuals to experience a quarter-life crisis . In addition, based on demographic data regarding residence status, more early adult individuals are living with their parents or family than those living with their spouses, siblings, or living alone. Ideally, early adult individuals are more independent and no longer dependent on their parents . On the other hand, early adult individuals have the perception that they want to no longer burden their parents . This feeling of being trapped in a difficult situation is known to trigger a quarter-life crisis in early adulthood . In the time of the Covid-19 pandemic, it is increasingly making each individual have limited space for movement. The reality is that early adulthood individuals need social support to help them deal with crises in their lives. Andayani found that social support provided for individuals will be able to help them carry out good coping strategies to overcome the crisis they are facing. In this study, it is explained that the family is the closest support system for early adult individuals, especially during this Covid-19 pandemic, because early adult individuals also need good family functioning to help them face the crisis. Interaction between family members is one way of managing crises and adjusting to the circumstances that occur . Good individual interpersonal relationships and the high social support received by early adult individuals can help reduce the quarter-life crisis experienced . --- CONCLUSION Based on the research data, it can be concluded that there is a significant correlation between family functioning and the quarter-life crisis. This shows that the family, which is the closest person to each individual, has a role in getting through the crisis faced by individuals in early adulthood. This study shows that the family does not only play a role in the developmental stages of children and adolescents, but even into early adulthood, the family still plays a role. This research is an initial study related to the role of family functioning in the quarterlife crisis in early adulthood, especially during the Covid-19 pandemic. Therefore, the researcher hopes that this research can be further developed by adding other variables that can play a role in overcoming the quarter-life crisis in early adulthood. In addition, it is hoped that future researchers will set more specific subject criteria, so that data comparisons can be carried out.

This study aims to determine the relationship between family functioning and the quarter-life crisis in early adulthood during the Covid-19 pandemic. The subjects in this study were early adult individuals aged 18-29 years with a total of 123 subjects. Data collection was done by the purposive sampling method. This research instrument uses the Family Assessment Device (FAD) Scale and the Quarter Life Crisis Quiz. Data were analyzed by the non-parametric statistical analysis technique Spearman Rho. The results of data processing obtained a correlation coefficient (p) of -0.226 with a significance value of 0.012 (p <0.05), which means that there is a negative relationship between family functioning and quarter-life crisis in early adulthood. Where if the functioning of the family is good then the quarter-life crisis is low and vice versa, if the functioning of the family is bad then the quarter-life crisis is high.

Introduction Rethinking the concept of privacy in the digital age inevitably entangles the descriptive and the normative dimensions of this concept. Theoretically these two dimensions of privacy can be distinguished. One dimension can describe the degree of privacy people enjoy, without taking a normative stance about the desirable degree of privacy. In normative discussions, the focus is on the reasons why privacy is important for leading a fulfilling life. This distinction should not distract us from the fact that privacy is not a completely neutral concept; instead, it has a positive connotation. For example, an invasion of privacy is a violation of or intrusion into something valuable that should be protected. Discussion of the concept, however, brings into question why privacy should be cherished and protected. In the digital age, the normative dimension is the object of intense discussion. Existing dangers to privacy-because of big data applications, cloud computing, and profiling-are widely recognized, but feelings of resignation and why should we bother lie dormant. Defenders of privacy are regularly faced with scepticism, which is fueled by Schmidt's 'Innocent people have nothing to hide' and Zuckerberg's 'Having two identities for yourself is a lack of integrity' . Traditionally in defences of privacy the focus has been on the individual . Privacy was defined in terms of an individual's space, which was seen as necessary for meeting the individual's vital interests. In the last decade, however, we have seen a shift in the emphasis. A view of privacy as the norm that regulates and structures social life has gained importance in both law and philosophical literature. For instance, the European Court of Human Rights previously stressed that data protection was an individual's right not to be interfered with. However, more and more the Court is focusing on individuals' privacy as protection of their relationships with other human beings . In philosophical literature on privacy, many scholars have explicitly distanced themselves from the individual approach and instead study the social dimensions of privacy . Helen Nissenbaum is by far the most important spokesperson for the social approach. She has introduced the notion of contextual integrity as an alternative to what she describes as too much focus on individuals' rights based notions of privacy . Nissenbaum criticizes the so-called interest-based approach, which defines conflicts in terms of interests of the parties involved. For instance, 'Uncontroversial acceptance of healthcare monitoring systems can be explained by pointing to the roughly even service to the interest of patients, hospitals, healthcare professionals and so on'. The problem with this approach, according to Nissenbaum, is that it sooner or later leads to 'hard fought interest brawls', which more often than not are settled to the advantage of the more powerful parties . It is necessary to create a justificatory platform to reason in moral terms. As a rightsbased approach is not satisfactory, she proposes a normative approach that does more justice to the social dimension. The distinction between a focus on the individual and privacy as social value is not only of academic importance. For policies on privacy, this makes quite a difference. On the one hand, the emphasis can be on an individual's right to decide about personal interests and transparency for empowering the individual, as for instance the European Data Protection Supervisor asserts . On the other hand, the emphasis can also be on institutional arrangements that protect social relationships. The fact that good privacy policies require measures should not be a reason to overlook their fundamental differences. In this paper, we compare individual-based justifications of privacy with the social approach. We open with a discussion of the strengths of the individual-focused approach by relating privacy to a concept that has a strong normative sense and is most closely associated with individual-based privacy conceptions: autonomy. As we will see, a defence of privacy along these lines is both possible and necessary. In our discussion of the social approach, we focus on Helen Nissenbaum's model. A critical discussion of the normative dimension will lead to suggestions for strengthening this model. --- The individual approach --- The importance of privacy: autonomy The history of justifications of privacy starts with Warren and Brandeis's legal definition of privacy as the right to be left alone . This classic definition is completely in line with the literal meaning of privacy. The word is a negativum of public. The right to privacy is essentially the right of individuals to have their own domain, separated from the public . The basic way to describe this right to be left alone is in terms of access to a person. In classic articles, Gavison and Reiman characterize privacy as the degree of access that others have to you through information, attendance, and proximity . Discussion about the importance of privacy for the individual intensified in the second half of the twentieth century, as patterns of living in societies became more and more individualistic. Privacy became linked to the valued notion of autonomy and the underlying idea of individual freedom. In both literature on privacy and judicial statements, this connection between privacy and autonomy has been a topic of intense discussion. Sometimes the two concepts were even blended together, even though they should remain distinct. A sharp distinction between privacy and autonomy is necessary to get to grips with the normative dimension of privacy. The concept autonomy is derived from the ancient Greek words autos and nomos . Especially within the Kantian framework, the concept is explicated in terms of a rational individual who, reflecting independently, takes his own decisions. Being autonomous was thus understood mainly as having control over one's own life. In many domains of professional ethics , autonomy is a key concept in defining how human beings should be treated. The right of individuals to control their own life should always be respected. The patient, the consumer, and the research participant each must be able to make his or her own choices . Physicians are supposed to fully inform patients; advertisers who are caught lying are censured; and informed consent is a standard requirement of research ethics. In each of these cases, persons should not be forced, tempted, or seduced into performing actions they do not want to do. When privacy and autonomy are connected, privacy is described as a way of controlling one's own personal environment. An invasion of privacy disturbs control over one's personal sphere. This notion of privacy is closely related to secrecy. A person who deliberately gains access to information that the other person wants to keep secret is violating the other person's autonomy through information control. We see the emphasis on privacy as control over information in, for instance, Marmor's description of privacy as 'grounded in people's interest in having a reasonable measure of control over the ways in which they can present themselves to others' . Autonomy, however, does not entail an exhaustive description of privacy. It is possible that someone could have the ability to control, yet he or she lacks privacy. For instance, a woman who frequently absentmindedly forgets to close the curtains before she undresses enables her neighbour to watch her. If the neighbour does so, we can speak about a loss of the woman's privacy. Nevertheless, the woman still has the ability to control. At any moment, she could choose to close the curtains. Thus, privacy requires more than just autonomy. The distinction between privacy and autonomy becomes clearer in Judith Jarvis Thompson's classic thought experiment . Imagine that my neighbour invented some elaborate X-ray device that enabled him to look through the walls. I would thereby lose control over who can look at me, but my privacy would not be violated until my neighbour actually started to look through the walls. It is the actual looking that violates privacy, not the acquisition of the power to look. If my neighbour starts observing through the walls but I'm not aware of it and believe that I am carrying out my duties in the privacy of my own home, my autonomy would not be directly undermined. Not only in thought experiments, but also in literature and everyday life, we witness the difference between autonomy and privacy. Taylor refers to Scrooge in Dickens' A Christmas Carol who is present as a ghost at family parties. His covert observation of the intimate Christmas dinner party implies a breach of privacy, although he does not influence the behaviour of the other people. In everyday life, we do not experience an inadvertent breach of privacy as loss of autonomy. These examples make it clear that there is a difference between autonomy, which is about control, and privacy, which is about knowledge and access to information. The most natural way to connect the two concepts is to consider privacy as a tool that fosters and encourages autonomy. Privacy thus understood contributes to demarcation of a personal sphere, which makes it easier for a person to make decisions independently of other people. But a loss of privacy does not automatically imply loss of autonomy. A violation of privacy will result in autonomy being undermined only when at least one additional condition is met: the observing person is in one way or another influencing the other person . Such a violation of privacy can take various forms. For instance, the person involved might feel pressure to alter her behaviour just because she knows she is being observed. Or a person who is not aware of being observed is being manipulated. This, in fact, occurs more than ever before in the digital age. --- Loss of autonomy in the digital age In the more than 100 years following Warren and Brandeis' publication of their definition, privacy was mainly considered to be a spatial notion. For example, the right to be left alone was the right to have one's own space in a territorial sense, e.g., at home behind closed curtains, where other people were not allowed. An important topic in discussions of privacy was the embarrassment experienced when someone else entered the private spatial domain. Consider, for example, public figures whose privacy is invaded by obtrusive photographers or people who feel invaded when someone unexpectedly enters their home . The digital age is characterized by the omnipresence of hidden cameras and other surveillance devices. This kind of observation and the corresponding embarrassment that it can cause have changed our ideas about privacy. The main concern is not the intrusive eye of another person, but the constant observation, which can lead to the panopticon experience of the interiorized gaze of the other. It is self-evident that the additional conditions are now being met, viz., the person's autonomy is threatened. In situations in which the observed person feels impeded to follow his impulses , the loss of privacy leads to diminished autonomy. The loss of autonomy resulting from persistent surveillance becomes even more striking when we take into consideration the unprecedented collection and storage of non-visual information. Collecting data on individuals, such as through the activity of profiling, offers commercial parties and other institutions endless possibilities for approaching people in ways that meet the institution's own interests. Driven by invisible algorithms, these institutions temp, nudge, seduce, and convince individuals to participate for reasons that are advantageous to the institution. The widespread application of algorithms in decision-making processes intensifies the problem of loss of autonomy in at least two respects. First, when algorithms are used to track people's behaviour, there is no 'observer' in the strict sense of the word; no human actually ever checks the individual's search profile. Nevertheless, the invisibility of the watchful entity does not diminish the precision with which the behaviour is being tracked; in fact, it is quite the opposite. Second, in the digital age mere awareness of the possibility that surveillance techniques exist has an impact on human behaviour, independently of whether there is actually an observing entity. More than ever before, Foucault's addition to Bentham's panopticon model is relevant. The gaze of the other person is internalized. This brings us to the conclusion that, despite the fact that a loss of privacy does not necessarily involve a loss of autonomy, in the digital age when privacy is under threat, the independence of individual decisions is typically also compromised. These observations are striking when we consider that Western societies in particular focus on the individual person, whose autonomy is esteemed very highly. We can contrast the self-image and ego vocabulary that prevail in everyday life with online situations where an individual's autonomy is lost. There are two examples of this from domains where autonomy has traditionally been considered to be very important and where it has come under threat. --- Advertising In consumer and advertising ethics, the consumer's free choice is the moral cornerstone. In the online world, this ethical value is scarcely met. Digitalisation facilitates customised advertising, which originally was presented as a service for the individual. Tailored information was supposed to strengthen a person's capacities to make choices to his own advantage. But now the procedure has become degenerated; people are placed into a filter bubble based on algorithms and corporate policies that are unknown to the target persons. Individuals' control and knowledge about the flow of information are lost. As we all are keenly aware, requiring people to agree with terms and conditions does nothing to solve the problem. In the first place, very few people even read them. This kind of autonomy is apparently too demanding for most people to exercise. Secondly, the terms and conditions do not themselves say anything about the algorithms. Today's consumer finds himself in a grey area, where he struggles between exercising autonomy and being influenced by others. Of course, it is an empirical question as to what degree the algorithms influence customers' behaviour. The least we can say is that the wide application of algorithms suggests that they must have a substantial effect. Following the critical study of Sunstein in which he warns that the political landscape might become fragmented , much research has been undertaken on the influence of algorithms on political opinions. This has resulted in a nuanced view of the widespread existence of 'confirmation bias'. For instance, it has been shown that the need for information that confirms one's opinion differs from other kinds of information and that it is stronger in those people who have more extreme political opinions. Furthermore, there turns out to be a major difference between how often individuals actively search for opinions similar to their own and how often they consciously avoid noticing opinions that differ from their own . People surfing the Internet often encounter news they were not consciously looking for, but which they nevertheless take seriously. This is called 'inadvertent' attention for news . The question how online networks influence exposure to perspectives that cut across ideological lines received a lot of attention after the Brexit referendum and Trump election. Using data of 10.1 million Facebook users Bakshy et al. confirm that digital technologies have the potential to limit exposure to attitude-challenging information. The authors observed substantial polarization among hard content shared by users, with the most frequently shared links clearly aligned with largely liberal or conservative populations. But one-sided algorithms are not always of decisive importance. The flow of information on Facebook is structured by how individuals are connected in the network. How much crosscutting content an individual encounters depends on who his friends are and what information those friends share. According to Bakshy et al. on average more than 20% of an individual's Facebook friends who report an ideological affiliation are from the opposing party, leaving substantial room for exposure to opposing viewpoints . Dubois and Blank, using a nationally representative survey of adult internet users in the UK found that individuals do tend to expose themselves to information and ideas they agree with. But they do not tend to avoid information and ideas that are conflicting. Particularly those who are interested in politics and those with diverse media diets tend to avoid echo chambers. Dubois & Blank observe that many studies are single platform studies, whereas most individuals use a variety of media in their news and political information seeking practices. Measuring exposure to conflicting ideas on one platform does not account for the ways in with individuals collect information across the entire media environment. Even individuals who have a strong partisan affiliation report using both general newssites which are largely non-partisan and include a variety of issues . These findings are consistent with other studies that indicate that only a subset of Americans have heavily skewed media consumption patterns . --- Research ethics Corporations such as Google and Facebook, as well as data brokers use people's personal information in their research activities. One disturbing example is the research that Facebook conducted in 2014. The corporation experimented on hundreds of thousands of unwitting users, attempting to induce an emotional state in them by selectively showing either positive or negative stories in their news feeds . Acquiring information by manipulating people without their informed consent and without debriefing them is a gross violation of the ethical standards that established research institutions must follow. Such violations of people's autonomy indicate a striking contrast between the offline ideals of most users and their online practices. Whereas in the offline world we typically take autonomy as a moral cornerstone, on the Internet this ideal is not upheld. How to deal with this discrepancy in values upheld in the real world and on the Internet is one of the central challenges in discussions about privacy. When we do not strive for more clarity and transparency in the flow of information, we relinquish autonomy, a value that is deeply embedded in Western cultures. --- The social approach We might be tempted to associate the emergence of the social approach in discussions about privacy with the digital age, as if only in these times of rapid information flow reflection on the social dimension of privacy is justified. This, however, would be a false suggestion. During the twentieth century, an important undercurrent in discussions of privacy was an emphasis on the importance of privacy for social relationships. Privacy was seen as a component of a well-functioning society , in that it plays an important role in what is described as a differentiated society. Privacy guarantees social boundaries that help to maintain the variety of social environments. Because privacy provides contexts for people to develop in different kinds of relationships, respect for privacy enriches social life. Privacy also facilitates interactions among people along generally agreed patterns . As the poet Robert Frost remarked in Mending Wall , Good fences make good neighbors. This characteristic of privacy is important not only at an institutional level. In people's private lives the creation and maintenance of different kinds of relationships is possible only when subtle differences in patterns of social behaviour and social expectations are recognized . Remarkably, this subtlety becomes clearest in examples of intrusions of privacy in unoccupied public places. Consider someone who deliberately attempts to sit beside lovers who are sitting together on a park bench, or intrusive bystanders at the scene of a car accident. In both cases, the intrusions of the privacy of the persons involved are very important. The most trivial words and gestures can reflect a deep dedication and intense relationship between two people. In one of the first descriptions of the core of privacy, the English jurist and philosopher Stephens depicted it as an observation which is sympathetic . Sympathetic is derived from the Greek word sympathein, which means being involved with the same. Indeed, in private situations, different people experience the same things as important. A small, clearly distinguished domain is created, and the events should be shared only by those who directly participate in them. The persons involved are tied together by having undergone common experiences. They have an immediate relationship to what is at stake, and in this relationship they are deeply engrossed. An outside observer who has not participated in the common experience is viewed as invading their privacy. He cannot share the meaning of what is going on because he has not been directly involved. When understood this way the concept of privacy is helpful in explaining the difference between occasionally being noticed and being eavesdropped upon. In cases involving eavesdropping, someone participates in an indirect and corrupt way in what is going on. The participation is indirect because the person acquires knowledge without participating directly; the things that are at stake should not concern him. The participation is corrupt because the indirect participant is not genuinely interested in what is going on. He sees the others involved not primarily as people with their own sensibilities, goals, and aspirations, but as the objects of his own curiosity. When the other people become aware that they are being observed, they begin to see themselves through the eyes of the observing person, and they thereby lose spontaneity. Their direct involvement in the meaning of what is at stake is lost. In cases like these, neither the content of the action nor the secrecy surrounding it qualifies the actions as belonging to the private sphere. The content might be very trivial, but it would be offensive to the lovers sitting on the park bench to suggest that what they are expressing to each other could be made public. The most commonplace of actions-for instance, walking with one's children down the street-can be private. Note the indignation of people in the public eye about obtrusive photographers who take photographs of public figures while they are doing ordinary things like we all do. The essence of secrecy is intentional concealment, but the private situations that we discuss here concern behaviour, inward emotions, and convictions that can be shown and experienced in various places that are accessible to everyone, as for instance in the case of the young couple we saw sitting in the park . This characteristic of privacy in social relationships cannot be captured by the concept of autonomy in the sense of an individual independently and deliberately making his or her own choices. What is at stake in situations like these is not a lack of transparency. There is no question about the autonomy of an independent individual. The person would be deeply engrossed in precarious and delicate situations involving social relationships. An intrusion on this person's privacy would mean that he feels inhibited in being immersed in the social interaction and share the meaning at stake. In order to do justice to this notion of privacy, other strategies for protecting privacy are required. It is not primarily an individual's mastery that must be protected; rather, it is the possibility for the individual to be properly embedded in social relationships. To answer the question of how this concept of privacy manifests itself in the digital age, we turn to Helen Nissenbaum's contextual integrity model, which is an elaboration of socially embedded privacy in the digital age. --- Helen Nissenbaum's contextual integrity model After having conducted several preliminary studies, Helen Nissenbaum published Privacy in Context , a book that became very influential in philosophical and political debates on privacy. It inspired the Obama administration in the United States to focus on the principle of respect for context as an important notion in a document on the privacy of consumer data . The core idea of Nissenbaum's model is presented in the opening pages of her book: 'What people care most about is not simply restricting the flow of information but ensuring that it flows appropriately.' In Nissenbaum's view, the notion 'appropriate' can be understood to mean that normative standards are not determined by an abstract, theoretically developed default. The criteria for people's actions and the expectations of the actions of other people are developed in the context of social structures that have evolved over time, and which are experienced in daily life. As examples of contexts, Nissenbaum mentions health care, education, religion, and family. The storage, monitoring, and tracking of data are allowed insofar as they serve the goals of the context. Privacy rules are characterized by an emphasis on data security and confidentiality, in order to ensure that the flow of information is limited only to the people directly involved. The key players in the context have the responsibility to prevent the data from falling into the wrong hands. Nissenbaum's model is well-suited for the information age. It describes privacy in terms of the flow of information, and the model is easy to apply to institutional gatekeepers who deal with data streams. At the same time, the contextual approach deviates from the classical view of autonomy. The personal control of information loses ground, and shared responsibility that is expressed through broader principles becomes more important. Nissenbaum considers it a serious disadvantage of the autonomy approach that it is usually associated with notions of privacy that are based on individuals' rights. In the articulation of justificatory frameworks in policymaking and the legal arena, we often see major conflicts among parties who insist that their rights and interests should be protected. She also distances herself from the connection between privacy and secrecy . Privacy is not forfeited by the fact that someone knows something about another person. Within contexts, information about persons might flow relatively freely. In line with this, Nissenbaum puts into perspective the classic distinction between the private and the public realm. Contexts might transgress borders between the public and the private. For instance, professionals in social healthcare work with information that comes from intimate spheres. As professionals, they are, however, part of the public domain. It is their professional responsibility to deal properly with the flow of information within the realm of their own activities. --- Normative weakness and the threat of conservatism Nissenbaum's rejection of autonomy as the basis for privacy raises questions about the normative strength of her model. Does she indeed deliver the justificatory platform or framework to reason in moral terms? She asserts that her model does do so when she claims that the context procures a clear orientation, which can guide policies on privacy. This claim suggests that it is completely clear what a context is, as is the way in which it delivers a normative framework. In this respect, Nissenbaum's work has some flaws. In her description of context as a structured social setting that guides behaviour, Nissenbaum refers to a wide array of scholars from social theory and philosophy. Nissenbaum , for instance, reviews Bourdieu's field theory, Schatzki's notion of practice in which activities are structured teleologically, and Walzer's Spheres of Justice. There are, however, major differences among these authors. Schatzki focuses on action theory and the way in which people develop meaningful activities; Walzer describes the plural distribution of social goods in different spheres of human activity; and Bourdieu focuses on power relationships. When searching for a normative framework, it matters which of these approaches is being taken as the starting point. The theories also differ in their emphasis on a descriptive versus a normative analysis. This vagueness about the normative framework is a serious problem because protection of privacy in the digital age requires systemic criteria to measure new developments against established customs. Nissenbaum assumes at the start that online technologies change the way in which information flows, but they do not change the principles that guide the flow of information. The principles by which digital information flows must be derived from the institutions as they function in the off-line world, i.e., the background social institutions . Consider online banking as an example. In the digital age, contacts between costumers and banks have completely changed. Impressive buildings in which people previously made financial transactions have been partly replaced by the digital flow of information. But the core principles regarding the actions of the actors have not changed. This implies that people working within the context are familiar with the sensible issues, and 1 3 they have the final say. The only thing that must be done is to translate the principles to the new situation. In case the novel practice results in a departure from entrenched norms, as Nissenbaum says, the novel practice is flagged as a breach, and we have prima facie evidence that contextual integrity has been violated . Indeed, Nissenbaum admits that this starting point is inherently conservative, and she flags departures from entrenched practice as problematic . She leaves open the possibility that completely new developments can lead to a revision of existing standards, and she gives ample guidelines about how to implement such a revision . Nissenbaum's emphasis on existing practices must be understood in the context of a non-philosophical and nonsociological source, e.g., the notion of reasonable expectation, which plays an important role in United States jurisprudence on privacy. In the conclusion of her book, Nissenbaum describes privacy as 'a right to live in a world in which our expectations about the flow of personal information are, for the most part, met'. Reasonable expectation was the core notion in the famous case of Katz versus United States, which laid the foundation for privacy discussions in the United States. Before Katz, it had already been recognized that within one's own home, there was a justified expectation of privacy. Katz dealt with the kind of privacy situations in the public sphere that was described in the preceding paragraph. In this case, a phone call had been made from a public phone booth while enforcement agents used an external listening device to listen to the conversation. The Court considered this to be unjustified. The Fourth Amendment to the United States Constitution protects people, but not places; therefore, the actions of the enforcement agents constituted an intrusion. Regardless of location, oral statements are protected if there is a reasonable expectation of privacy. This extension of privacy was a revolutionary development, and the notion of reasonable expectation turned out to work well. For instance, in cases where the distinction between hard-to-obtain information and information that is in plain view plays an important role. In many cases, however, just because information is in plain view does not mean there is a reasonable expectation of privacy. Consider the situation where the police accidentally uncover illegal drugs concealed in an automobile. In cases like this, an appeal to privacy to protect criminals cannot be justified. However, the normative strength of the notion reasonable expectation is weak. The notion refers to existing practices; reasonable is what in a society counts as reasonable. In many cases, this might work out well. We usually do not need polls to make it clear what reasonable means. Eavesdropping is despised, yet video surveillance in a taxi is generally accepted. Police arbitrarily invading a house is not justified; however, police actively working to find concealed drugs are justified. In times of rapid development, referring to existing practices to find ultimate normative justification is not a good strategy, for at least two reasons. First, the danger of rigid conservatism might be just around the corner. This danger was already present in Nissenbaum's idea that standards for online intrusions of privacy must be derived from the offline world. In times of technological developments new problems make their appearance, and new technologies change the effects of existing rules. Particularly in the digital age, practices and normative conceptions are under pressure; existing frameworks cannot be used unequivocally. In the times of Katz, the distinction between hard-to-obtain information and information in plain view was based on how easy it was to access the information, irrespective of the type of information. This distinction is out-of-date in the digital age. The revolution in techniques of surveillance makes almost all information that is in plain view information. Any development in surveillance or monitoring, if communicated well, might be placed under the umbrella of reasonable expectation. Suppose a government takes highly questionably measures and is completely honest about doing so. The government does not want to surprise its citizens, so it duly informs the public that this is how things are being done. Anyone who makes a phone call has the expectation that her data will be stored. We all know this is not simply a hypothetical example. The same pattern can be distinguished in the way Google and Facebook justify their practices. Thanks to Mark Zuckerberg's and Eric Schmidt's statements, Facebook and Google users do not have expectations about privacy. Ironically, the insistence on transparency, which is so often heard in debates on privacy, takes the sting out of the idea of reasonable expectation. Transparency implies that data streams can flow in all directions, as long as the responsible persons are open and honest about it . Some would suggest that the word reasonable has a certain normative strength. The word refers to standards that have a certain degree of plausibility and are widely shared. Again, however, in order to guarantee protection of privacy, we need more guidance about what these standards mean, for the concept itself does not provide this guidance. The matter is turned upside down when we search for normative strengths simply by referring to current practices. The threat of conservatism in the digital age and the failure of the notion reasonable expectation lead us to the conclusion that strong anchors, which meet certain criteria, are needed. This is first of all apparent in the conservative-progressive dimension. The standards must be related to existing frameworks; alienation from these hampers acceptance. On the other hand, they shouldn't be so rigid that promising new developments are impeded. Second, it is apparent in the general-specific dimension. To motivate people, they must be so general that a wide range of applications is possible. Nevertheless, they should not be too vague; they must be specific enough to contain guidelines for action. A variety of notions that describe normative standards accompany Nissenbaum's reference to various philosophical and sociological sources. As far as the dimension conservative-progressive is concerned, she switches, on the one hand, between internal logic of and settled rationale for social systems, and she pleads, on the other hand, for the moral superiority of new practices . Nissenbaum also speaks about ultimate criteria as delivered by the purposes and ends of the context. This description is too concrete in times of rapid technological developments. Today's targets become outmoded tomorrow. Some more general notion is required. In a recent refinement of her model, Nissenbaum provides more clarity. For example, she mentions a few domains of cooperative activities that need not count as context per se. The business model for instance does not count as context, because in business the core value is earning money. When everything is for sale, it is impossible to develop independent, substantive landmarks. She also makes it clear that a describing context as a technological system is highly problematic. It leads to technological determinism, and therefore is a petitio principi. Normative standards about how to deal with technological problems are derived from technological developments. A proper context can count as what she describes as a social domain. Remarkably, she hardly considers this notion. The search for independent substantive landmarks might be guided by the expression norms and values, which Nissenbaum uses in her book. Norms are fixed standards. Usually they are concrete descriptions of particular things that must be realised or derived. Norms are necessary for guiding actions, but in times of fast changes they are too rigid. Values, on the other hand, are very general, even though they are not vague. Values such as justice, responsibility, and efficiency are used in a wide variety of contexts. This is especially true for the group of values that is concerned with the way in which we treat other people. These values surpass the context; they are important in society as a whole. They are, therefore, too general to deliver a normative orientation for actions within a context. One way to solve this problem would be to rewrite the values in a context-specific sense. This requires orientation points that refer to characteristics of the contexts. At the end of her book, Nissenbaum admits that her description of context is deficient; she acknowledges that further research on the concept is necessary. We suggest following a suggestion that Nissenbaum herself made. In a short paragraph in Privacy in context, she refers to Michael Walzer's conception of goods as constitutive for contexts. It is the only notion to which she devotes a full paragraph; intriguingly, however, she does not elaborate on this concept in her later work. This notion could be very useful for making more explicit the underlying normativeness in contexts. --- The concept of substantial goods In his famous Spheres of Justice, Walzer stresses that he does not include material objects of transaction in his definition of goods. Instead, he uses a broader and more abstract notion of goods. They are immaterial qualities that people conceive and create in the course of their actions. In his book, he comments on goods such as security, education, health, kinship, and life. While performing an action, people are oriented towards goods such as these. The goods come into people's minds before they come into their hands. Goods are, moreover, crucial for social relationships . The development of goods takes place in social contexts. For people to be able to live together, they must have more or less shared conceptions about the meaning of vital goods. The main goal of Walzer's book is to show that different spheres of actions are characterized by different conceptions of goods, and subsequently different distributions of principles. The book turned out to be a very important expression of an idea that became very influential in determining standards for professional conduct: When human beings closely share an orientation on good actions with other human beings, this leads to a proper professional life. Only when goods are determined is it possible to adjust the standards. Without going into detail, we can point to two lines of thought that have contributed to elucidation and specification of the notion good. Both Charles Taylor and Bernard Williams have distinguished goods from objects of impulsive desires and wishes by explaining that goods have an impact on a deep level of motivation. Goods 'are judged as belonging to qualitatively different modes of living' . They are the fulfilment of deeper commitments and engagements. Not the intensity of the desire but the sense of worth that makes life meaningful is characteristic of human attitudes towards goods. Attachment to and engagement with goods extend over a longer period and lead to a deeper fulfilment when satisfied. Goods give meaning to professional life . For professional ethics, Alisdair MacIntyre's contributions have been of great importance. He elaborated on a distinctive characteristic of the concept good, which professionals have very often used in dealing with moral dilemmas. In socially established cooperative activities-MacIntyre mentions various examples of these, such as chess, portraitpainting, and education-people are guided by internal goods, which are defined as abstract qualities that are realised in the course of an active life. MacIntyre distinguishes between internal goods and external goods such as money, power, and prestige. External goods are necessary only for maintaining organizations and institutions, so that the kernel for a practice exists in realising internal goods. The distinction between internal and external goods can be made along two lines. First, external goods are called external as they also can be acquired through activities that are not restricted to the practice. This is true in the sense that in activities outside the practices money, power, and prestige play a role, but it is also true in the sense that within practices it is possible to acquire money, power, and prestige through dishonest means. In opposition to this internal goods can be acquired only by excelling in activities that belong to the practice. Secondly, external goods are always in some individual's possession. The more someone has of them, the less there is for other people. They are always objects for competition. Internal goods, on the other hand, are not in short supply. Their achievement is good for the whole community whose members participate in the practice; they can be shared in the full sense of the word. Many people can be orientated towards acquiring them without being in conflict with one another. In fact, a common orientation strengthens the motivation of each member of the community. The differences among these authors do not invalidate their common focus. The distinctions they make are insightful for understanding how certain kinds of activities contribute to a meaningful life. We describe them under the heading 'substantial goods', which furnish us with a normative framework that can be used to evaluate activities. During recent decades, this line of thought has played an important role in public administration , journalism , business , healthcare , and science. It has been particularly helpful to distinguish between qualities that are related to the content of a work and institutional and external pressures. For instance, the appropriate task for a variety of professions that stress quantitative performance measures can be elucidated using the emphasis on substantial goods; they include journalists working in a democracy, scientists working in academic institutions, and public administrators who must answer to higher-level management. The ultimate goal of their actions does not lie in complying with external standards, but in realising goods that are themselves recognized as being of substantive importance. --- Substantial goods in Helen Nissenbaum's model In the application of this line of thought to Helen Nissenbaum's model, we make explicit the goods that are at stake in a context, and we take them as the starting point for decisions about the flow of information. This strategy can contribute to the solution of several problems that currently stand in the way of further applying Nissenbaum's model. A more explicit articulation of the goods at stake will be helpful in solving the problem of conservatism. We have discussed how the notion of 'reasonable expectation' and Nissenbaum's model might evoke the reproach of someone with a conservative orientation to fixed standards that do not do justice to new developments. The notion of substantial goods enables us to describe activities under a normative perspective without being restricted to certain activities. The meaning of goods can be translated in various activities. New developments lead to new interpretations of the goods involved, which, in turn, facilitate innovation. Take, for instance, education. Under the umbrella of having a good education, a wide variety of patterns of education can be developed, and new trends can be incorporated. Another advantage of elaboration of the notion of goods is that it contributes to a sharper context-specific meaning of broad, general values, such as justice, respect, and integrity. These values are very important throughout society as a whole. But the price they have to pay for the overall appreciation is that they are vague and abstract. A more precise meaning requires them to be applied in concrete contexts. This is exactly what Michael Walzer does with the value 'justice' in Spheres of Justice. He shows that the criteria for distribution are dependent on standards that differ from one context to another. Likewise, a precise description of the meaning of the notion 'respect' in education differs from respect as understood in healthcare . Knowledge of the substantial goods at stake is helpful when it comes to concretizing these broad notions. And this is not simply a superfluous luxury in the digital age. For instance, in healthcare explicit awareness of the meaning of 'respect' for the patient helps to determine the appropriate flow of information that benefits the patient's health. It is, therefore, helpful in protecting the interests of the patient from institutional pressures or pressures from special interest groups. In addition to these merits, an articulation of the substantial goods delivers a welcomed intervention in an otherwise awkward debate about the different roles that privacy can play. Privacy is not exclusively positive. It can, for instance, be used to conceal poor practices. Hiding information is a central feature of deception. For instance, feminists have stated that privacy is the enemy of equality… placing ordinary people at the mercy of powerful people . For criminals, privacy is a cover-up for their activities. Relating privacy to the substantial goods it serves is helpful in these debates, in which privacy seems to be a doubleedged sword. When it is clear which kinds of goods privacy serves , a context-specific discussion on the value of privacy is possible. Finally, the notion of goods importantly contains a normative orientation, which is distinguished from, for instance, economic imperatives. After all, commercial interests are increasingly hampering privacy. A stronger awareness of the substantial goods at stake strengthens arguments against commodification. This is even more important as privacy is increasingly encroached upon in terms of trade-offs. People are being seduced to choose between, for instance, more privacy versus more customized offers from corporations or more privacy versus paying a lower insurance premium. In such trade-offs, privacy is described as a luxury that only wealthy people can afford . How far can we go without spoiling what is vital for leading a good life? A strong articulation of substantive goods will be helpful placing a barrier between commercial pressures and leading a good life. --- Conclusions During the past decade, we have witnessed the emergence of the so-called social approach to privacy. This approach must be clearly distinguished from an autonomy approach. These two approaches rely on different normative frameworks and different justification strategies. Both of them have their merit in the digital age. Changing technologies threaten autonomy, and autonomy is indispensable for making clear what is at stake in discussions of privacy. Neglecting autonomy and the processes that threaten to undermine it is harmful for individuals. The social approach, which has been an undercurrent for decades, gains importance in the digital age. When privacy is defined in terms of control over flows of information, an approach is required that surpasses the perspective of the individual. The right to privacy provides protection in relationships with other human beings and with institutions, where the fulfilment and development of one's personal identity can be realised. The normative strength of this approach can be improved by a more explicit elaboration of the goods that are at stake. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License , which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author and the source, provide a link to the Creative Commons license, and indicate if changes were made. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This paper takes as a starting point a recent development in privacy-debates: the emphasis on social and institutional environments in the definition and the defence of privacy. Recognizing the merits of this approach I supplement it in two respects. First, an analysis of the relation between privacy and autonomy teaches that in the digital age more than ever individual autonomy is threatened. The striking contrast between on the one hand offline vocabulary, where autonomy and individual decision making prevail, and on the other online practices is a challenge that cannot be met in a social approach. Secondly, I elucidate the background of the social approach. Its importance is not exclusively related to the digital age. In public life we regularly face privacy-moments, when in a small distinguished social domain few people are commonly involved in common experiences. In the digital age the contextual integrity model of Helen Nissenbaum has become very influential. However this model has some problems. Nissenbaum refers to a variety of sources and uses several terms to explain the normativity in her model. The notion 'context' is not specific and faces the reproach of conservatism. We elaborate on the most promising suggestion: an elaboration on the notion 'goods' as it can be found in the works of Michael Walzer and Alisdair Macintyre. Developing criteria for defining a normative framework requires making explicit the substantive goods that are at stake in a context, and take them as the starting point for decisions about the flow of information. Doing so delivers stronger and more specific orientations that are indispensible in discussions about digital privacy.

Introduction Promotion of cognitive health has been a public health priority in rapidly aging societies considering its impact not only on older adults' quality of life, but also on their families, health care system and economy [1]. Vietnam is one of the countries with fastest rate of aging in the world [2]. The number of people aged ≥65 years in Vietnam was 7.4 million in 2019, accounting for 7.7% of population [3], which is expected to increase to 18.1% by 2049 [4]. Hearing loss, the most prevalent sensory deficit affecting about one in three adults aged over 65 years [5], has not been a priority in cognitive impairment risk management for long [6]. However, cohort studies have recently showed that even mild levels of hearing loss increase the longer-term risk of cognitive decline [7,8]. However, reported results on the association between cognitive impairment and hearing loss are conflicting [9,10] and the underlying mechanism to clearly explain these two associations is not yet established. Hearing loss leads to difficulties in communication and creates barriers in interaction [11,12]. Social isolation, defined as having a small social network or a lack of close relationships or sources of social support [13], is one of the factors that relate both with cognitive impairment and hearing loss [14,15]. The development of information technology has diverted ways of communication from simple telephone calling to video calls or text messaging application, which allows declined visual and hearing function to be mutually complemented [16]. Easy-to-use options, including modulating pitch and amplitude on communication devices, enable older adults to compensate peripheral functional deficit of age related hearing loss [17]. In addition, communication device usage makes up for face-to-face communication limitation due to changes in family structure and lifestyles [18]. Considering the interrelationships of cognitive impairment, hearing loss, and interpersonal communication, the question emerges how usage of communication tools may affect the association between cognitive impairment and hearing loss. In Vietnam, with the rapid development of information and communication technology, telephone and internet access have become more accessible and affordable. The percentage of internet users per 100 inhabitants in Vietnam exceeds 50%, and the number of mobile cellular telephone subscribers is equal to the size of the Vietnamese population [3,19]. In 2019, 91.7% of households owned phone or mobile phone or tablet [3,20]. In addition, communication applying these technologies into usage of smartphones or social media has been penetrated even among older adults in communities where face to face communication with their children, relatives, and close friends is limited due to changes in family structure and lifestyles [21]. To date, there were few primary studies in Vietnam focused on the cognitive impairment of older adults. These studies mainly investigated epidemiological aspects of cognitive impairment. The previous Vietnam reports showed the prevalence of cognitive impairment ranged from 29% to 48% [22][23][24]. However, a lack of study included mild cognitive impairment , an early stage of dementia. Moreover, though much research has documented that hearing loss was associated with cognitive impairment in high-income countries, a minimal number of studies have been done in low-and middle-income countries, including Vietnam, and few have focused on the role of communication patterns. A better understanding of communication patterns' role in the association between hearing loss and cognitive impairment would provide valuable insights into potential approaches in preventing or delaying cognitive decline progress. This study was performed to estimate the prevalence of cognitive impairment among older adults in central Vietnam and explore the effects of the use of communication devices on the association between hearing loss and cognitive impairment. --- Methods --- --- Measurements The study participants attended a face-to-face interview with interviewers who were public health specialists with psychiatric knowledge. Questions designed in English were converted to Vietnamese by a forward and back translation process. --- Sociodemographic and Types of Interaction In addition to age and sex, level of education was categorized into elementary school or lower, secondary or high school, and university or higher. Living area was categorized as rural or urban. Living with spouse, and children were categorized as "yes" or "no." Financial strain was categorized as "no" when participants had enough money for their daily needs over the past month, or "yes" if they lacked money for daily needs. Interaction using communication devices was defined as the use of tools of telephone, e-mail, or social media to communicate with family and others. Interaction not using communication devices was defined as face-to-face direct interactions with family and others at social gatherings, such as going out together or visiting each other's homes. Both interactions using and not using communication devices were classified as frequent or infrequent . --- Health Status and Lifestyles Cognitive Function Cognitive function was evaluated using the MMSE [25], a paper-based test that is a commonly used standard instrument for detection of cognitive impairment [26,27]. The MMSE includes two parts, the first of which requires vocal responses and covers orientation to time and place, word repetition and recall, and attention, while the second part tests the ability to name objects, follow verbal and written commands, write sentences, and copy complex polygons. The MMSE total score ranges from 0 to 30, with higher scores indicating better cognitive function. Cognitive function evaluated by MMSE was divided into three categories: MMSE 0-23, MMSE 24-27, and MMSE 28-30 based on cutoff points of 23/24 and 27/28 reported to distinguish different older adults' cognition [27][28][29]. --- Sensory Function A short questionnaire to assess self-perceived hearing and vision loss was administered at the interviews. In community surveys to cover a large population, this method is widely used, and several studies have shown that self-rated hearing impairment is correlated with audiometric measures in older adults [30,31]. Participants were asked to rate their hearing and vision ability as: no difficulty, difficult, or very difficult. Participants with hearing or vision ability classified as difficult or very difficult were categorized as having hearing or vision loss. --- Instrumental Activities of Daily Living Eight items of the Lawton Instrumental Activities of Daily Living , i.e., using a telephone, shopping, food preparation, housekeeping, doing laundry, using transportation, taking medications, and financial behavior, were used to assess the ability of older adults participants to perform daily tasks [32]. Difficulty with IADL was defined as the inability to perform at least one of the above items independently [33]. --- Presence of Chronic Disease The presence of chronic disease was categorized as no, one, and more than one chronic disease based on self-reporting of clinical diagnosis history. --- Smoking Current smoking status was categorized as yes or no. --- Statistical Analysis The frequencies of demographic and socioeconomic characteristics, interaction types, cognitive function, health status, living arrangement, and lifestyles of participants were calculated. The chi-square test was used to compare the levels of cognitive impairment according to the frequencies of interaction types, sociodemographic characteristics, health status, and lifestyles of participants. Ordinal logistic regression analysis was performed to quantify the associations between hearing loss and cognitive function outcomes according to the frequencies of interaction types, with adjustments for sociodemographic characteristics, health status, living arrangement, and lifestyle. Ordinal logistic regression is the best fit when the dependent variable is ordinal and can be ordered in a natural way [34]. Odds ratio >1 indicates exposure associated with higher odds of decreased cognitive function. Statistical analyses were performed using IBM SPSS Statistics version 25.0 . In all analyses, p < 0.05 was taken to indicate statistical significance. --- Results The characteristics of participants are shown in Table 1. The total number of study participants included in the statistical analysis was 644 literate adults aged 60 years and above, nearly half of whom were aged 60-69 years old, the majority were women , and more than a half had elementary school or lower educational level. Most subjects lived with a spouse or/and children. Self-rated hearing loss was documented in 21.9% of participants. There was no significant difference in the characteristics of participants between the original sample size and the sample of only literate participants . Table 2 presents the levels of cognitive function according to the type of interactions, and the characteristics of the participants. Overall, 124 participants were categorized as having severe cognitive impairment , 152 had mild cognitive impairment , and 368 had normal cognitive function . The prevalence rates of MMSE group scores were significantly different between participants with different frequencies of interaction types and hearing function . Table 3 shows the results of multivariable ordinal regression analysis of the association between hearing loss and cognitive function, stratified according to the frequencies of interaction using and not using communication devices. In the all combined model , cognitive impairment was associated with hearing loss, vision loss, being female, age over 80, lower education, current smoking, and difficulty with IADL. Model 2 showed association of hearing loss with cognitive impairment in participants with infrequent interactions using devices . However, association between hearing loss and cognitive impairment was attenuated in model 3, and this relationship was not significant in participants with frequent interactions using communication devices . In models 4 and 5, self-rated hearing loss showed a significant association with cognitive impairment in participants with both infrequent and frequent interactions not using communication devices. Furthermore, vision loss, current smoker, and IADL difficulty showed significant associations with cognitive impairment regardless the frequencies of the interaction types. --- Discussion Severe and mild cognitive impairment had prevalence rates of 19.3% and 23.6%, respectively, in our study population. The results presented here also suggested that the association hearing loss and cognitive function varied according to the frequencies and ways of communication. In particular, hearing loss was associated with decreased cognitive function among participants with infrequent interactions using devices and among those who had face-to-face interaction without devices regardless of the frequency. In contrast, frequent interactions using communication devices attenuated the association between hearing loss and cognitive impairment. --- Prevalence of Mild and Severe Cognitive Impairment In the present study, the combined prevalence of mild and severe cognitive impairment was 42.9%, highlighting the public health impacts of these conditions and the need for national strategies to prevent cognitive impairment in older adults [35]. Based on 10 studies in eight countries the Cohort Studies of Memory in an International Consortium showed that the prevalence of MCI ranged from 2.1% to 20.7% [36]. The COSMIC used the same criterion for MCI as in the present study , but participants were people aged ≥ 65 years and participants with dementia were excluded. With regard to the prevalence of severe cognitive impairment, MMSE score 0-23 was used as the criterion to detect dementia and had sensitivity of 0.89 and specificity of 0.89 [26]. Using the same criterion of MMSE 0-23, but with some differences in methodologies and study populations, other studies in Vietnam reported severe cognitive impairment prevalence rates of 29-48% [22,24]. Furthermore, in our study, the combined prevalence of mild and severe cognitive impairment at 42.9% highlighted the public health impact of these conditions and the urgency for conducting national strategies to prevent or delay cognitive impairment in older adults [35]. --- Diverse Association of Hearing Loss and Cognitive Function According to Interaction's Types The results of the present study showed cognitive impairment was more prevalent among older adults with hearing loss. Hearing loss has been recently recognized as a risk factor for dementia [6,37,38]. Hearing loss may be causally associated with cognitive impairment via increased cognitive load, changes in brain structure and function, and increased social isolation [14]. Our results showed that frequent interactions with family and others at social gatherings using communication devices attenuated the association between hearing loss and cognitive impairment. This may be explained by the attenuating effects of frequent interactions with communication supportive devices on social isolation in older adults with hearing loss, while the infrequent interactions or both frequent and infrequent interactions without using communication devices showed no such effect. Direct interactions with family and others at social gatherings, such as going out together or visiting each other's homes not applying any communication device, are traditional ways to provide or receive social support. However, the direct interactions could bring challenges for older adults sometimes. Frequent interactions and dense social networks sometimes result in intrusive support, overwhelming advice and interference, and may exacerbate stress [39,40]. In particular, older adults may perceive well-intentioned support efforts from family or friends as control. Although such well-intentioned support can have beneficial effects on health outcomes, it can potentially lead to the development of interpersonal conflict and stress [39,41]. These aspects of the direct interactions without communication technology support may become more severe in older adults with hearing loss with partly limited communication ability. In contrast, interactions involving the use of communication devices, such as telephone, e-mail, or social media, can somewhat offset the limitations of the direct interactions. Communication using devices are much easier to connect to a selected person regardless of time and geographical barriers, thus allowing older adults to gain access to the support that they need. In addition, with high rates of urbanization, older adults may have limited choice of living with a "significant family member or others." Indirect interactions with use of indirect means of communication allow older adults to choose the people with whom they connect. Although these selected individuals cannot provide as much instrumental support as the people who live with older adults, but they have the advantage of potentially providing better emotional support [42]. In addition, having the ability to use indirect means of communication, such as telephone, is beneficial for the self-efficacy of older adults [43]. In Vietnam, with the rapid development of information and communication technology, telephone and internet access have become more accessible and affordable. The percentage of internet users per 100 inhabitants in Vietnam exceeds 50%, and the number of mobile cellular telephone subscribers is equal to the size of the Vietnamese population [3,19]. In the present study, 83% of older adults had the ability to use the telephone at different levels. These observations highlight the significant advantages of public health intervention programs based on interaction using communication devices. Noteworthy, communication means should be particularly designed for older adults who may have cognitive and functional limitations. Keeping in mind that even though some older adults do not have their own communication devices or face difficulties in learning how to use them, their housemates can operate communication devices for them. The major strengths of this study included the use of population-based representative data, face-to-face interview, and standard data collection tools. Ordinal logistic regression allowed us to examine three levels of cognitive function as a dependent variable, including MCI, which is an early stage of cognitive decline that may have potential benefits for early preventive interventions. The results of this study revealed the critical role of interaction using communication devices, including telephone, mail, and online social networks, in modifying the association between hearing impairment and cognitive function. This study had several limitations. First, due to its cross-sectional design, the results of associations of variables could not determine causal relationships. Further longitudinal studies are required to make causal inferences. Second, our results may have been subject to recall bias. If necessary, demographic information was double-checked with family members of the older adults included in the study. Third, the study relied on a self-reported measure of hearing loss. Our results were interpreted on the basis of understanding that self-rated hearing impairment is correlated with audiometric measures in older adults [31]. However, this correlation is still a matter of debate for cases of mild hearing impairment. Fourth, validity of MMSE in Vietnamese version to evaluate cognition of the Vietnamese population would be carefully examined in a future study. In addition, as MMSE includes two questions that evaluate reading and writing ability, illiterate participants were excluded from the analytical statistics to reduce misclassification of cognitive impairment by MMSE. This exclusion was helpful in analyzing the frequency of use of interaction using communication devices that require reading and writing ability, such as e-mail and social media. Therefore, our results should be interpreted in the context of the exclusion of illiterate participants. Further longitudinal studies are required to elucidate the benefit of communication using devices on the association between hearing loss and cognitive impairment. Both quantitative and qualitative study designs are recommended. For example, a quantitative study could measure the impact of the specific means of communication on cognitive function in the specific context. A qualitative study could measure the advantages and disadvantages of using different means of communication from either perspective of older adults or their caregivers. --- Conclusions The association between cognitive impairment and hearing loss of older adults varied according to frequencies and ways of communication. Results of a study conducted in one of the world's fastest aging societies, Vietnam, showed that frequent communication using devices attenuated the association between hearing loss and cognitive impairment. These results suggested that fitted communication methods for older adults whose sensory functions declined with aging is vital to maintain their cognitive function. --- Data Availability Statement: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to them containing information that could compromise the privacy/consent of research participants. --- Author Contributions: Conceptualization, T.D.T.H. and K.N.; methodology, T.D.T.H. and K.N.; software, T.D.T.H. and K.N; validation, K.N.; formal analysis, T.D.T.H. and K.N.; investigation, V.N.H.D. and T.V.V.; resources, K.N. and T.V.V.; data curation, T.D.T.H.; writing-original draft preparation, T.D.T.H. and K.N.; writing-review and editing, T.D.T.H., K.N., K.S., V.N.H.D., and T.V.V.; visualization, T.D.T.H., K.N., and K.S.; supervision, K.N.; project administration, K.N. and T.V.V.; funding acquisition, K.N. and T.V.V. All authors have read and agreed to the published version of the manuscript. --- Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, approved by the Institutional Ethics Committee of Hue University of Medicine and Pharmacy, Vietnam . Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

This study examined the prevalence of cognitive impairment among older adults in central Vietnam and the roles of communication (with or without communication devices) in the association between cognitive impairment and hearing loss. This cross-sectional study was performed on 725 randomly selected community-dwelling older adults aged ≥60 years from Thua Thien Hue province, Vietnam. Participants attended a face-to-face survey. Sociodemographic characteristics, social interaction with or without communication devices, health status and cognitive function using the Mini-Mental State Examination were reported. Ordinal logistic regression analysis was performed to quantify the association between hearing loss and cognitive function by frequency of communication with and without devices. Mild and severe cognitive impairment had prevalence rates of 23.6% and 19.3%, respectively. Cognitive impairment was more prevalent among older adults with hearing-loss, vision loss and difficulties with instrumental activities of daily living (IADL). The association between hearing loss and cognitive impairment was not significant when older adults had frequent communication with others using devices. This study presented the relatively high prevalence of cognitive impairment in community-dwelling older adults in Vietnam. Frequent communication using devices attenuated the association between hearing loss and cognitive impairment.

Introduction Research into learning analytics has garnered much attention for its potential impact upon a number of central issues in education. For instance, the identification of learning strategies , the prediction of academic success , and the provision of personalized feedback at scale , to name a few. While this field of research promises much, the spectre of validity looms large, and many of the most frequently relied upon measures have not been subjected to robust validation. A pertinent example of this is time-on-task, the estimation of which was rarely discussed in the literature. Instead, researchers would often opt for a heuristic approach such as limiting session activity to a defined time period . However, there was little consideration of the consequences such estimation heuristics had on the results of the final predictive model. To address this oversight, Kovanović et al. investigated how different time-on-task estimation methods affected predictive models of learner outcomes. Across diverse learning contexts, the authors found that estimation methods play an important role in shaping the final study results. Concerns regarding validity ultimately relate to the extent to which a metric actually measures what it purports to measure. This is known as construct validity and is highly relevant to learning analytics methods, particularly in the context of this study on social network analysis . SNA has been one of the most commonly applied methods within learning analytics . While SNA can offer insight into the types of relationships and interactions that occur between individuals, groups, and communities, little research has considered the validity of findings derived from common SNA methods. For instance, although Batool and Niazi assessed the construct validity of centrality metrics in complex networks, studies such as this are the exception rather than the rule. Existing research has paid little attention to the validity of a number of common SNA constructs and, in particular, the impact of various tie definitions on these constructs remains largely overlooked. Following Messick , validity may be deconstructed into a number of different aspects, including structural validity, or the fidelity of the scoring structure to the structure of the construct itself ; generalizability, or extent to which score properties generalize to and across populations and settings ; and external validity, such as supportive or dissuasive evidence arising from related constructs. The present study investigates the construct validity of a number of social tie definitions in the context of online discussion forums. These definitions seek to represent the relationships formed between individuals on the basis of interactions and mutual participation within threads. That is, we assess how variations in tie definition result in different characterizations of these relationships. In doing so, we investigate three aspects of construct validity. Structural validity is assessed by comparing tie definitions on the basis of the structural features of the derived networks, and by using statistical models to compare the statistical properties of these networks. External validity is evaluated by investigating how measures of network centrality are associated with academic performance, and generalizability is assessed by pursuing the foregoing analysis in two distinct learning settings. --- Literature Review --- SNA and Discussion Forums The analysis of discussion forums, particularly Massive Open Online Course discussion forums, has received considerable attention in recent years. In this body of research, SNA has proven to be a powerful tool in extracting patterns of connections between learners, exploring their relationship with learning, and generating understanding about the underlying relational structure of a community across a variety of contexts. In particular, the emergence of MOOCs has provided ample opportunity for the application of SNA methods . Given the increasing number of students enrolling in MOOCs , SNA has become an increasingly adopted tool for visualizing and extracting interaction patterns from social learning activities , as well as for investigating the association of network centrality with constructs such as academic performance , sense of community , social presence , and creative potential . There is considerable heterogeneity in how learners interact with the discussion forum. Gillani and colleagues , for example, analyzed forum users on the basis of co-participation in the same threads, and found that the coherence of the network mainly depends on a small set of central users. Rather than a close-knit community, forum users may be more accurately characterized as a loosely connected crowd. Poquet and Dawson explicitly analyzed different user groups, and found that regular users form a denser, more centralized network as they have more opportunities to establish connections. Further work by Boroujeni, Hecking, Hoppe, and Dillenbourg confirmed that membership of these groups remains stable over time. However, there is more to discussion forums than structure alone; Wise and Cui distinguished between discussions that were related to course material and those that were not. They found that students who made both content and non-content related posts had a higher passing rate than those who only contributed to one type. Furthermore, those who contributed to content-related threads performed slightly better than those who did not. The results of these analyses, however, have not always been consistent. For instance, Joksimović et al. investigated the factors that influence social connections in two instances of a MOOC, offered in English and Spanish, that taught students how to program. Ties were extracted on the basis of direct reply from an online discussion forum. In examining the association between centrality degree, closeness, betweenness, and academic performance, the authors found weighted degree was significantly associated only in the English offering, while the effects of betweenness and closeness were only found in the Spanish offering. Furthermore, the authors found evidence of performance-based homophily, indicating that learners tend to talk to those in the same performance group as themselves. Another study, by Jiang et al. , also investigated the associations between social centrality and academic performance. Their study was conducted on two MOOCs in algebra and finance, and ties were extracted via co-presence in a thread, that is, on the basis of shared activity and participation in the discussion. While degree and betweenness were positively correlated with academic performance in the algebra course, no significant correlation was found between any centrality measure and academic performance in the finance course. In further contradiction of Joksimović's findings, the authors found that students tend to talk to those in different performance groups than themselves. The findings of these two studies are largely inconsistent; a discrepancy which may in part be attributed to methodological differences. For instance, Joksimović et al. , hypothesize that the association between academic assessment and network centrality measures was moderated by the presence of Simmelian ties ). In lieu of such a hypothesis, Jiang and colleagues' methodology did not consider the presence of a Simmelian influence. In this case and others, researchers have used different methods to extract social ties yet the effects on those extractions are rarely studied. While in the case of these two studies, the effects of tie extraction methods are studied in connection with the association between network centrality and academic performance, the same methodological oversight may be found regarding other constructs and hypotheses. Moreover, not all research into networked learning has relied upon MOOCs and, in investigating how social tie extraction methods impact upon the structures and statistical properties of networks, there is scope for a comparison between networks extracted from MOOCs and other, more formal educational contexts. --- Network Processes and Exponential Random Graph Models Studies that apply SNA methods rely upon mathematical models to describe relationships between variables, to reveal important characteristics, and to identify processes within the social network . For instance, descriptive models enable us to identify whether or not reciprocity exists within a given network. However, to understand whether or not such processes occur more often than expected if ties were generated randomly, we must rely on statistical models . One commonly proposed method is the Exponential Random Graph Model . Introduced by Frank and Strauss and Wasserman and Pattison , ERGMs belong to a family of probability models that allow for generalizable inferences over the structural foundations of social behavioural patterns within networks . ERGMs treat network ties as random variables, and model the overall network structure through a set of local network processes, such as triadic closure, mutuality, or transitivity . The model assumes each tie within these processes is conditionally dependent, indicating that "empirical network ties do not form at random, but they self-organize into various patterns arising from underlying social processes" . Though ERGMs have long been successfully applied in other fields, their application to the structural analysis of forum networks is relatively novel . In general, these results have revealed a reciprocal tie effect within networks, and a lack of network centralization beyond a few influential nodes. For instance, Kellogg et al. used ERGMs to provide a more comprehensive understanding of the dynamic processes underpinning peer support learning in MOOCs. The authors used both descriptive and statistical methods and found a strong and significant reciprocity effect, indicating that students are more likely to aid their peers when there is prior evidence of reciprocity. In a more recent study, Joksimović et al. utilized ERGMs to determine whether network social dynamics, such as Simmelian ties, have an impact on the predictive power of network positions. The study found that incorporating both descriptive and statistical models allowed for more nuanced and contextually salient inferences about learning within a network. Poquet, Dawson, & Dowell found that different facilitation, or pedagogical, approaches mediated the extent of reciprocity. That is, while direct reciprocal ties were characteristic of non-facilitated forums, triadic reciprocal ties were more prominent in forums with a high degree of facilitation . While statistical models such as ERGMs have facilitated much valuable research and provided considerable insight into network processes, the literature has neglected research into whether and, if so, to what extent network processes and statistical properties are influenced by variations in the tie definitions that underpin them. --- Social Tie Definitions Research into SNA and, in particular, SNA studies of MOOCs have relied upon a variety of definitions to construct social ties. While some authors defined ties on the basis of direct replies, others have relied on co-presence. As the basis of any SNA analysis, tie definition is crucial and each definition carries with it a set of assumptions about the nature of social interactions. In the literature, this theoretical oversight remains largely unaddressed and studies often establish a tie definition with no explanation or rationale. Even when one is provided, each decision often carries its own shortcomings. For instance, Gruzd & Haythornthwaite consider three potential tie definitions and note that each makes specific assumptions about the nature of social interactions that may not hold. In a study of MOOC forums, Wise, Cui, and Jin investigated the impact of different tie definitions on social network structures and the resultant characteristics at the network, community, and individual node level. While their study found that network properties were characterized by a limited sensitivity to differences in tie definitions, their analysis was limited to descriptive statistics and did not consider the statistical properties of networks, such as the propensity for reciprocity or homophilic ties. Accordingly, there is scope for an investigation into how different tie definitions relate to differences in the statistical properties of networks and the interpretation of such social networks. Social tie definitions can typically be classified into two distinct types: those that interpret a tie as created when an individual speaks to another, and those that extract ties on the basis of co-participation within a discussion. Perhaps the most prevalent and straightforward of the former is Direct Reply. Under this rubric, a tie is constructed when there is a reply relationship between two nodes in the same thread. For instance, between the starter of a thread and the author of a reply post addressed to it, or between the author of a reply post and the author of a reply to that reply. While this definition has been widely used there is no guarantee that users will opt for the correct location and level of post, nor that the platform itself will support a sufficiently rich reply structure. For instance, in one popular platform for online discussions, Piazza, only three levels of post are supported: post, reply, and reply to a reply. If a poster wishes to reply to a "reply to a reply" post, it is logged as another "reply to a reply" post. In building a network, a Direct Reply tie definition would link this new post to the "reply" post rather than the "reply to a reply" post to which it was originally intended to address . Accordingly, the extent to which the reply structure thus derived reflects the actual relations among learners is open to question. To address such concerns, Zhu and colleagues proposed the Star Reply tie definition. While Direct Reply considers multiple levels of replies and defines ties as connections across levels, Star Reply does away with reply structures and considers all posts within a thread as tied to the thread starter. The justification for this is that even if a reply post does not directly address the thread starter, it was made in the context of the discussion originated by the thread starter. While Star Reply emphasizes the thread starter, it fails to distinguish between different levels of replies and does not consider connections formed between posters within the same thread. To address this, Direct Star amalgamates the two and defines ties across different levels within a reply structure on the basis of Direct Reply, while also linking posts within a discussion back to the thread starter. However, the methods thus far identified strictly emphasize the act of speaking to another individual. Within a thread, a prospective poster may read much of the existing discussion before penning their own reply. Accordingly, defining ties on the basis of speaking contact alone overlooks the interactions between individuals who do not speak directly, but share an interest and an awareness of each other within the same thread. Tie definitions of the second typethose based on co-participation within a discussionseek to address this issue by creating a network of co-presence across nodes. Within such a network, a tie is defined as being present in the same part of the discussion; there is no necessity for direct interaction. Ties are thus created without regard for the reply structure present in a discussion: connections are formed both between a parent node and its children , and between the children themselves. Accordingly, this type of tie definition represents online discussions not as strict hierarchies but as collective conversations. Within this type of tie definition, a common approach is that of total co-presence, where any two nodes in the same thread are connected, regardless of post type . While this is often used to map interaction, in the case of large threads it can prove problematic. In the case of small threads, linking all individuals as part of a collective discussion might be reasonable, however, this assumption becomes implausible when the number of replies is very large. One way to address this problem, proposed by Wise and colleagues is to set a cap on the reasonable number of posts in the same thread to create a measure of limited co-presence. Beyond this threshold, all posts within subthreads are connected to all other posts within that subthread, and the thread starter. An alternative method of assessing co-participation that has been largely unexplored is that of viewing ties as contained within a moving window. Within a large thread, a prospective poster may only attend to recent posts in framing their reply and so the collective conversation of which they are part is defined as some subset of the overall thread. A moving window, defined as some number of posts, moves sequentially over a thread and, at every step, all posts within the window are connected. This approach ignores the hierarchical structure of a discussion and instead emphasizes each post as being part of a temporally defined, collective discussion. However, there is no a priori rationale for choosing one window size over another, and different sizes may lead to a variety of different conclusions. While each tie definition carries with it a set of assumptions about the nature of social interaction, in the literature little heed was paid to this, and extraction methods may instead be chosen on the basis of expediency, such as whichever structure is readily permitted by the discussion platform. Furthermore, there has been little research into the impact that variations in tie definitions have, both on the statistical properties of networks and on the association between network centrality metrics and academic performance. --- Study Framing In this study, we examine the effects that different social tie definitions have on the structural and statistical properties of the derived networks. These range from network-level properties such as reciprocity to individual properties, such as the association between metrics of centrality and academic performance. To validate our results, our analysis is applied in two separate contexts: a blended learning environment and a MOOC. The importance of doing so is two-fold: on the one hand, it provides a glimpse into how differences in learning contexts may impact upon social interaction. On the other, the two contexts allow us to assess the construct validity of tie definitions by measuring their impact on the structural and statistical properties of the resultant networks. The paucity of existing research into whether network construction choices determine network properties motivates our two research questions: RQ1: Do differences in tie formation mechanisms determine the statistical properties of networks across different learning contexts? RQ2: Do differences in tie formation mechanisms affect the association between social centrality and academic performance across different learning contexts? --- Method --- Data Sources This study analyzed forum discussions from two separate courses. The first dataset comes from a flipped classroom, firstyear engineering course at an Australian higher education institution offered in 2016. The course, called Introduction to Computer Systems , lasted 13 weeks and, of a total enrollment of 477 students, 227 students participated in the discussion forum. The flipped classroom design was composed of two elements: a set of online resources intended to be completed in preparation for the plenary session , and the re-framing of the plenary session to embrace an active learning design requiring student preparation and participation in collaborative problem-solving tasks . The second dataset comes from a course called Code Yourself! , which was delivered on the Coursera platform in 2015. The MOOC was designed to introduce teenagers to computer programming, while covering basic topics in software engineering and computational thinking. The course lasted five weeks and, of a total enrollment of 59,900 students, discussion forum data was available for 1,421 students. The content consisted of lecture videos, quizzes, and peer-assessed programming projects. If students scored at least 50% in their coursework, they were deemed to have passed, while a distinction was awarded to students receiving a score of 75% or more. Participation in the discussion forum was not required in either course. Forum activity in ICS consisted of 536 threads, comprised of 1,115 posts. Activity in CY, by contrast, consisted of 774 threads, comprised of 5,950 posts. Summary statistics of the two forums are provided in Table 1. The courses were selected to provide two disparate learning contexts for assessing the construct validity of typical SNA methods. In particular, the two courses exhibit drastic differences regarding structure: while ICS is a blended learning environment where the students are likely to have offline connections not captured by the discussion forum, CY is a MOOC where students are likely to interact solely through the discussion forum. This difference is particularly salient since ICS involves offline, collaborative problem solving. Furthermore, ICS is considerably longer, lasting 13 weeks compared to just five for CY. Pedagogy also differs: in ICS, instructors mediate and interact with students in the forum, with the intention of prompting in-depth discussion of the relevant concepts. By contrast, no such mediation exists in CY. These differences and others frame two different contexts and are essential for understanding and interpreting the different social relationships that arise within them. --- Tie Extraction Ties were extracted using the six tie definitions. Self-ties were excluded in all cases. Direct Reply Ties : The author of each post was connected with the author of its parent post. Concretely, for each thread in the discussion forum and each post within each thread, if a post was either an instructor answer, a student answer, or a level-two post , a tie was created from the level-two poster to the thread starter. However, if a post was classified as a level-three post , a tie was created from the levelthree poster to the author of the parent level-two post . Star Reply Ties : The author of each level-two and level-three post was connected with the author of the thread starting post. To be more concrete, for each thread in the discussion forum, the thread starter was identified and, for each post in the thread, a tie was created from the poster to the thread starter. Direct Reply & Star Ties : Ties defined in both Direct Reply and Star Reply were included but the same tie was never counted more than once. Specifically, for each thread in the discussion forum and each post within each thread, if the post was an instructor answer, a student answer, or a level-two post, a tie was created from the poster to the thread starter. In the case of level-three post, a tie was created from the level-three poster to the level-two poster and, if they were not one and the same person, the thread starter too. Total Co-presence : All authors in the same thread were connected with each other. In this case, ties are considered to be undirected. Limited Co-presence : All users in small threads were connected to each other with undirected ties; in larger threads users were connected to all other users in their sub-thread and the thread starter only. For threads of five or more posts, if a post was a level-two post the level-two poster was connected to the thread starter. However, if level-three posts exist , then each level-three post was linked to each other, the level-two post, and the thread starter. for each thread in the discussion forum, if the number of posts within a thread was less than N, then a tie was created between each post. Otherwise, starting from the first post, the first N posts are selected, and an undirected tie was created between each post, then the window moved to the second post and the next N posts were selected and ties created. This process repeated until the window reached the end of the thread. In this study we investigated windows of sizes two through five. Given our definitions, each type of social tie resulted in the number of connections as show in Table 2. --- Analysis --- Social Network Analysis To address our research questions, networks were extracted for the two courses in accordance with the six tie definitions. Social network analysis was then conducted across all networks in two complementary phases: structural and statistical network analysis. Our analysis of the networks' structural features relied on some of the most commonly used node-level SNA metrics to characterize centrality, including degree, closeness, betweenness, and eigenvector centrality. Degree centrality captures the local structure surrounding the node, and indicates the number of connections a node has . For this reason, degree is often considered a measure of popularity . Closeness centrality measures the distance of a given node to all other nodes in a network and so can be viewed as a measure of each node's potential to connect with other nodes. Betweenness measures the number of shortest paths between all other nodes that a given node lies on, and so can be viewed as a metric of brokerage or the extent to which a node bridges distinct parts of the network. Finally, eigenvector centrality gives greater prominence to a node the more it is connected to other highly prominent nodes. Accordingly, it can be viewed as a ranked metric of influence. Additionally, we investigated structural features at the network-level, including density, diameter, and average path length. Within a network, density measures the proportion of actual connections between nodes to all possible connections and so can be viewed as a measure of the extent to which all members of a network are connected to each other . Diameter measures the maximum eccentricity of any node in a network; that is, the maximum distance between any two nodes. Finally, average path length measures the average number of steps along the shortest paths for all possible pairs of network nodes. For the statistical analysis of networks, ERGMs were used to reveal a variety of network statistics and investigate network formation processes. In particular, we aimed to investigate the effects of reciprocity, popularity, and transitivity. As a network statistic, reciprocity represents the tendency of students to form mutual ties and group together . In the context of our datasets and tie definitions, this would indicate whether or not students tend to continue interaction with their peers who replied to their posts. As this metric represents directed loops of length two, it only applies in the case of reply-based networks . Popularity was modelled by the geometrically weighted degree distribution . Gwidegree is a statistic that geometrically discounts the value of incoming ties when the indegrees are summed in the statistic or, more intuitively, captures a popularity effect. Gwodegree considers the number of ties an individual sends in the network, and captures structures that result from highly active nodes. Transitivity refers to the extent to which the relation that ties two connected nodes in a network is transitive: that is, the extent to which the friend of my friend is also my friend. This statistic is represented by the geometrically weighted edgewise shared partner distribution . For each of the networks we consider a variety of models. In the case of reply-based networks , we examined a model for each of our statistics of interest . Similarly, for co-participation-based networks , we examined a model for each of our statistics of interest . Models were then analyzed on the basis of goodness-of-fit statistics. Networks were extracted using the ergm 3.8.0 R package. --- Regression Analysis To examine the association between academic performance and our node-level measures of centrality, and so answer our second research question, we conducted a regression analysis. In the case of reply-based networks, we examined six metrics and, in the case of co-participation-based networks, which do not distinguish between in-and out-going ties, we examined four. Since our dependent variable, the course outcome, was measured differently in our two datasets, two distinct approaches were required. In the case of ICS, the dependent variable was continuous, so a linear regression model was fitted. By contrast, the CY course outcome was categorical . Accordingly, multinomial logistic regression, a method that explains the association between a categorical dependent variable and one or more continuous independent variables , was adopted. To investigate this association, four models were fitted for each dataset. Each model included the dependent variable , one of the centrality measures, and, in order to control for an activity effect, a variable representing an individual's forum post count. Multinomial logistic regressions were performed using the mlogit 0.2-4 R package . In the case of ICS, the dependent variable was heavily skewed, and all independent variables across both courses appeared to following a power law distribution; they were therefore log transformed. --- Results --- Networks Formed by Six Tie Definitions Descriptive statistics for both datasets reveal clear distinctions between reply-based tie definitions and those based on coparticipation. Network centrality metrics were calculated by averaging over the node-level values for each network and centrality type, except for eigenvector centrality. Being more akin to a ranking measure, this network metric was calculated as the sum of differences between each node's eigenvector centrality and the maximum eigenvector centrality, divided by the maximum possible such value. Reply-based definitions produced networks of striking similarity regarding centrality metrics at both node and network level . Regarding co-participation-based definitions, the range of Moving Windows investigated exhibit clear trends across all centrality and network level metrics. As the window size decreased, the number of connections to each was, on average, attenuated, as was the overall density of the network. Furthermore, the distribution of influence across the networks, as measured by eigenvector centrality increased. Compared to the other co-participation-based tie definitions, Total Co-Presence produced dramatically distinct networks in both datasets. By contrast, Limited Co-presence resulted in very similar networks to the Moving Window 3 definition across both courses. --- Statistical Network Properties In both courses under investigation, the three reply-based tie definitions produced networks with largely consistent statistical properties. Estimated coefficients are presented in Table 5. Across all reply-based definitions and datasets, gwesp was insignificant, indicating an absence of transitive ties. This consistency across two disparate learning environments is surprising: in the case of ICS, students interact in both the discussion forum and the face-to-face plenary sessions, and accordingly one might expect the derived networks to resemble those emerging from social media, where transitive ties are a sine qua non . Regarding reply-based networks, the effect of reciprocity was significant in all networks across both courses, except for Star Reply in ICS. Across all tie definitions and courses, the effects of popularity and activity, as measured by gwidegree and gwodegree, were strong, negative, and highly significant, indicating an absence network structures characterized by highly popular or active agents. In the case of co-participation-based networks, results across both courses were consistent in that all of the investigated network processes were predominantly absent, and the baseline model provided the best fit. The only exception to this pattern was for Moving Window 5 and Moving Window 4 in the CY course. Here the derived networks exhibited evidence of transitive ties. In future research, it is worth investigating to what extent this transitivity is induced by selective mixing, as increasing the likelihood of within category ties provides opportunities for completed triangles within categories, especially when groups are small, as the low density in Table 4 indicates . --- Centrality and Academic Achievement Assessing the association between node-level centrality measures, forum activity, and academic outcomes revealed further differences between the tie definitions. In the case of reply-based networks in the ICS dataset , no centrality metrics exhibited any significant association with course performance. However, for all centrality metrics except for indegree, activity was significantly and positively associated with course performance . In the case of co-participation-based networks in the ICS dataset , no centrality metrics except closeness and eigenvector were significant. However, for all tie definitions except for Limited Co-presence , and Moving Windows 4, 3, and 2 , activity was significantly and positively associated with course performance. In the case of Total Co-presence, closeness centrality was significantly and negatively associated with course performance, indicating that as the mean distance between nodes decreased, academic outcomes suffered. However, it should also be noted that these assessments across centrality measures effectively constitute multiple comparisons that have not been controlled for. Given the number of estimated parameters, the occurrence of some significant parameters at the 5% level is likely even under the null hypothesis. For the CY dataset, in the case of reply-based networks , in-degree centrality was significantly associated with obtaining a certificate of distinction = 179.18, p<0.001; Star -χ 2 = 213.43, p<0.001; Direct Star -χ 2 = 178.77, p<0.001), but it did not have a significant impact upon the likelihood of obtaining a normal certificate. By contrast, for Direct Reply and Direct Star Reply, out-degree centrality increased the likelihood of obtaining a normal certificate = 168.85, p<0.001; Direct Star -χ 2 = 192.82, p<0.001) but not a certificate of distinction. Betweenness centrality was significantly and negatively associated with course performance across all reply-based networks = 1098.20, p<0.001; Star -χ 2 = 584.01, p<0.001; Direct Star -χ 2 = 1010.50, p<0.001). Specifically, increases in betweenness significantly reduced the likelihood of obtaining a certificate with distinction. In the case of co-participation-based networks in the CY dataset , nodes ranked higher by eigenvector centrality were significantly less likely to obtain either certificate in the cases of Total and Limited Co-presence = 1953.20, p<0.001; Limited Co-presence -χ 2 = 2265, p<0.001) but were significantly more likely to obtain either certificate across all other definitions = 2737.70, p=0.078; Moving Window 4 -χ 2 = 2738.00, p=0.125; Moving Window 3 -χ 2 = 2750.80, p=0.173; Moving Window 2 -χ 2 = 2679.30, p=0.167). Increases in activity significantly increased the likelihood of obtaining both a distinction and a normal certificate for all metrics except for eigenvector centrality where influence was only significantly associated with a normal certificate for Moving Windows 4 and 3. --- Discussion --- Structural Network Properties Descriptive statistics for both datasets clearly partitioned social ties according to reply-based and coparticipation-based definitions. While these two tie types produced distinct network structures, there remained some notable intra-type variations. In particular, Total Co-presence produced dramatically different networks with high values of degree centrality. This finding, in keeping with Wise et al. , suggests that Total Co-presence should be used with caution due to the disproportionate influence it assigns to large threads. By contrast, in both datasets Limited Co-presence produced networks comparable to Moving Window, in particular Moving Window 3. There are a number of possible explanations for this similarity, such as the predominance of short threads and associated sub-threads in both datasets . --- Statistical Network Properties In addressing our first research question, there is evidence that across different learning contexts and pedagogies, variations in social tie formation mechanisms may produce different statistical properties in the derived networks. In the case of replybased networks, we investigated the propensity of networks to form directed loops of length two , a popularity and activity effect , and the extent to which the friend of my friend is also my friend . Across all tie definitions, the results were broadly consistent for our statistics of interest, except for Star Reply in the ICS course, where reciprocal ties were notably absent. In the case of co-participation-based networks, we investigated the propensity of networks to exhibit a popularity effect , and the propensity for transitive ties to form . The co-participation-based tie definitions we investigated produce a number of transitive triangles within each thread and sub-thread. However, a transitive effect is only identified in the case of Moving Window 5 and 4. The predominance of "NA" values in Tables 6a and6b is the result of model degeneracy. The absence of reciprocal ties in Star Reply may in part be explained by both the definition itself, whereby all ties are from responders to a thread starter, and the relatively low student count and thread count of the ICS dataset compared to the CY dataset; since reciprocal ties are not created within Star Reply threads, a larger student and thread count provides greater opportunity for reciprocity to manifest itself. Beyond this exception, the estimated coefficients are broadly consistent on an intra-course basis. While the estimates in CY are quite high, these are in line with those found in existing studies . As Lusher et al. have argued, it appears that a strong reciprocal effect may be seen as a defining characteristic of interaction in online social networks in general. Furthermore, Lusher et al. identified such networks as "self-disclosing," characterized by strong relations between nodes. In these networks, students self-disclose themselves to establish social presence , creating comfortable learning and knowledge sharing environments. However, the low network level cohesion, evidenced by low density, indicates that students commonly interact with smaller groups . Across all reply-based tie definitions and courses, the effects of popularity and activity were strong, negative, and significant. Such an effect could indicate that within the network, the distribution of popularity and activity were largely homogeneous, rather than being centralized on in-or out-degree. Regarding popularity, this result is consistent with existing studies . In the case of reply-based CY definitions, where reciprocity and a negative popularity effect were particularly strong, the interpretation is quite intuitive: rather than be concentrated in a few individuals, the high propensity of students to engage with each other on a reciprocal basis distributes the effects of popularity over the population. --- Centrality and Academic Achievement Regarding our second research question, our results indicate that the choice of tie definition can affect the observed association between centrality and academic performance. For instance, for all reply-based networks in the CY dataset, indegree centrality significantly improved the likelihood of obtaining a certificate of distinction. However, for the very same networks, betweenness centrality significantly decreased the likelihood of obtaining a certificate of distinction. Given these findings, it is important to assess the underlying assumptions that give rise to such inconsistencies. For instance, while in-degree centrality was significantly and positively associated with obtaining a distinction in all CY replybased networks, the relation was reverted in the case of Total Co-presence. This may be because the construct being measured differs between the two definitions. In the case of reply-based networks, in-degree centrality indicates the extent of social prominence. However, in the case of Total Co-presence, degree centrality measures the extent of shared interest. While shared interest increases with thread size, social prominence is diluted, which could account for the contrary associations. Similarly, in the CY dataset, eigenvector centrality rank across all tie definitions was significantly associated with obtaining a distinction, but the direction of the association depends upon the tie definition. While this association was positive for most definitions, it was negative for Total and Limited Co-presence. This may be because reply-based and, to a limited extent, Moving Window definitions represent the purposeful, direct exchange of information. Total and Limited Co-presence, by contrast, dilute this effect, place inflated importance on large threads, and so provide limited information for assessing influence. These findings give cause to reiterate the warning provided by Wise et al. that Total Co-presence and, to a lesser extent, Limited Co-presence should be used with caution. While our results indicate that the choice of tie definitions can affect observed associations, it is important to emphasize that these comparisons have been made at the overall network level, not for specific individuals. It remains unclear to what extent individual centrality metrics are consistent across definitions. This is an interesting avenue of future research, and is an essential consideration when seeking to identify individuals with certain social status. --- Learning and Pedagogical Context While inconsistent associations between centrality metrics and performance may be in part explained by tie definition, they may also be attributable to differences in learning and pedagogical context. Regarding such contextual factors, the two courses analyzed exhibit important differences. For instance, while ICS is a blended learning environment where students interact both inside and outside the discussion forum, CY is a MOOC where the forum is students' only point of contact. This could result in MOOC interactions being characterized more by Q&A than in-depth discussions. While a content analysis would have to be conducted to ascertain this in our dataset, the literature provides some evidence in favour of such a hypothesis: for instance, Gillani & Eynon found that forums harbour crowds, not communities of learners; networks were fragmented and became increasingly so over the duration of the course. Furthermore, although instructor mediation existed in ICS, no such mediation occurred in CY. Poquet et al. found that different facilitation strategies mediated a reciprocal effect whereby non-facilitated forums were characterized by direct reciprocal ties. Our findings replicate this result: a reciprocal effect was present across all reply-based tie definitions but was almost three times stronger in the case of CY. Pedagogy may also have impacted student behaviour: for instance, ICS involved a collaborative problem-solving exercise in the plenary session, which could have led learners to participate differently in the discussion forum. Participation may also be affected by contextual factors. For instance, while students created far more posts in the CY forum, students, on average, posted a similar number of times in each course. However, a small proportion of MOOC users even participated in the forum, let alone consistently; not only did a far greater proportion of ICS participate, but they also had offline connections formed over a far longer course period . While our research questions did not directly address the impact of pedagogy and learning context, such factors likely played an important role and should be explicitly addressed before any conclusions or comparisons can be made between courses. However, our results also point to the importance of selecting an appropriate tie definition for a given research goal. For instance, reply-based tie definitions emphasize the purposeful, directed exchange of information between individuals and the derived networks may be useful for identifying roles or influence within a group. Co-participation-based definitions, such as Total and Limited Co-presence, instead treat all ties within a thread as homogenous and focus on identifying shared interest. Our more novel tie definition, Moving Window, has a number of appropriate applications, depending on the course context and window size. For instance, it may be useful within a collaborative learning context where posts within a thread are strongly related to recent posts within the same thread. However, such a structure is highly idealized: not only do learners not always read discussions chronologically , but in an asynchronous, many-to-many discussion forum, messages may refer to several others appearing far earlier in the chain . That said, the Moving Window definition emphasizes the temporal structure of threads, a potentially important aspect overlooked by more conventional tie definitions. --- Implications This study investigated the construct validity of a number of social tie definitions. Such ties purport to characterize the relationships formed between individuals on the basis of interactions within an online discussion forum. Structural validity was assessed by comparing the definitions on the basis of the structural and statistical properties of the networks they induced from our datasets. Our tie definitions could be categorized into two types and while we found broadly consistent structural and statistical properties within these two categories, across category comparisons revealed striking differences. External validity was assessed by investigating how measures of network centrality were associated with academic performance. While we found that increased social centrality was predominantly associated with opportunities and improved academic outcomes for students, there were some notable exceptions including significant, negative associations. This would indicate that external validity cannot be assured, and that the choice of tie definition does matter. We also assessed the extent to which our findings generalized by conducting our analyses in two distinct learning settings. Regarding the structural properties of networks, we found reply-based tie definitions produced strikingly similar node-level centrality measures, even in spite of the considerable differences in course context and scale. This was not reflected in the case of co-participation-based networks although, in both contexts, Total Co-presence produced vastly inflated figures. Cross-context similarities were also found within the networks' statistical properties: for reply-based tie definitions, both courses exhibited a significant, negative popularity effect counter-balanced by a significant, positive reciprocal effect. Regarding the association between centrality and academic performance, most metrics enjoyed consistent associations. However, there were deviations, particularly Total Co-presence which, compared to other definitions, in some cases exhibited the opposite association. Though, in many cases, our results generalized across the definitions under study, the departures from this consistency indicate that the validity of SNA methods cannot be assured, and researchers should proceed with caution. Our results lend support to the argument that researchers should be transparent in their choice of tie definition and, moreover, provide justification for their choice. Given the impact that tie definitions can have, it is advised that researchers try a number of different methods to ascertain the extent to which such methodological choices can bias their results. On the basis of this study, we recommend future SNA researchers pursue an exploratory comparison of Total Co-presence with a reply-based definition, as this could produce contrasting results and provide clarity on the internal validity of their chosen methods. --- Declaration of Conflicting Interest The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The widespread adoption of digital e-learning environments and other learning technology has provided researchers with ready access to large quantities of data. Much of this data comes from discussion forums and has been studied with analytical methods drawn from social network analysis. However, within this large body of research there exists considerable variation in the definition of what constitutes a social tie, and the consequences of this choice are rarely described or examined. This paper presents findings from two distinct learning environments regarding different social tie extraction methods and their influence on the structural and statistical properties of the induced networks, and the association between measures of centrality and academic performance. Our findings indicate that social tie definitions play an important role in shaping the results of our analyses. The primary purpose of this paper is to raise awareness of the consequences that such methodological choices may have, and to promote transparency in future research.• Social network analysis has been one of the most commonly applied methods within learning analytics. However, many of the common constructs and tools these methodologies employ have not been subjected to robust validation. Such concerns pertain to construct validity: namely, does a metric actually measure what it purports to measure? • In this study, we find that different social tie extraction methods influence the structural and statistical properties of the induced networks, as well as the associations between centrality measures and academic performance. • Our results emphasize not only the importance of transparency in the choice of tie definition, but also the importance of providing a justification for that choice. Given the impact that tie definitions may have, we advise that practitioners investigate a number of options to ascertain the extent to which such methodological choices can bias their results.

Background --- Childhood obesity Childhood obesity remains prevalent across the world, presenting one of the most challenging public health problems of this century [1]. Once established, obesity and related comorbid chronic conditions often persist into adolescence and adulthood [2]. The persistent nature of this condition may result from the establishment of obesity-related behaviors in early childhood, including poor diet, obesogenic eating behaviors, and physical inactivity, which often track through adulthood [3]. Therefore, infancy and toddlerhood may be critical periods for obesity prevention efforts. Health behavior patterns underlying the development of childhood obesity are influenced by a complex ecology of factors [4]. Thus, interventions designed to change obesity-related behaviors require multilevel approaches with multiple components [5]. Currently, no compelling evidence advocates for one program or method for preventing childhood obesity. However, comprehensive approaches addressing both behavioral risk factors and psychosocial support within relevant contexts tend to offer more promising outcomes [6,7]. For young children, family homes are ideal settings for the implementation of childhood obesity preventions strategies [8][9][10][11], as the family home represents a microsystem of processes by which child functioning is shaped [12]. However, more research is needed to understand how features of family homes may influence such efforts. --- Chaos and childhood obesity Chaos is one feature of family home environments that may be consequential for early-childhood weight development, but evidence is mixed. For example, crosssectional studies investigating direct associations between chaos and weight status among preschool-aged children report null findings [13,14]. One prospective study of caregiver-reported chaos, measured twice over a six-month period, indicated higher levels of chaos were associated with higher body mass index z-score in among infants [15]. Other studies propose chaos may operate through mediators such as cortisol patterns, child eating behaviors, and sleep duration to contribute to poorer child weight outcomes [14,16]. Chaotic environments are often described as noisy, crowded, and lacking organization [17]. Furthermore, both structural and temporal instability in the form of frequent changes in adults' romantic partners, residential mobility, loss of family income, and disrupted family routines and rituals may also contribute to chaos [18]. Chaos is more likely to occur among households with fewer socioeconomic resources [17]. However, transdisciplinary research consistently demonstrates the detrimental effects of chaos on child health and development, above and beyond the influence of socioeconomic status [17][18][19], even among samples that are homogeneous, with regards to SES [20]. Moreover, it has been proposed that chaos may act as the mechanism by which SES affects child health and development [20][21][22]. Within the context of the family home, chaos may undermine essential processes that facilitate healthy weight development [23]. For example, the elevated stimulation and unpredictability associated with higher levels of chaos may be stressful for young children [14]. Additionally, caregivers living in more chaotic households may exhibit less warmth and responsiveness towards their children [24,25]. It has been proposed that the ways in which caregivers respond to their children during moments of heightened stress may impact the organization of emerging stress physiology in early life [26]. The mechanisms responsible for physiological responses to stress are closely related to the processes governing mood and appetite regulation [27,28], which are linked to obesogenic child eating behaviors [29,30]. Moreover, caring for a small child is difficult and can be stressful for caregivers, especially as children reach toddlerhood and demand more autonomy [31]. The rapid development occurring in toddlerhood is often coupled with new behaviors that may add to familylevel chaos and create barriers to establishing household structure and routines, which may protect against obesity in early childhood [32]. Thus, examining chaos amidst the unique challenges of toddlerhood may provide critical information that can be used to inform early childhood obesity prevention strategies. --- Measuring Chaos in childhood obesity research A recent systematic review of chaos and structure in family home environments in relation to early childhood obesity found associations with child weight outcomes in the majority of studies, but the direction of results was inconsistent, and measures of chaos differed substantially [33]. This variability is likely due, in part, to challenges associated with measuring chaos. Chaos is complex and is thought to be composed of multiple constructs [34], yet most studies examining chaos-obesity relationships refer to only specific indicators of chaos, like crowding [35] or a lack of routines [32,36]. Conversely, other popular measures, such as the Confusion, Hubbub, and Order Scale [37], may lack the nuance necessary to identify important subdomains of chaos [34]. Coinciding with this critique, Lumeng and colleagues used a subset of eight items to describe "emotional chaos" as a component of the CHAOS measure, in their study of stress, eating behaviors, and early-childhood weight outcomes [14]. Furthermore, measures like the CHAOS rely on caregiver perceptions which tend to be subjective and influenced by factors such as coping strategies and personality traits [38]. One potentially promising strategy for measuring family-level chaos may include direct observations of family homes using numerous environmental indicators. To the best of our knowledge, no study has described such a strategy in the childhood obesity literature. However, examples exist in other research domains. For instance, lead investigators of The Family Life Project [39], a study designed to longitudinally assess child health and development and family function among households living in low-income rural regions of the U.S. [39], conducted five direct observations of household chaos over a three year period using 10 indicators [34]. Factor analyses of these 10 indicators resulted in a two factor structure consisting of disorganization and instability [34]. In subsequent analyses of these chaos findings from the Family Life Project, researchers showed that chaos in the form of disorganization was more important for outcomes like child language development [34] and academic achievement [22], than chaos in the form of instability. Thus, a more objective approach to assessing chaos using multiple chaos-related conditions may support efforts to reconceptualize aspects of chaos and determine which matter for early-childhood weight outcomes. --- Study aims and objectives In the present study, we aimed to characterize the home and neighborhood environments of a contemporary cohort of toddlers and explore potential contributors to chaotic environments. Our analyses utilized direct observations of family homes. To accomplish our aim, we examined chaos using a concurrent mixed methods research design. The objectives for this study were to examine the underlying structure of environmental and household chaos using direct observations of the immediate neighborhood and family home environment and to establish preliminary evidence for construct validity using qualitative fieldnotes. We hypothesized that more comprehensive and nuanced assessments of family home environments would provide additional evidence for a multi-factor structure of chaos, including disorganization, noise, and instability. We then discussed our findings in the context of current early childhood obesity literature and offer considerations for future studies. --- Methods --- Study population Data are from Play & Grow-a prospective cohort study of 299 parent-child dyads from central Ohio. Study design and cohort characteristics for the Play & Grow Study have been previously described [40] but are briefly summarized here. The target population for Play & Grow included 18-month-old children living in central Ohio. A sampling frame was constructed using patient medical records from Nationwide Children's Hospital in Columbus, Ohio. Caregiverchild dyads were enrolled between 2017 and 2019. Dyads enrolled included primary caregivers and children who were born singleton with gestational ages between 23 and 42 weeks. Enrolled dyads lived within 15 miles of NCH with no family plans to move beyond that radius during the study and the participating caregiver attested to taking part in the child's meals on a regular basis. Participants were excluded from recruitment if the child had deafness, blindness, food allergies, gestational age > 42 weeks, or if the child was tube-fed or a patient for a clinical feeding disorder. The final cohort consisted of caregiver-child dyads who were diverse with regards to gestational age, race/ethnicity, household composition, education, and household income . Play & Grow is ongoing. Thus, we utilized data from the first and second assessments, which took place when children were approximately 18-and 24-months of age. Assessments included caregiver surveys and direct observations of family homes. We limited or analyses to only records with complete data on the variables examined in this study . Our analytic sample differed from the original Play & Grow cohort, with regards to caregiver age, food insecurity, and household income . The study was conducted in accordance with the Declaration of Helsinki and the Institutional Review Board of NCH approved study procedures. Researchers obtained written documentation of informed consent for all subjects. --- Data collection We utilized Rapid Assessment Procedures [41] to simultaneously collect quantitative and qualitative data describing neighborhood and household conditions. RAP make use of traditional anthropological techniques, such as participant observation, interviewing, and analysis of quantitative data, over a shortened and more focused period of fieldwork [41]. Typically, RAP are implemented by multidisciplinary teams across multiple sites, include prompt turn arounds on data analyses, and are participatory in nature [41,42]. While RAP may never meet the methodological standards sought by most anthropologists, researchers across disciplines increasingly recognize the advantages of RAP for gaining insight into complex social and material settings. For example, RAP have been used in domains including health education [43], pandemic response in clinical settings [44], and health information technologies [45]. Our RAP consisted of quantitative audits of neighborhood and household characteristics and participant observation techniques in neighborhoods and family homes. --- Observations of neighborhood and household environments As part of the second wave of data collection, pairs of trained researchers drove to participant homes when children were 24-months of age. Teams consisted of a Lead and an Assistant Researcher. The Lead Researcher directed the visit and led a variety of study protocols. The Assistant Researcher provided support and was tasked with conducting an extensive mixed methods observation of neighborhood and household conditions. To facilitate this observation, we designed a novel data collection tool to describe a variety of neighborhood and household conditions by adapting existing environmental audits and questionnaires [34,37,[46][47][48] . The Assistant Researcher was also trained to supplement quantitative observation data with a rapid participant observation to describe various conditions and interactions noted in participants' neighborhoods and homes. Participant observation is a traditional anthropological technique often used when researchers aim to develop an understanding of participants' lived experiences amidst natural settings [52]. We adapted key features of participant observation to be implemented over numerous home visits lasting approximately 100 minutes each. For at least 10 min prior to the start of the home visit, the immediate neighborhood was observed from the vehicle with the windows down . The Assistant Researcher also examined the exterior of the family home while unpacking study materials from the vehicle and walking to the entrance of the participant's home. The interior of family homes was observed for the remainder of the scheduled visit . The Assistant Researcher was permitted to interact with participants in ways that built rapport. However, conversations between the study team and participants occurred mostly with the Lead Researcher. This left ample time for the Assistant to observe and discreetly write descriptive fieldnotes. Assistant Researchers were also encouraged to practice critical self-reflexivity by writing notes describing their experiences, challenges, or personal biases they noticed while conducting observations. Following visits, study staff returned to research offices where they logged their neighborhood and household observations and wrote a brief ethnography using their jotted fieldnotes. --- Research staff training and reliability Prior to data collection, research staff received a half-day training involving a two-hour classroom session and a two-hour field practice component. A second classroom-based review session was conducted once data collection was underway. Photos of varying neighborhood and household conditions were rated and discussed. Detailed descriptions of each rating were The telephone took up a lot of time in the home No; Yes provided. Based on group consensus, definitions for ratings and descriptions were recorded and organized in a manual for reference and future trainings. During the field component, trainees traveled to the home of a research team member where each trainee completed and discussed the observation form. Trainees, who consisted mostly of college-educated, white, middle-class females under age 40 years, were required to demonstrate 80% rater agreement from a minimum of five observations before they were certified to collect data. --- Data analyses --- Quantitative analysis We used items from the observation of neighborhood and home environments to describe chaos. The original data collection tool consisted of 32 items. However, some of these items were better indicators of socioeconomic disadvantage or more aligned with constructs such as neighborhood social cohesion [54] or neighborhood disorder and decay [48]. Therefore, we selected 14 items that were most like other measures of environmental and household chaos . We also included another seven items derived from caregiver surveys that were administered as part of the 18-and 24-month visits to supplement measurements of household instability [18]. We chose to do this because such indicators are not possible to observe during a 100-min home visit. We reviewed the distributions of responses for the initial 21 items and chose to exclude two due to little variability in item responses. Thus, we sought to empirically derive measures of environmental and household chaos from a total of 19 items . We developed scales describing chaos using exploratory factor analyses [55] with unweighted least squares and oblique rotation methods. All items considered for the EFA were ordinal or binary. Therefore, our factor analysis was based on polychoric correlations, rather than Pearson's correlations [56]. We chose to employ unweighted least squares for ordinal indicators, because it has been shown to be robust to smaller sample sizes, skewed data, and provides greater accuracy and less variability in estimates, when compared to diagonally weighted least squares [57]. Factor extraction was informed by a scree plot [58] and our theoretical understanding of chaos. Our final factor structure required factors to have a minimum of three items, as fewer than three items generally results in weak factors [58]. Following previously published work, we assigned an item to a factor if the primary loading was ≥ |0.40| [57] and the item did not crossload [58]. If an item failed to meet our criteria for factor assignment, the item was removed during the structure development process. Once our factor structure was identified, we generated summary scores for our measures of chaos. Because our EFA included items with different response options , we chose to rescale items within a range [0, 1] using minmax feature scaling [59] to ensure items were equally weighted. Once rescaling was completed, we summed items according to their factor assignments then estimated the internal consistency for each scale using Cronbach's Alpha. We conducted descriptive statistics , and P values from one-way ANOVA) to described how measures of chaos distribute across characteristics of the sample, including child, caregiver, and household characteristics. Variables to describe cohort characteristics were predominantly derived from the caregiver survey administered at the 18-month assessment. Quantitative analyses, including the EFA, were conducted using SAS . --- Qualitative analysis Due to the large number of homes visited by researchers during the 24-month assessment, we chose to examine and compare qualitative records from a randomly selected subset of families. To do this, we categorized factor scores into quartiles and randomly selected records from the highest quartile and records from the lowest quartile of factor scores. A thematic analysis [60] was conducted using the brief ethnographies. Informed by the indicators of chaos selected from the neighborhood and household observation, we used a deductive approach to develop codes, though an initial round of open coding was completed to assess patterns in the data and codes missing from our a priori coding structure [61]. A final codebook was constructed with code definitions to ensure consistency across coding. Coding was conducted by the first author and records were coded until thematic saturation [52] was achieved. A total of 88 records were coded and codes were managed electronically using QSR NVivo . --- Results --- Quantitative findings The scree plot showed a large break between two and three factors and a smaller break between four and five factors. The eigenvalues for the first five factors were 4.1, 2.2, 1.5, 1.2, and 0.9. The total variance explained by two, three, and four factors combined were 58.2, 72.4, and 83.4%, respectively. We examined the factor structures of a two, three, and four factor solutions to assess the face validity of each potential scale. Both the three and four factor solutions contained numerous indicators that cross-loaded and factors with less than three items. Therefore, we concluded a two-factor solution provided the best fit for our data. Our final factor structure required factors to have a minimum of three items, factor loadings ≥ |0.40|, and no cross-loaded items. As a result, seven items were excluded from our factor assignments . Eight items were assigned to the first factor. We labeled this factor household disorganization and it included items describing interior household conditions and household dynamics, such as interior noise, clutter, commotion, overcrowding with furniture, telephone use, communication between household members, and overall preparedness for the study visit. Our second factor, labeled neighborhood noise, consisted of four items describing the types and amount of noise heard outside participants' homes . After rescaling items within a range of [0, 1], theoretical scores for household disorganization could range from [0,8], though observed scores ranged from [0, 7.3] . Theoretical and observed scores for neighborhood noise ranged from [0,4] . Cronbach's Alpha was acceptable for both scales . Children's gestational age and sex were not associated with measures of chaos . As expected, higher levels of both household disorganization and neighborhood noise were associated with characteristics often indicative of socioeconomic advantage, though there was variability within these groups. Caregivers living in more disorganized homes and more noisy neighborhoods tended to be younger, identify as non-Hispanic Black or non-Hispanic other , were less educated, and were more often unmarried. Additionally, participants from more disorganized homes and noisy neighborhoods less often lived in single-family homes and reported lower annual household income. The number of household occupants was associated with household disorganization, but not neighborhood noise, with higher ratings of disorganization assigned to households with two occupants or five or more occupants and lower ratings assigned to households with three or four occupants. Symptoms of depression were marginally associated with household disorganization , but not associated with neighborhood noise . Finally, food insecurity was significantly associated with more household disorganization , but only marginally associated with neighborhood noise . --- Qualitative findings Household disorganization Qualitative data from our brief ethnographies supported the quantitative indicators that were selected to describe household disorganization . The indicator for commotion provided a summary of the amount of movement, activities, and noise occurring within the home. Thus, other indicators, like the interior noise rating, interruptions, and loud speaking, were often intertwined with descriptions of commotion within households. In homes with higher levels of disorganization , researchers often noted people talking over one another or yelling. Staff also noted increased foot traffic within homes. For example, one observer wrote, "…several people… were coming in and out of the house while we were there… a teenage boy present at the beginning of the visit…left. The… father also came home partially through the meal… people were entering and exiting from… the back of the apartment." In contrast, homes labeled as being the least disorganized were depicted as "…not having a lot of activity going on." Observers used words like "calm", "peaceful", and "relaxing" to describe to overall atmosphere for such homes and family members were often described as speaking at low, even volumes . Qualitative descriptions of telephone use also varied. Namely, in households that were the most disorganized, observers more frequently described noise from telephones or use of mobile phones during visit activities, whereas in the most organized homes, staff noted rarely seeing or hearing mobile phones. Descriptions of clutter inside homes were often interwoven with descriptions of crowding due to furniture. Together, these indicators appeared to illustrate the organization of a home's physical space. For example, in homes that were the most disorganized, staff illustrated environments where tables and other surfaces were covered in various items, like household ornaments, papers, laundry, or appliances. During one home visit, a household member shared her experience of "losing her stuff in the home due to how cluttered it [was]". Staff also described environments that were so crowded with furniture and other items that the space appeared to be "unusable" or "difficult to get around". In contrast, homes described as having the least disorganization appeared to have organizational systems in the form of "bins" or "shelves" that helped "consolidate" household items, like children's toys. Additionally, furniture did not appear to interfere with mobility throughout the home. The rating for family preparedness often reflected signs that participants remembered their scheduled visit and attempted to follow visit-preparation instructions provided by the research team. In homes with high levels of disorganization, observers frequently noted that caregivers did not complete surveys ahead of time and did not place pets in a separate space before allowing staff to enter their home. Additionally, other family members sometimes appeared "surprised" by the presence of staff, suggesting participants did not inform them of the visit. Conversely, staff were often greeted promptly by caregivers from homes with the least disorganization. Family members could sometimes be seen waiting at the door or looking through windows in anticipation of study staff arrival. Caregivers often complete surveys within the recommended timeframe and placed family pets in separate rooms or outside prior to staff entering the home. There was also evidence from the least chaotic homes of family communication in preparation for the visit. For example, one observer wrote, "…It was evident that mom and dad had discussed the study… before we got there… [because] there was no question about who would do what activities…". In addition to themes directly supporting our quantitative measure of household disorganization, we also noted excerpts describing aspects of the social environment that extended past our eight indicators. For example, in the least disorganized homes, observers consistently noted exchanges and interactions between household members that were generally peaceful and harmonious. In such cases, both caregivers and children appeared to be "very engaged" and enjoyed their time together. One observer wrote, "[The child] was engag[ed] and seem[ed] really happy to be with mom. Mom… always responded to him, was chatting with him, and smiling at him. [The child] often looked to mom for feedback… Even when mom was busy with the survey, she was always paying attention to [the child] enough to [respond] to him when he [addressed] her." Peaceful exchanges noted by staff often occurred during home visits where more than one caregiver was present . Caregivers were described as behaving "warm[ly]" and "friendly" towards one another and were often successful at "divide… tasks between each other". Caregivers' ability to remain "calm and patient" with their children, even during tantrums or moments of fussiness, appeared to result in more peaceful interactions overall. Staff also noted displays of affection or support between family members living in more organized households. Such descriptions often included moments when researchers observed a caregiver and child hugging or cuddling. Caregivers shared with study staff positive feelings they had towards their children. For example, one father "… spoke about [his children's] school and about the [child participant's] growth in vocabulary and mentioned that he had counted to eight." In other instances, staff noted other family members, like siblings, demonstrating support for the participating child, "[older sister] wanted to help [her brother] when he was upset during measurements by showing him how to do them [and] that they were easy and not at all scary. She even held his hand during height measurements...". In contrast, homes with higher levels of disorganization often included staff descriptions of more turbulent exchanges between household members. In such cases, caregivers and children were often observed struggling through visit activities. --- "Mom… seemed very stressed when child did not understand [or] did not follow her requests… [She] Table 4 The distribution of household disorganization and neighborhood noise according to cohort characteristics With the limited space, siblings going up and down stairs, parents going up and down stairs and elevated voices, it felt very chaotic in the home. The home was calm and peaceful...Both parents… did not appear to be in any rush….. [The] home [did] not have a lot of activity going on. Interior Noise Rating …there were six other siblings that were in the home two of which were very young and stayed in the kitchen with staff, they all spoke in their normal speaking voices, but with the small space it echoed loudly in the home and seemed louder… The smoke detector beeped during the entire visit indicating the battery needed to be changed and the washer was running during... activities. The home was mostly quiet. The child whined..., [but] was not overly loud. Dad and sister played and read together. [They] giggled and spoke but were mostly quiet/[indoor] speaking volume. I could not hear any sounds from household appliances. --- Interruptions A few minutes into the visit, multiple siblings and friends walked through the back door. They loudly spoke over one another, and it was difficult to hear [the] mom and [child] over them. Throughout the visit, mom would yell across the house at siblings to get them to do various tasks or to come join for the meal. While family spoke often, their voices were never raised. I would describe it as using "indoor voices". Loud Speaking The great grandma got upset with the dogs [for barking] and yelled at them several times saying "I'm going to bust you!" They never raised their voices to the children but were stern [at times]… Telephone Use Mom's phone made a lot of noise… Mom spent most of our visit looking at her phone and playing with the youngest baby. I never heard or saw mom or dad use their phone during the visit. Cluttered Interior; ..The seven-year-old [cousin]… described losing her stuff in the home due to how cluttered it is. She [said she] carried her toys and clothes around in a trash bag to keep track of them. Playroom had lots of interactive toys: cars with racetrack that could shoot off the cars into a loop-de-loop, play kitchen set, animated toys that sing/dance, blocks/building things. Toys were scattered around the edges of the room, or in smaller baskets, so it seemed like the space had an organization system. Crowded with Furniture When we walked into the home, there was a living room with a couch, big chair, two desk chairs, highchair, coffee table, tv stand, and TV. In addition to the furniture, there was a guitar, big speakers, random pieces of wood, unidentified electronic devices, and lots of wires. This room was hard to navigate, and I had trouble finding a spot to do anthropometric measurements. I also felt like I kept accidentally bumping into furniture or knick-knacks on the furniture. The living room had a couple very large couches and a round leather ottoman and coffee table, but it was not overcrowded and there was a lot of open space.... Against the back wall were many plastic bins with kids toys organized in them, and some toys out on the floor. Survey was done hours before the visit... [When we arrived] grandma answered the door and seemed surprised we were there. [She] spent at least 3 min wrangling the dogs to get them out of the way while we waited outside. Dad greeted us at the door promptly after we knocked. The dog was locked away upstairs before we even entered... Dad showed signs of remembering details of the study and seemed prepared for what we were doing at the home visit... Mom was running a few minutes late, but she wasn't the primary respondent and dad had already communicated that she was be home a few minutes after we arrived prior to us showing up for the home visit. All signs indicated the family was well-prepared for our visit. --- High Neighborhood Noise Low Neighborhood Noise Exterior Noise Rating The apartment complex... was in was on the corner of a fairly busy cross section. About 20 cars passed by in front of the home and about the same amount passed by on the other direction to the side of the building... We heard a emergency vehicle siren and honking, most likely more than one for about 3 mins or more... Occasionally heard a low rumbling of a large engine in the distance. Around the same time as the sirens, we heard a small engine airplane and then a helicopter nearby. When all was quiet, there was a faint whoosh from the traffic in the distance. The neighborhood was very quiet. I could not hear any highway traffic, only the occasional car driving past where we were parked or a nearby street. Traffic volume was light. I only counted 4-5 cars passing by during the observation. I did not note any noise from airplanes or trains. Neighbors from across the street were walking out to their car and yelling. One person yelled, "Oh my God! Unlock the door". Loud Ambient Sounds In the 15 mins we sat there, 3 airplanes went by producing a very loud sound and lasting for at least a min each time. ...the sounds of a very high altitude plane flying overhead--it was so faint that I wouldn't consider it "loud ambient" noise. Hear Exterior Noise Inside When sitting in the living room you can hear the cars/trucks passing by from the street. Also hear people's voices outside, one airplane sound, and music . [I rated it] as very noisy because of the multiple sounds. I was not able to hear any noise coming from outside, even when we were hanging around the front door to hide out of site during the meal kept apologizing throughout the visit… [and] would make… comments [to her son] like, "Come on, you can do this. I know you can do this for us. Why aren't you?"'..." In fewer cases, staff witnessed family members engaging in active arguments during the study visit. For example, one researcher observed, "Mom and partner [having] another hushed, but agitated argument when they thought we were out of ear shot. Mom used several expletives." Finally, researchers often used words like "passive" or "lack of engagement" to describe caregivers in households that were more disorganized. --- Neighborhood noise Qualitative data from our brief ethnographies provided preliminary construct validity for our indicators of neighborhood noise . In most neighborhoods, the exterior noise rating represented a holistic description of the types of noise and the volume of such noises observed over a brief period. Across levels of neighborhood noise, staff indicated car traffic, in the neighborhood or on a nearby thoroughfare, was a consistent source of noise. However, among a subset of neighborhoods with the highest noise ratings, observers highlighted the home's proximity to major highways/interstates. One staff member wrote, "The apartment complex was built directly next to the highway. There was only a concrete partition separating the highway from the complex parking lot. The partition did very little to cut down noise. It sounded like I should be able to see the vehicles as they drove past, but I couldn't. The highway noise was extremely loud and constant. I could identify every semi-truck that went by." Conversely, in the quietest neighborhoods, observers would sometimes draw attention to the distance between the participant's home and known interstate highways . In such cases, staff sometimes noted a participant's home was in "a [more] rural part of the city", on a cul-de-sac, or had a "dense forest of trees blocking…" sounds from nearby highways. Ambient noises were often the same across neighborhoods, despite the level of noise observed. Airplanes and emergency vehicle sirens were frequently heard. Occasionally, staff would note the presences of noise from a nearby construction site or an individual vehicle with a loud engine. However, among homes described as having the lowest neighborhood noise, researchers more frequently described sources of ambient noise as being noticeable to a lesser degree. They did this by conditioning their descriptions using words like "faint" or "muffled", or described noise as being "sporadic" rather than "constant". Unique to neighborhoods with the highest noise ratings, some observers noted the presence of loud music playing from vehicles driving through the neighborhood. One researcher wrote, "two cars pulled in at different times that had their music turned up very loud… we could feel [vibrations from] the bass". The ability to hear neighborhood noises from inside participant homes differed according to neighborhood noise ratings. In homes from the quietest neighborhoods, research staff often made statements like, "no outside noises [could be] heard from inside the home". Sometimes staff would suggest that interior sounds, such as subtle humming from appliances or family members talking, might "drown… out" the exterior noises. In the few cases where neighborhood noises could be heard while inside the home, observers made a point to note that the family had the "… windows [and] front door… open because of the weather" or that study staff "…were hanging around the front door…" when they heard such noises. In contrast, while inside homes located in the noisiest neighborhoods, observers repeatedly described hearing vehicle or highway noise and loud ambient noises, such as sirens, airplanes, and at times, construction. For example, one observer wrote, "We could also hear noise from the highway and construction outside, especially the large trucks going by." Another offered, "[I] could hear some loud engines revving outside and then an airplane and train at one point." In fewer cases, research staff also noted being able to hear loud music playing from passing vehicles while inside the home. For instance, "…there were several… cars [with loud stereos] that pulled into the complex that we could hear the beat and the tune of the song they were listening to [from] inside the home". On the rare occasion that observers were unable to hear neighborhood noises while Table 5 Example excerpts providing preliminary construct validity of indicators of chaos selected from the exploratory factor analysis Rating of Exterior Noise Audible Inside ...the sound from the road traffic outside was very noticeable inside the home. The adult's bedroom shared the wall that faced the street, and so did the main living space. Child's room was towards the back of the house. I could hear regular passenger vehicles, but especially large semi's as they drove past. I was only able to hear some of the traffic from outside when we were hiding out of sight by the front door. inside a participant's home, staff suggested the inability to hear such noises may be due to characteristics of the home. For example, one researcher wrote, "I tried very hard to hear highway noise and couldn't. Either the building materials did a good job insulating against noise pollution, or the [air conditioning] was… loud enough… to cover the exterior noise, or both." --- Discussion --- Summary of findings Chaos is known to negatively influence a wide range of family, caregiver, and child outcomes [19]. In recent years, researchers have considered the role of chaos in child weight status, but results are mixed, and conclusions are limited by the heterogeneity in which chaos is operationalized [15,33,62]. To improve upon limitations of previous chaos-obesity investigations, we proposed reconceptualizing aspects of chaos to facilitate future research efforts that aim to determine which matter for childhood obesity development. Thus, in the present study we examined the underlying structure of multiple indicators of family-level chaos from direct observations of neighborhood and home environments, using a concurrent mixed methods approach. We found evidence to suggest numerous indicators of chaos may be governed by higher-order constructs, including household disorganization and neighborhood noise. This evidence was further supported by themes derived from qualitative fieldnotes, which provide preliminary construct validity for a novel chaos assessment tool. The methodology and results in the present study closely align with those described by Vernon-Feagans and colleagues , who assessed family-level chaos via direct observations using multiple indicators of chaos [34]. Concurrent with their methods and results, we utilized direct observations of family homes and found evidence to suggest chaos may be comprised of multiple constructs. However, our study incorporated both quantitative and qualitative assessment of chaos, which presented opportunities for data triangulation, expansion of descriptions of chaos, and further contextualized the broader social and material environments in which chaos occurred [52]. For example, in addition to providing evidence to support our indicators of chaos, themes emerged from our qualitative analysis to suggest family dynamics varied according to the level of household disorganization. Specifically, among homes with the lowest levels of disorganization, study staff described what appeared to be more peaceful and harmonious exchanges between household members. In contrast, observers noted a greater frequency of turbulent exchanges between household members from homes with the highest levels of disorganization. Previous research suggests greater family functioning [63] and high quality relationships between caregivers and children [64][65][66] may be protective against childhood obesity. Yet, chaos may degrade the quality of such relationships [24,67]. It has also been proposed that the quality of interpersonal interactions occurring between family members may moderate the effect of chaos on children's risk for obesity. For example, one qualitative study conducted semistructured interviews with 20 ethnically diverse caregiver-child dyads and described experiences where household chaos not only influenced the structure and quality of family meals, but also created more challenging mealtime interactions among family members experiencing difficulties in their interpersonal relationships [68]. Similar findings were echoed from one quantitative study among 108 caregiver-toddler dyads where researchers reported children exposed to higher levels of chaos engaged in obesogenic eating behaviors to a greater degree, but only when maternal emotional responsiveness during mealtimes was low [69]. The pathways by which chaos may be linked to child weight outcomes are likely complex, and the unique challenges associated with caring for young children may add to family-level chaos, creating additional stress for caregivers. Our qualitative findings build upon emerging literature which suggests caregiverchild interactions may be important context for studies of chaos-obesity relationships, especially during early developmental periods, like toddlerhood. However, given the exploratory nature of these findings, this interpretation is speculative and requires additional study to determine how chaos and caregiver-toddler interaction may work in concert to influence childhood obesity risk. Our scale describing disorganization closely aligns with what Matheny and colleagues labeled environmental confusion, in the development of the CHAOS [37]. This suggests the CHAOS may provide a foundation for developing measurement tools designed for structured, direct observations of disorganization in family homes. We believe direct observations may be necessary to avoid potential bias often associated with caregiverreported measures [70]. For example, one study examining parent and adolescent perceptions of household chaos using the CHAOS found perceptions of chaos in shared home environments were only moderately correlated , implying individual differences may influence perceptions of chaos [71]. Another analysis examined associations between maternal personality characteristics and perceptions of chaos using the CHAOS and concluded mothers with high stimulus sensitivity perceived home environments as more chaotic than what was objectively measured by trained observers [38]. While caregiverreported measures offer quick, cost-effective alternatives to direct observations, disentangling caregiver characteristics from measures of chaos may be impossible without more objective assessments. Still, direct observations conducted by trained researchers are not without shortcomings, including vulnerability to bias resulting from observers' personality, knowledge, beliefs, and experiences. We were mindful of this limitation when designing our data collection procedures. To mitigate potential bias in our direct observations, staff were trained to collect both descriptive and reflecting fieldnotes which facilitated staff engagement in reflexivity as they assigned ratings. Never-the-less, individual biases may have played a role in our observations. Therefore, concurrent use of caregiver-reported and objective measures of chaos in future studies may be an essential next step to inform future chaos-related research. A second factor of chaos, neighborhood noise, was identified through our EFA. Studies examining noise, as one feature of chaos, suggest cardiovascular stress indicators and neuroendocrine stress hormones, implicated in obesity development, may be sensitive to louder environments [72]. However, current definitions of chaos include little specificity around types and sources of noise [17,37]. Interestingly, one indicator of chaos from our observation, that described the level of interior noise, was highly correlated with our factor of disorganization, but minimally correlated with our factor of neighborhood noise. Such distinctions may suggest noise typologies are a necessary level of nuance for measuring environmental and household chaos, with different implications for childhood obesity research. For example, our thematic analysis further contextualized our neighborhood noise ratings by indicating that participants living in the noisiest neighborhoods often lived close to interstate highways. Highway construction in the U.S. has disproportionately burdened Black and Brown communities and contributed to the residential concentration of poverty [73]. Obesity is known to be a condition that disproportionately affects non-white children [74,75] and children residing in households with fewer socioeconomic resources [76]. Thus, neighborhood noise may be one aspect of chaos more closely linked with structural disadvantage and requires multifaceted interventions designed to address a variety of upstream social inequalities. Future studies of chaos, within the context of child weight development, may benefit from efforts to describe the variability of chaos within and across socioeconomic groups. Contrary to what we hypothesized, our EFA did not identify instability as an independent factor contributing to chaos. Prior to selecting our final model, we considered other factor structures that incorporated indicators thought to be associated with instability, such as mealtime routines, bedtime routines, and changes to the household composition. However, the internal consistencies associated with these alternative structures were poor, the face validity was less convincing, and we found little to no support for alternative structures in our qualitative data. Moreover, our lack of support for instability as a factor of chaos may be attributed to the cross-sectional nature of our study design. For example, Vernon-Feagans and colleagues identified instability as an independent factor of chaos through direct observations of family homes. However, Vernon-Feagans et al. conducted repeated assessments over a three year period [34]. Unlike other aspects of chaos, which tend to persist, instability often occurs periodically. Thus, single assessments of chaos may be insufficient for detecting factors, like instability. Within this vein, time may be a key component missing in most studies examining associations between chaos and earlychildhood weight outcomes. For example, null findings have been reported in cross-sectional studies examining direct associations between caregiver-reported chaos and early-childhood weight outcomes [13,14]. Conversely, one study that assessed caregiver-reported chaos twice over a six month period indicated infant BMI z-score was significantly higher when household chaos was higher [15]. Therefore, longitudinal assessments may be necessary for identifying molar constructs thought to govern chaos, as well as associations that may exist between chaos and early-childhood weight outcomes. --- Limitations Our study has limitations that must be considered. Observations of chaos were conducted during a single visit in participant homes. As some aspects of chaos may be acute while others are chronic, we may not have observed the true variation of environmental and household chaos. Furthermore, the presence of study staff and execution of study protocols during the visit may have contributed to an unusual home environment that factored into our staff's ratings. Future studies incorporating objective measure of chaos should strive for repeated assessments to ensure what is measured is "typical" for households. Our data collection tool for measuring household chaos was novel. Thus, without more rigorous testing of psychometric properties, construct validity and generalizability of our tool may be limited. Furthermore, protocols for conducting observations were developed and implemented by mostly middle-class, white females and our initial training for our observation protocol was limited to a single field practice component in a neighborhood where one research team member resided. While few studies have examined challenges to conducting direct observations of chaos, a wealth of research demonstrates divergent descriptions of parenting styles when researchers seek to observe behaviors across diverse groups [77,78]. Though our protocols and trainings attempted to overcome systematic error using multiple methodologies, our homogenous research team did not reflect the diverse cohort of families making up the Play & Grow study. Therefore, it is possible that researcher observations reflect cultural differences that may or may not be symbolic of chaos. Furthermore, most observers interacted and built rapport with families at previous assessments. It is unknown whether these previous interactions influence ratings and fieldnotes. Finally, though we included two items on household routines in our quantitative assessment, household routines were largely neglected from our observations of chaos. Family routines may be key aspects of chaos with important implications for childhood obesity [32,79]. Future research should combine factors, such as disorganization and noise, with measure of family routines to understand how best to operationalize chaos. --- Conclusions Chaos represents a complex, multifaceted construct with implications spanning various research disciplines [80], including public health research focused on early childhood obesity. Previous research investigating chaosobesity relationships in early-childhood may be limited by the challenges associated with measuring chaos. Therefore, this study advanced the literature by contributing to efforts to reconceptualize aspects of chaos and identifying conceptually distinct subdomains, including disorganization and neighborhood noise. As obesity prevention researchers look to family home environments as preferred settings for prevention efforts [81], more contemporary measures, such as those relying on direct observations which account for multiple underlying factors of chaos, may yield valuable insight on factors contributing to early-childhood obesity risk. --- --- Abbreviations CHAOS: The Confusion, Hubbub, and Order Scale; NCH: Nationwide Children's Hospital; RAP: Rapid Assessment Procedures; EFA: Exploratory Factor Analysis Authors' contributions KLK designed and conceptualized this research, led data collection, led analyses and interpretation of data, and wrote the manuscript. AP participated in the design and conceptualization of data collection methods, assisted with data collection, assisted with analyses, and critically revised the manuscript. RA advised the conceptualization of analytic methods, supervised data analyses, and critically reviewed the manuscript. BZ participated in early development of the data collection methods and critically reviewed the manuscript. SAK supervised data collection and critically reviewed the manuscript. SEA supervised the design and conceptualization of this research, supervised analyses, and interpretation of data, and critically revised the manuscript. The author read and approved the final manuscript. --- --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Chaos has implications for child health that may extend to childhood obesity. Yet, results from studies describing associations between chaos and childhood obesity are mixed. New approaches to studying the environments of young children may help to clarify chaos-obesity relationships. Methods: We conducted a concurrent mixed methods analysis of quantitative and qualitative data describing home and neighborhood chaos among a diverse cohort of 283 caregiver-toddlers dyads from Ohio. We examined the underlying structure of environmental and household chaos using exploratory factor analysis then sought to validate the structure using qualitative field notes. We generated total scores for factors of chaos and described their distributions overall and according to cohort characteristics. Additionally, we conducted a thematic content analysis of brief ethnographies to provide preliminary construct validity for our indicators of chaos. Results: Dyads varied according to household composition, income, education, and race/ethnicity. We found evidence for a multi-factor structure for chaos, which included disorganization and neighborhood noise. Household disorganization scores ranged from 0 to 7.3 and were on average 2.1 (SD = 1.8). Neighborhood noise scores ranged from 0 to 4 and were on average 1.1 (SD = 1.1). Both disorganization and neighborhood noise were associated with indicators of socioeconomic disadvantage, such as lower educational attainment and household income. Qualitative data from households with high and low scores on the two identified factors were aligned in ways that were supportive of construct validity and further contextualized the social and material environments in which chaos occurred.

Interpersonal violence is among the most important preventable causes of premature mortality and morbidity. Excluding war, it leads to around 410 000 deaths per year and is the 19th most common cause of death globally. 1 Morbidity is also substantial, although there are large variations, it is in the top five causes of disability-adjusted living years in central and tropical Latin America, and southern Sub-Saharan Africa. 2 Trends in violence vary depending on the outcome used: decreases in violence-related mortality have been reported from 2000 to 2015, 1 whereas morbidity has remained unchanged. 1,2 Public health has moved toward a prevention model for violence, 3 and influential World Health Organization reports have focused on delineating risk factors. 4 Identifying modifiable risk factors could potentially reduce risks and assist in developing interventions. However, these reports are limited by being narrative reviews of the evidence without quantitative methods to evaluate the strength, quality and consistency of risk factors. To address limitations in previous work and provide an overview, we conducted an umbrella review of the evidence from existing systematic reviews and meta-analyses on risk factors for violence. --- Methods No specific ethical approval was required for this research as it was a synthesis of secondary data from published sources. --- Search strategy The systematic search strategy was prospectively registered on PROSPERO 5 . The original search incorporated both risk factors for violence and suicide, and this paper reports the violence search. Three databases were searched from their start dates until January 2018: PsycINFO , Medline and Global Health , supplemented by targeted searches on Google Scholar and PubMed . Keywords for violence were combined with search terms for risk factors and publications . Citations and reference lists of relevant reviews were hand-searched. Targeted searches were used to identify additional studies by first author names and specific risk factors that were not identified in our initial search . --- Study eligibility Eligible studies were meta-analyses or systematic reviews that examined risk factors for violence in the general population, and provided effect sizes and data to calculate 95% confidence intervals. We aimed to measure interpersonal violence and included a broad range of violence outcomes, such as assault, violent crime and sexual violence. Although this is a broad scope, we aimed to include only those reviews that used some measure of interpersonal violence as outcome . Published and unpublished reviews in any language were considered. Excluded studies were those with methodologies other than a meta-analysis or systematic review, such as individual casecontrol or cohort studies. As the primary research question was risk factors in the general population, reviews that investigated selected populations, such as prisoners or those with a specific diagnosis, were excluded. Reviews that focused on reoffending risks or those examined interventions for violence were also excluded. [6][7][8] If more than one eligible review was found on the same risk factor, the most recent one was included. --- Data extraction Data were extracted with a standardised form. Reported effect sizes with 95% confidence intervals were recorded with other key information. Separate effect sizes for gender, the effect size of the largest study included in each meta-analysis and the effect size for the different study designs were extracted. When these data were not recorded, we corresponded directly with authors. Extracted data were independently cross-checked by a post-doctoral researcher , and any queries were resolved by discussion with the project supervisor . --- Statistical analyses As the reporting of effect sizes varied between studies , they were converted to comparable measures. For the primary outcome, all effect sizes were converted to odds ratios . For those reported as Cohen's d, log-transformed odds ratios were calculated. 9-11 Effect sizes reported as correlation coefficients were converted first to Cohen's d and then to log-transformed odds ratios. Odds ratios were categorised as follows: weak, 1.0-1.5; moderate, 1.6-2.5; strong, 2.6-9.9 and very strong, ≥10.0. 12 --- Categorisation of risk factors and outcome measures Risk factors and outcome measures were qualitatively analysed after the search, and common categories were identified. We identified distinct categories of outcome measures that were reported separately. Meta-analyses with other related outcome measures, such as aggression and hostility, were reported as secondary outcomes in Supplementary Appendix 2. --- Population attributable risk fractions Population attributable risk fractions indicate the proportion of an outcome that would theoretically not occur in a population if a given risk factor was eliminated, assuming causality between risk factor and outcome. We estimated the proportion of cases that could be attributed to each risk factor in the general population . Although causal inferences were not possible for some risk factors, PAFs provide a measure of the maximum possible effect that each risk factor has at a population level by taking into account the risk factor's prevalence. 13 Thus, if a risk factor has a large effect size but low prevalence, its effect at a population level will be lower than a risk factor with low or moderate effect but a high prevalence. --- Tests of quality of evidence Reviews were assessed for quality by various approaches. First, we scored the Assessing the Methodological Quality of Systematic Reviews tool. 14 Scores of 0-3 are considered low, 4-7 are medium and 8-11 are high. 12 Second, we compared the effect size for the largest included study in each meta-analysis with the overall quoted meta-analysis effect size. Results where the largest included study effect size was close to the overall meta-analysis effect size were deemed to be more precise. 15 Third, we calculated ratios between overall metaanalysis effect size and that of the largest included study in each meta-analysis. A meta-analysis overall effect size/largest included study effect size ratio of more than one indicates a larger effect size in the meta-analyses compared with its largest included study, and is an indication of bias. 16 Fourth, a comparison was made between meta-analyses' overall effect size and the number of cases included in each meta-analysis , when sufficient data were available. Fifth, we assessed the relationship between study design and effect size. Where sufficient data were available, results were extracted for pooled overall effect sizes of prospective studies alone and compared with overall meta-analysis' effect sizes. Finally, we presented prediction interval calculations for risk factors. Prediction intervals provide an estimate of the ranges in which future observations will fall. Risk factors with prediction intervals that did not cross the null value were deemed to be of higher quality. Those that cross the null value suggest that they may not be significant if tested in a new population. 17 To summarise these quality tests, a scoring system was developed, which also included between-study heterogeneity and whether adequate adjustments for confounders was conducted . All analyses were performed with STATA-IC version 13. --- Results Twenty-two meta-analyses on risk factors for violence were identified. This included information from over 120 000 individuals from 1139 individual studies across 14 different countries. Risk factors were grouped into broad categories or domains of neuropsychiatric, historic and other. Because of high heterogeneity and non-comparability, results were not further pooled. The largest effect sizes for violence were found in the neuropsychiatric category , with substance misuse ranking most highly. Antisocial personality disorder had the strongest link to violence within the category of personality disorders. Some childhood and adolescent factors were important . Four meta-analyses examined parental factors that were associated with violence 20,26,31,35 . These factors included poor attachment to parents, parental incarceration, antisocial attitudes in parents and more general problems within the family. --- Intimate partner violence Six meta-analyses focused on intimate partner violence. [32][33][34][35][36][37] Two risk factors overlapped with risk factors for any interpersonal violence, namely substance misuse and exposure to violence. Other risk factors for intimate partner violence appeared to be specific to relationships, such as marital dissatisfaction and previous abuse by one partner toward the other . --- Sexual violence and homicide Two reviews provided data for risk factors for sexual violence alone, 38,39 and only one review provided separate risk estimates for homicide 21 . Risk factors for sexual violence broadly overlapped with risk factors for any interpersonal violence. Data were more limited for the homicide review although two neuropsychiatric risk factors overlapped with interpersonal violence. --- Risk factors stratified by gender Where possible, results were stratified by gender . Effect sizes for women appeared to be larger than for men for all neuropsychiatric violence risk factors. --- PAFs Although PAFs assume causality, they provide an estimate of the maximum possible effect that removing a risk factor could have, and PAFs for individual risk factors may overlap and add up to more than 100%. 40 The highest PAFs for violence were substance misuse, witnessing or being a victim of violence in childhood, and personality disorder . --- Other reviews We identified a further 13 systematic reviews and meta-analyses that provided additional information. For violence, these were for the secondary outcomes of aggression and hostility rather than interpersonal violence . Risk factors for aggression included two main themes: biological factors and witnessing violence . Negative findings included the lack of evidence for candidate genes associated with aggression in a meta-analysis and field synopsis of 185 studies of the field. 41 --- Quality assessments Despite mostly high scores on AMSTAR, other analyses found indications of poorer quality. There were small study effects and around 60% of reviews had overall effect sizes larger than the effect size quoted in each meta-analysis' largest included study . There was no statistically significant correlation between meta-analyses' overall effect size and the number of cases included in each meta-analysis, when sufficient data were available. Of the 12 included risk factors, seven were found to exclude the null value using prediction intervals . Three meta-analyses enabled investigation of study design. 21,24,25 One review, which examined being bullied as a risk factor, reported a lower pooled effect size for prospective studies . 24 Two other reviews did not find statistically significant differences by study design . Overall, using a scoring system based on quality indicators and a threshold of four or above for highquality studies, seven risk factors for violence met these criteria. None of the risk factors for intimate partner violence or sexual offending met this quality threshold . --- Discussion We have presented an overview of risk factors for interpersonal violence from 22 meta-analyses based on over 120 000 individuals. We have presented associations, PAFs and measures of evidence quality, and investigated risk factors for related outcomes of homicide, intimate partner violence and sexual offending. To our knowledge, this is the first quantitative meta-review of the field. In addition, novel features include bringing together relative risks and estimates of population effect, using tests of methodological quality to determine the strength of the underlying evidence, and the breadth of the outcomes and the ability to compare effect sizes between them. There were three principal findings. First, based on relative risk, the strongest risk factors were typically in the neuropsychiatric domain. Second, in terms of population effect, there was some overlap with factors that had the strongest relative effects, with substance use disorders, schizophrenia and personality disorders having high PAFs and relative risks. Third, the overall quality of the underlying evidence was not strong, with the majority of reviews demonstrating small study effects and large heterogeneity. By focusing on risk factors, this umbrella review has identified individual-level determinants. Socioeconomic causes of violence will rely on ecological studies that were not included. A number of implications arise from this work. First, it suggests that many important risk factors for violence are modifiable, and public health can realistically include substantial reductions globally if these factors are confirmed in treatment trials as causal. 42 Second, violence prevention strategies should incorporate guidelines and targets for the identification, assessment and treatment of psychiatric disorders. However, diagnostic categories themselves are not sole treatment goals, and active symptoms and comorbidities, which mediate the above-reported associations with violence, should also be targeted. Our findings challenge the current view of criminology as a field that appears to under-recognise mental health in the aetiology of violent crime. 43 In contrast, this umbrella review found no relevant meta-analyses that were among the top five risk factors in terms of quality for socioeconomic variables, and only one for a psychosocial factor . One possible explanation is that the focus of many included reviews were neuropsychiatric conditions rather than socioeconomic factors. In addition, within the former, the variation in socioeconomic factors is limited, and thus studying their effects will require more general population samples. At the same time, it should be noted that criminal history variables are among the strongest for individuals with psychiatric Scores: Prediction interval excluding null value = 1; P-value <0.05 for random effects model = 1; low heterogeneity = 1; number of cases > 1000 = 1; no evidence to suggest small study effects = 1; confounders adjusted for = 1. disorders, underscoring the need to strengthen the relationship between criminal justice and mental health services to manage future risks. Third, on a population level, antisocial personality disorder is an important risk factor for violence, and more research on links between such disorders and these outcomes is warranted. Although little evidence exists to suggest that the underlying personality disorders are treatable, some common symptoms arising from them are modifiable. 44 Another risk factor identified, which has been less widely discussed, is witnessing or being a victim of violence in childhood. The mechanism for how this contributes to adult violence perpetration needs examination, and may provide targets for intervention. Nevertheless, it suggests that interventions in childhood and adolescence for antisocial behaviour should consider any such history and broaden treatments for victims to include children who have witnessed violence. Finally, research should focus on longitudinal studies, investigate sources of heterogeneity and improve adjustment for confounding. Sibling controls are one powerful approach to do so, 45 and can provide important evidence as they account for familial confounding . Ultimately, strong evidence of causal inference for identified risk factors will need to be tested in trials. However, many trials in this area may not be feasible for practical and ethical reasons, and quasi-experimental designs will play an important role in developing the evidence base. Limitations of the current meta-review include the possibility that the included meta-analyses have been superseded by more recent, high-quality individual studies. For example, the reviews on traumatic brain injury and schizophrenia are from 2009. 21,22 However, both of these have been confirmed by more recent, large population-based studies. 46 In relation to traumatic brain injury, a large Swedish population and sibling comparison investigation found robust links with violent crime after adjustment for sociodemographic confounders, 47 and an Australian study also found a link when violent crime was used as an outcome . 48 In addition, how violence was operationalised was necessarily heterogeneous, reflecting the lack of a consensus in the field for the best outcome. 49 Importantly, although these will alter prevalence of outcomes, they does not appear to affect risk estimates as the prevalence of outcomes is consistently reported in the cases and general population controls. How might treatment reduce violence? One approach is simply to target and treat underlying psychiatric disorders as well as symptoms and other mediators of risk. Randomised controlled trials provide little evidence for this approach as they are not usually powered or designed to investigate rare outcomes. Observational data provide stronger support for antipsychotic medication reducing violence risk, 50 and are important sources of evidence when randomised controlled trials are not feasible. For example, clozapine may have specific violence-reducing effects 51 and psychological therapies that specifically target aggression could also be considered. There is some evidence for structured group therapy in drug-using offenders to prevent reoffending. 52 Screening for violence risk in selected populations 53 needs further research to clarify its potential role, including use of trial methodology. Targeting high-risk groups, such as released prisoners and individuals with antisocial personality disorder, should be prioritised for future intervention research. Treatments in childhood and adolescence require improvement. 54 In addition, preventative approaches should be developed to address the potential importance of the two childhood risk factors that we have identified: being bullied and witnessing or experiencing violence.

Interpersonal violence is a leading cause of morbidity and mortality. The strength and population effect of modifiable risk factors for interpersonal violence, and the quality of the research evidence is not known.We aimed to examine the strength and population effect of modifiable risk factors for interpersonal violence, and the quality and reproducibility of the research evidence.We conducted an umbrella review of systematic reviews and meta-analyses of risk factors for interpersonal violence. A systematic search was conducted to identify systematic reviews and meta-analyses in general population samples. Effect sizes were extracted, converted into odds ratios and synthesised, and population attributable risk fractions (PAF) were calculated. Quality analyses were performed, including of small study effects, adjustment for confounders and heterogeneity. Secondary analyses for aggression, intimate partner violence and homicide were conducted, and systematic reviews (without meta-analyses) were summarised.We identified 22 meta-analyses reporting on risk factors for interpersonal violence. Neuropsychiatric disorders were among the strongest in relative and absolute terms. The neuropsychiatric risk factor that had the largest effect at a population level were substance use disorders, with a PAF of 14.8% (95% CI 9.0-21.6%), and the most important historical factor was witnessing or being a victim of violence in childhood (PAF = 12.2%, 95% CI 6.5-17.4%). There was evidence of small study effects and large heterogeneity.National strategies for the prevention of interpersonal violence may need to review policies concerning the identification and treatment of modifiable risk factors.

intensive and thus reserved for the elite . From one population to another, from one level of wealth to another, humans will cope with resources that are often far below what technology can offer. The least resource-intensive systems will be the most used. While the development costs of a chatbot equipped with medical expertise may seem prohibitive , their occasional use by individuals incurs minimal costs. Access to medical expertise is about to become universal. The question of whether this will include the use of sensors interfaced with or embedded in mobile phones is unclear in the short term. Today, validated technologies are relatively few [Majumder 2019]. They utilize cameras, LEDs, and mobility sensors to measure heart rate and variability, to examine the retina, or to identify skin lesions requiring special attention. No other technologies, particularly biochemical ones, have proven themselves in this format to date, and research on smartphone-controlled microfluidic systems has not yet led to mainstream applications. Even without these sensors, in a context of a dwindling number of healthcare providers, the development and generalization of automatic consultation is inevitable. It will likely be widely shared worldwide, similar to the rapid, global dissemination of mobile telephony, a complex technology that has reached even the most remote parts of the globe. This inevitable evolution is already taking place in a liberalized environment. While the illegal practice of medicine used to be subject to control, and sometimes to repressive action, the necessary structures are not in place today to guarantee the dissemination of harmless, reliable solutions. The strategy adopted by Open AI is symptomatic of this challenge, since its chatbot systematically responds to any medical question by saying that a specialist opinion should be taken, and is not capable of providing medical advice. Establishing a shared quality assurance system, therefore, emerges as a crucial priority. Another pressing issue concerns the role of empathy in healthcare. What will be the consequences of the diminishing human contact in patient care? This question is pertinent: Will synthetic empathy be capable of substituting for human empathy in patient care [Perry 2023]? While this query may sound thought-provoking, it is equally important to be concerned about the existing challenges patients face in accessing empathetic caregivers for meaningful conversations. --- Statements and Declarations --- Authors' contribution Emmanuel Lagarde is the only contributor to this manuscript. --- --- Role of Funding Source Emmanuel Lagarde is employed by INSERM, a French governmental biomedical research agency. No other funding source was involved in the preparation of this manuscript.

The emergence of artificial intelligence in healthcare is probably leading to another two-speed world. On one hand, widely accessible AI applications such as language models are becoming ubiquitous, while on the other, resourceintensive technologies like robotic surgery and personalized medicine will be reserved for a privileged few. This development signifies a growing disparity in access to AI advancements. In this context, the role of empathy and emotional aspects in patient care comes to the forefront. With the rise of AI, there's a critical examination of whether synthetic empathy can adequately replace human empathy in patient care, emphasizing the necessity of maintaining human elements in an increasingly automated healthcare environment.

Introduction Currently, the state and prospects of the healthcare industry are among the top-priority issues in European countries. Socially oriented states involve the parallel development of the economic, political, and modern technological sectors, as well as the efficiency and quality of the medical sector, to improve the population's quality of life. The quality of life and health of its people constitute an indicator of the success and competitiveness of a country. Therefore, the attention of states and societies is focused on the sustainable development of the medical system to make it able to respond flexibly and adapt to new complex and large-scale challenges. In recent years, there has been significant progress in the health systems of European countries. Ensuring the proper quality of medical care is one of the main tasks of the transformation processes of European states. However, some states have many questions about the medical industry. This requires strengthening national health systems and developing policies and strategies for medical systems at the level of certain countries. In response to modern challenges related to human health threats, relevant officials are constantly monitoring, evaluating, and developing progressive health policies in all European countries. These policies will allow for adapting medical services to the population's needs, identifying the latest priorities in the rapidly changing and difficult financial and economic situation, choosing the best medical technologies, and regulating the balance between therapeutic and preventive measures. Health authorities strive to improve the efficiency of the health system to improve people's health and meet the growing expectations of public satisfaction with medical services. In turn, improving and regulating the medical system and the quality of medical services requires understanding the indicators used to measure and evaluate the healthcare system. Currently, there are many qualitative and quantitative indicators for measuring various health system characteristics used in countries worldwide. Such key indicators for each country may differ significantly, depending on the socio-economic and political development of the country. Therefore, it is essential to define the most relevant indicators of each country and why it is necessary to introduce and ensure international world standards of the healthcare system to be able to compare and analyze the experiences of advanced countries around the world in this matter in the future. It should be noted that health scientists within countries identify certain official sets of indicators with different balances of the key aspects used by the state regulatory authorities in the medical fields of their specifc country. The following scientists have studied the development, research, analysis, and monitoring of the dimension indicators of the health care system: Beaussier A. et al. [1] highlighted indicators of health care quality measurement; Khan S. et al. [2] explored public health indicators; Gartner J. et al. [3] reviewed key health performance indicators; Labella B. et al. [4] calculate patient safety indicators; and Carini E. et al. [5] evaluated the performance indicators of medical institutions, etc. Other notable publications include Lyeonov S. et al. [6], Tiutiunyk I. V. et al. [7], Smiianov V. A. et al. [8], Aliyeva Z. [9], Kolosok S. et al. [10], Piven D. et al. [11], Shipko A. et al. [12], Strangfeldova J. et al. [13], Privara A. [14], and Ivankova V. et al. [15]. The peculiarities of the formation of the integral health care system indicators are reflected in the scientific studies of the following scientists: Stelzer D. et al. [16] suggest the use a regional integrated health care model "Healthy Kinzigtal" using quality indicators for optimizing health care and economic efficiency, and van den Akker E. F. M. M. et al. [17] describe the development and implementation of a comprehensive integral assessment approach to health status in patients, etc. Particular attention should be paid to the paper by Vasilyeva T. et al. [18] on the formation of integral indicators of the socio-political and economic situation in a country for the assessment of the dynamics of bifurcation transformations in the economy. Cabinova V. et al. [19] is another noteworthy source on the topic. It is also worth researching the degree of satisfaction with medical services. This issue is quite specific and has mixed coverage in the scientific literature. However, the following specialists are engaged in particular approaches to this topic: Baranska A. et al. [20] conducted an assessment of the level of satisfaction with medical care among patients as an indicator of the quality of medical care; Vitale E. et al. [21] investigated the satisfaction level of the population regarding health care during the COVID-19 pandemic; Man E. et al. [22] defined patient satisfaction with private recovery services during the COVID-19 pandemic; Ren L. et al. [23] presented a survey on the cross-sectional degree of consumer community satisfaction with the primary care system; Lee Y. et al. [24] studied the subjective frame of patient satisfaction with the comprehensive nursing service; Smith et al. [25] tested the Determinants of Hospital Service Quality; and Carmo Caccia-Bava M. et al. [26] revealed important factors for success in hospitals. Other notable publications on this topic include Probst D.T. et al. [27], Louis R. [28], Lesniewski, M.A. [29], Mrabet S. et al. [30], Gavurova B. et al. [31], Zaharia R. et al. [32], Gavurova B. et al. [33]., Halicka K. et al. [34], Rosenberg D. et al. [35], and Zain N.A.M. et al. [36]. Studying the scientific achievements of scientists regarding the research methods used in world practice, we note that factor analysis is one of the most common methods used in scientific research, as evidenced by information from the Scopus database, 3,664,361 publications on the topic. Moreover, factor analysis is most often used by specialists in the field of medicine, and publications in this field account for 49.06% of the total volume of published papers indexed in Scopus related to factor analysis. Using this research method, healthcare scientists have solved some complex analytical problems, such as machine methods of risk factor analysis and prediction of epidemiological studies proposed by Tran V. et al. [37]; a factor analysis study on the public's perspectives of qualities and behaviors a good doctor by Grundnig J. S. et al. [38]; and many others. Zhang L. et al. [39], Kuzior A. et al. [40], Rajan D. [41], Awojobi O.N. [42], Hinrichs G. et al. [43], and Kadar B. et al. [44] are other notable works employing factor analysis. Social sciences researchers also use the factor analysis method in their work . The paper by Vasilyeva T. et al. [45][46][47], regarding the use of factor analysis as one of the methods in modeling social and economic patterns associated with the COVID-19 pandemic, arouses particular interest. Researchers from other scientific fields also widely use factor analysis in their works . Considerable attention should be paid to the works of the following scientists using the elements of factor analysis: Kuzmenko O. V. et al. [48], regarding an approach to managing innovation to protect the financial sector against cybercrime, and Kuzmenko O. V. et al. [49] who employed factor analysis in the economic modeling to determine the influence of relevant indicators of gender policy on the efficiency of a banking system. Other notable papers in this regard include Didenko, I. et al. [50]; Brychko M. et al. [51]; Dao L.T. et al. [52]; Streimikiene D. [53]; Coman I. et al. [54]; Uslu A. et al. [55]; Ibe R. et al. [56]; and Quinonez Tapia F. et al. [57]. According to the Scopus database, scientists widely use descriptive analysis in many branches of science . Descriptive analysis is most commonly used in health system research-60.90% of the total number of publications related to descriptive analysis indexed in Scopus were from health system research . Thus, modern healthcare scientists suggest studying various issues using the descriptive analysis method. For example, Riediger N. D. et al. [58] used descriptive analysis of food pantries in twelve American states; Taljaard L. et al. [59] conducted a descriptive analysis of the case mix in East London, South Africa; Bayou N. B. et al. [60] used a descriptive structural analysis of quality of labor and delivery care in Ethiopia; and Wylie C. A. et al. [61] described a retrospective descriptive analysis. Descriptive analysis is also very often used in social sciences . Scientists in this field are currently studying some aspects based on descriptive analysis, which include a descriptive analysis of complaints related to COVID-19 in California by Thomas M. D. et al. [62]; a descriptive qualitative analysis of older adults' accounts in Chile by Shura R. et al. [63]; and others such as Njegovanovic A. [64], Sarihasan I. et al. [65], Pop R.-A. et al. [66], Dai X. et al. [67], Xuechang Zhu et al. [68], Halina Waniak-Michalak et al. [69], and Zaharia R. M. et al. [70]. Other scientific fields account for 20.54% of scientific publications in the Scopus database related to descriptive analysis. Lyeonov S. et al. [71] used descriptive analysis during the implementation of gravitational and intellectual data analysis to assess the money laundering risk of financial institutions, as well as Tommaso F. D. [72], Gallo P. et al. [73], Barrientos-Baez A. et al. [74], Alshoubaki H. et al. [75], Vysochan O. et al. [76], Belascu L. et al. [77], Kramarova K., Svabova L. et al. [78], Wildowicz-Szumarska A. [79], Blazevic Bognar Z. et al. [80], Loi N. T. N. [81], and Capolupo N. et al. [82]. The use of the canonical analysis toolkit is three times less than that of descriptive analysis, but it still attracts considerable interest among scientists . Most often, biochemistry, genetics, and molecular biology specialists use canonical analysis in their research . In contrast to descriptive analysis, canonical analysis is less used in Medicine and Social Sciences . The following works using canonical analysis deserve attention: a new insight from canonical correlation analysis when determining the relationship between the quality of work of medical professionals was presented by Wang W. et al. [83]; canonical correlation analysis of factors that influence the quality of life among patients was carried out by Liu Y. et al. [84]; the combination of canonical correlation analysis and holo-Hilbert spectral analysis was used by Lee P. et al. [85]; a canonical correlation analysis for testing the specificity of environmental risk factors for development was used by Bignardi G. et al. [86]; and canonical correlation analysis was applied in determining relationships between anthropometric variables by Malakar B. et al. [87]. Other notable uses of canonical analysis include Lyeonov S. V. et al. [88] and Gavurova B. et al. [89]. The aim of this study is to conduct a theoretical analysis and qualitative and quantitative assessments of indicators by developing an integral indicator in the context of behavioral, social, demographic, and economic factors that characterize the level of healthcare system development in European countries using multivariate statistical modeling methods. Thus, the theoretical basis of the main constructions of the research model is based on well-known and proven methods of this branch of science, namely, cluster analysis , factor analysis , descriptive analysis, and canonical analysis [83][84][85][86][87][88][89]. It is also based on previous authors' research [46,47,90], although these sources have not yet been properly disseminated in the field of health protection and have not been applied in the proposed integrated form of modeling. Considering the existing threats to human health and, accordingly, the associated problems in the organization and functioning of health systems, this study will address such gaps in the knowledge of the health system as: imperfections and gaps in the complex assessment of the level of healthcare system development in terms of some important behavioral, social, demographic, and economic factors not being used in the work of specialists in this industry while characterizing the level of healthcare system development in European countries; imperfections in the existing integrated indicators of the health system, which do not take into account many of the relevant factors; the lack of effective methods and approaches for assessing the level of health systems in European countries. --- Materials and Methods The study was implemented in three stages based on the World Bank indicators for European countries from 2000 to 2020 using Statistica 10 and Statistica Portable statistical packages. When conducting the study, the following restrictions were imposed for the study countries: in the first stage of the study, 42 European countries were selected from all countries of the world, 10 of which were studied in the second and third stages, selected by cluster analysis; for the study period, years from 2000 to 2020 were used. Stage 1 of the study included the formation and modeling of the statistical base of the study using descriptive analysis and applying the Statistica 10 and Statistica Portable statistical packages. To build models that would help establish the influence of certain factors on the indicator of the level of healthcare system development in European countries, it was proposed to define four groups of indicators according to the following constituent features: behavioral, social, demographic, and economic. The information base of the study is based on the World Bank indicators, which determine the public health system's behavioral, social, and demographic features in conjunction with the economic aspect. The source of the research data is the World Bank database-a reliable database of statistical data created by specialists at the World Bank. The formation and dissemination of this database are based on internationally accepted professional standards. The World Bank also cooperates with the international scientific and statistical community, namely, UN agencies, the Organization for Economic Cooperation and Development, the International Monetary Fund, and regional development banks. The World Bank ensures that all data in its database are high-quality and complete. The selection of European countries for the study was based on cluster analysis [91], which was conducted using Statistica 10 and Statistica Portable. The clustering of countries was based on iterative divisional k-means clustering. Four key indicators were initially selected as a statistical base for the further clustering of countries. Then, cluster analysis verified the adequacy of dividing 42 European countries into groups. To evaluate and compare clusters, we used variance analysis to select clusters 3, 4, and 5. At the descriptive analysis stage of throughput indicators, the values of the intergroup variances and intragroup variances of these characteristics, the value of the Fisher criterion , and the probability of a possible rejection of the null hypothesis were determined to indicate the adequacy of clustering. We used the the "Multivariate Exploratory Techniques"-"Canonical Analysis" package of the Statistica toolkit at this stage, where k means clustering -i.e., the analysis of variation -was used to directly identify specific groups of countries that are typical of their characteristics. Stage 2 of the study involved the determination of the degree and significance of the interrelations between the components characterizing indicators selected for the integral indicator's construction of the level of healthcare system development in European countries using canonical analysis. This stage involves causal analysis, i.e., identifying which groups of indicators are the causes of the issue under study and which are the consequences. Thus, canonical analysis makes it possible to reduce a multidimensional set of characteristic features to a narrower concentrated system consisting of pairs of elements that are the most correlated with each other. This procedure allows for a statistical assessment of the significance and relationships of the studied features. Mathematically, the primary purpose of canonical analysis involves determining the correlation of weighted sums, linear combinations called "canonical variables", from each possible set of characteristics that make up causal and effective features. The procedure for implementing canonical analysis uses the Statistica 10 and Statistica Portable packages. This approach makes it possible to obtain a processed standardized source base of easy-toanalyze tabular data . In the above Table , x ≥ y, x is the number of system attributes in the first equation from the first group, and y is the number of system attributes in the first equation from the second group. The estimation of the relationship between canonical variables H and F is described in Formula : H = p 1 a 1 + p 2 a 2 + . . . + p x a x F = q 1 b 1 + q 2 b 2 + . . . + q y b y where p i , i = 1, x , q j , j = 1, y are the corresponding weights of coefficients calculated when solving a problem with eigenvalues. Moreover, the change in these weights de-termines the difference in the value of canonical variables and the canonical correlation coefficient k ). In turn, the canonical correlation coefficient evaluates the dependence of two variables and determines the density of the dependence between canonical variables: k = cov varvar The significance of correlation dependence is assessed using a standard statistical criterion υ and the standard statistical confidence interval. Moreover, a higher significance level value corresponds to a lower level of trust. Statistica 10 and Statistica Portable software tools were used to implement canonical analysis. Initially, panel data were generated as a table of input data for the period for 10 European countries selected according to cluster analysis. Next, the dependence between groups of indicators was alternately determined in six tables by applying the function "Multivariate Exploratory Techniques"-"Canonical Analysis". Based on the generated data, we first checked the adequacy of the analysis. At this stage of the canonical analysis, the bandwidth indicators are as follows: R is the canonical correlation coefficient showing the strength and direction of the relationship between groups of indicators ; Chi 2 is the adequacy criterion ; P is the probability of rejecting the hypothesis that there is no relationship between groups of indicators ; and the total redundancy, which shows how much the variation of one group is explained by the variation of another group and shows which group of indicators' % total redundancy is greater, where the group of indicators is a consequence. Stage 3 of the study involves determining relevant indicators for assessing the level of healthcare system development in European countries , as well as the construction of an integral indicator of the level of healthcare system development in European countries. Factor analysis was performed using the principal component method. The selected type of factor analysis, i.e., principal components, is a mathematically based methodology that identifies relevant indicators and their structures, determines hidden indicators, establishes statistical relationships, and excludes non-influential indicators to simplify the analysis results. Factor analysis involves a simple logical construction of a generalization of the values of certain features and replaces correlated measures with uncorrelated factors. According to the method of principal components, the main components and generalized features are distinguished from the input indicators. Moreover, the mathematical model of the principal components method implies a logical assumption that a certain general result is produced from a set of interrelated features. Modeling according to this method provides the following [92] ): - The beginning of the construction of the matrix of input indicators ; -Formation of a matrix of standardized values ; -Formation of the matrix of pair correlations ; -Formation of a diagonal matrix of eigenvalues , a matrix of unnormalized vectors , matrices of normalized vectors , and calculation of the contribution of variable indicators; - The formed matrix of the factor expression and the matrix of principal components , as well as the values of the factors that allow determining the relevant factors and their weighting coefficients. Based on the weighting coefficients of the relevant factors, the weighted influence of the indicators under consideration is determined: R → S → K → D N → V → F → Q Therefore, the method of principal components involves constructing a factor space in which variables and observations are simultaneously classified to form the principal components. A vector space of variables and observations is constructed. A matrix of correlations or covariances is formed to obtain a new system of uncorrelated variables, that is, principal components. Principal components are formed as linear combinations of initial variables. That is, the input variables are transformed into new variables . Factor analysis is implemented using the Statistica 10 and Statistica Portable software packages, using the "Multivariate Exploratory Techniques" function "Principal Components and Classification Analysis". The factor analysis was based on input data sampling, where panel data were taken as input data in the form of a table of initial data for the period from 2000 to 2020 for 10 European countries selected according to cluster analysis . Within the framework of this stage, the principal components method was used to substantiate the expediency of considering the most influential ones that have the greatest weight in the group when assessing the level of development of the healthcare system in European countries. All four social, demographic, economic, and behavioral groups of selected indicators were used for further analysis at this stage. However, according to the results of the canonical analysis, special attention is paid to groups of social and demographic indicators that significantly impact other groups of indicators. To assess the level of healthcare system development in European countries, based on the data of indicators, a scree plot of eigenvalues of the correlation matrix of the input data was built using the "Multivariate Exploratory Techniques", "Principal Components and Classification Analysis", and "Scree plot" functions. "Multivariate Exploratory Techniques", "Principal Components and Classification Analysis", and "Eigenvalues" functions were used to form a table of eigenvalues of the correlation matrix and to derive statistical indicators of the group to assess the level of healthcare system development in European countries. Conducting the eigenvalues analysis of the correlation matrix of the input data indicators for assessing the level of healthcare system development of European countries confirms that the first three factors determine the relevant indicators because, together, they account for at least 70% of the variation of the resulting characteristic. Then, using the "Multivariate Exploratory Techniques", "Principal Components and Classification Analysis", and "Contributions" functions, we attain variable indicators of the group to assess the level of healthcare system development in European countries. The Table named "Intermediate values for the calculation of the relevance of indicators of the group for assessing the level of development of the healthcare system of European countries" was formed based on the eigenvalues of the correlation matrix of the input data to assess the level of healthcare system development of European countries considering the first three factors and the contribution of the variables. The information in this Table depicts the logic of calculating the arithmetic mean of the weighted impact of social indicators for assessing the level of healthcare system development in European countries on the value of this level by calculating the sum of the products of the weight coefficients of the factors, i.e., the eigenvalues of the correlation matrix of the input base of the selected factors. As a result of calculations, the values of the column "weighted impact of indicators" in Table 2 are obtained. That is, a weighted impact of indicators is obtained at the stage of the factor analysis of throughput indicators. To define an integral indicator of the level of healthcare system development of European countries, we emphasize that a qualitative description of the structure of the studied healthcare system in terms of determining the level of healthcare system development of European countries requires the development of an integral indicator, either using all the main components or a large enough quantity for analysis. Thus, we use the values of all indicators. Initially, disincentives are reduced to a comparable form of disincentives as a unit divided by the disincentive. After that, the input data are standardized using the Statistica 10 and Statistica Portable software tools using the "Data"-"Standardize" function. Furthermore, to define the integral indicator of the level of healthcare system development in European countries, we carry out a convolution procedure that allows us tp calculate the integral indicators for each group in the context of each year as well as the general integral indicator for each year ) : R T = ∑ f i m ∏ i=1 S f i i , where R T is an integral indicator of the level of healthcare system development of European countries; ∑ f i is the sum of the frequencies; f i is the frequency of the studied value for the i-indicator; S i is the studied indicator . From an economic point of view, the interpretation of the calculations is as follows: the higher the value of the calculated integral indicators, the better the level of healthcare system development. The overall integral indicators take values from 0 to 1. In the factor analysis stage, the integral indicators for each group in the context of each year and the general integral indicator of the level of development of the European countries' healthcare systems each year are output. The performance indicators include the arithmetic means by year in the context of each country and by country in the context of each year. --- Results In the first stage, the statistical base of the study was formed and modeled in the form of four groups of indicators, behavioral, social, demographic, and economic, using descriptive analysis. A group of 10 European countries was identified using a cluster analysis based on the application of an iterative divisive k-means method. Multiple units of indicators are determined by the factor analysis of indicators separately for each group in the context of each of the 10 European countries for each year of study . Evaluation indicators were selected for the period from 2000 to 2020. Thus, in the proposed modeling package, the following statistical data were selected to implement quantitative formalization and as indicators to be input intothe models: Economic indicators : Incentives: E0-GDP per capita ; E1-Government expenditure on education, total ; E2-Government expenditure per student, territory ; E4-Research and development expenditure ; E5-GNI per capita, Atlas method . Disincentive: E3-Poverty gap at USD 1.90 a day . Ten European countries were selected for the study: Austria, Belgium, Germany, Denmark, Finland, France, the United Kingdom, the Netherlands, Norway, and Sweden. Four key indicators were initially selected as a statistical basis for further clustering of countries: behavioral-B0 ); social-S0 ); demographic-D0 ); and economic-E0 ). An aalysis of the results of the clustering of European countries into three, four, and five clusters determined the adequacy of the three-cluster grouping of countries . Thus, three separate clusters were identified containing a grouping of European countries according to the selected key indicators in a systematic graphical form, indicating the number of member countries of each cluster. Euclidean distances from the grouping center as the defining metric of this type of grouping of European countries. Analyzing the clusters of European countries shows that the grouping fully corresponds to the overall level of development of the public health system in countries from the same cluster. Thus, the smallest cluster includes three countries, the average-sized cluster includes 10 countries, and the largest includes 29 countries. According to the number, composition, socio-economic development, and best practices of the countries in the groups, the second cluster was selected to define the countries for the study: Austria, Belgium, Germany, Denmark, Finland, France, the United Kingdom, the Netherlands, Norway, and Sweden. In the second stage, the degree and significance of the interrelations between the components characterizing the studied groups of indicators were determined using canonical correlations that form an indicator of the level of healthcare system development in European countries. Panel data were generated as a table of input data for the period from 2000 to 2020 for 10 European countries selected according to cluster analysis . The dependence between groups of indicators was alternately determined in the form of six tables : behavioral-social, behavioral-demographic, social-economic, demographic-economic, social-demographic, and behavioral-economic. The data analysis shown in Table 5 determined, first of all, that the analysis is adequate since the value of the canonical correlation coefficient is R = 0.96512, which is close to 1, the value of the adequacy criteria Chi 2 = 1180 is large enough to aim for infinity, and the value of the probability of the deviation of the hypothesis p = 0.0000 tends to 0. Similarly, the adequacy of the analysis is confirmed in other cases in this study . Second, the total redundancy for groups of behavioral indicators is 60.1847% and is 43.9606%for groups of social indicators, which indicates the existence of a relationship between behavioral and social groups of indicators, that is, an average influence of the group of social indicators on the group of behavioral indicators . The analysis of indicators in Table 6 also indicates that there are average-strength relationships between groups of behavioral-demographic indicators and social-economic indicators . The analysis of indicators in Table 7 indicates that there is a weak relationship between the groups of demographic and economic indicators. In Table 7, the total redundancy for the demographic indicator group is 31.4496% and is 48.3923% for the economic indicator group, i.e., economic indicators depend on demographic indicators, where demographic indicators are the cause and economic indicators are the consequence. Special attention should be paid to the analysis of indicators in Table 8, which indicates that there is a strong relationship between groups of social and demographic indicators. In Table 8, the total redundancy for the group of social indicators is 69.9279% and is 72.7378% for the group of demographic indicators, i.e., demographic indicators depend on social indicators, where social indicators are the cause and demographic indicators are the consequence. According to the indicators of Table 9 , it is concluded that the relationship between the groups of behavioral and economic indicators is either a two-way relationship, where behavioral indicators affect the economic ones and the economic indicators affect behavioral ones, or the data should be taken with a time lag. Thus, we emphasize that special attention in further research should be paid to the groups of social and demographic indicators, which, according to canonical analysis, are indicators and causes that significantly impact the corresponding groups of indicators. The third stage of factor modeling, conducted by applying the analysis of the principal components, made it possible to determine the relevant indicators for assessing the level of development of the healthcare system in European countries, allowing us to build which were the integral indicators. Thus, a scree plot of the eigenvalues of the correlation matrix of the input data was built to assess the social data of the level of healthcare system development in Europe in the context of Austria, Belgium, Germany, Denmark, Finland, France, the United Kingdom, the Netherlands, Norway, and Sweden. We formed a table of eigenvalues of the correlation matrix and derived statistical indicators of the social group to assess the level of healthcare system development in European countries ( Thus, we emphasize that special attention in further research should be paid to the groups of social and demographic indicators, which, according to canonical analysis, are indicators and causes that significantly impact the corresponding groups of indicators. The third stage of factor modeling, conducted by applying the analysis of the principal components, made it possible to determine the relevant indicators for assessing the level of development of the healthcare system in European countries, allowing us to build which were the integral indicators. Thus, a scree plot of the eigenvalues of the correlation matrix of the input data was built to assess the social data of the level of healthcare system development in Europe in the context of Austria, Belgium, Germany, Denmark, Finland, France, the Similarly, scree plots of the eigenvalues of the correlation matrix of the input data of the groups of demographic, economic, and behavioral indicators have been built to assess the level of the healthcare system development in European countries ; the "Multivariate Exploratory Techniques", "Principal Components and Classification Analysis", and "Eigenvalues" functions were used to form a table of eigenvalues of the correlation matrix and derive statistical demographic, economic, and behavioral indicators to assess the level of healthcare system development in European countries ; the "Multivariate Exploratory Techniques", "Principal Components and Classification Analysis", and "Eigenvalues" functions were used to form a table of eigenvalues of the correlation matrix and derive statistical demographic, economic, and behavioral indicators to assess the level of healthcare system development in European countries . An analysis of the eigenvalues of the correlation matrix of the input data in the indicators of the social group for assessing the level of the healthcare system development in European countries provides an opportunity to confirm that the first three factors should be taken to define the relevant indicators . These factors are as follows: factor 1-38.52%; factor 2-22.99%; and factor 3 -10.77%. Then, we form a table of variable indicators of the social group to assess the level of healthcare system development in European countries . Like the indicators of the social group, the relevant indicators for each group of indicators were determined, and the contribution of variables for evaluating the level of healthcare system development in European countries was determined for each group of indicators . Next, intermediate values were obtained to calculate the relevance of indicators in the social group in assessing the level of healthcare system development in European countries . Similarly to the social group, intermediate values for calculating relevance for each group of indicators were obtained . Thus, based on the data in Tables 14151617, we can conclude that among the indicators of the social group, the most important indicators with the greatest impact on the formation of an effective indicator of the level of healthcare system development in European countries are as follows: S6-Mortality rate, infant and S8-Mortality rate, under 5 , accounting for11% of the total impact in the group; S1-Birth rate, crude and S7-Mortality rate, neonatal , accounting for 10% each. Indicators with an average impact are: S4-Maternal mortality ratio , S9-Prevalence of anemia among children , and S10-Fertility rate, total , accounting for 9% of the total impact in the group each; S3-Incidence of tuberculosis and S5-Mortality caused by road traffic injury , accounting for 8% each; and S0-Population growth , accounting for 7%. The least important indicators are S2-Death rate, crude , accounting for 5%, and S11-Population, total, accounting for 3%. The demographic indicators with the greatest influence on the formation of an effective indicator are as follows: D0-Age dependency ratio and D4-Population ages 15-64 , accounting for 13% of total influence in the group; D3-Life expectancy at birth, male , D6-Population, female , and D7-Refugee population by country or territory of asylum, accounting for 12% each. Indicators with an average impact are: D5-Population ages 65 and above and D8-Refugee population by country or territory of origin, accounting for 11% of the total impact in the group; D2-Life expectancy at birth, female , accounting for 10%. The least important indicator is D1-Adolescent fertility rate (births per 1000 women ages [15][16][17][18][19], accounting for 7%. The economic indicators with the greatest impact on the formation of an effective indicator are as follows: E5-GNI per capita, Atlas method , accounting for 20% of the total impact in the group; E0-GDP per capita and E3-Poverty gap at USD 1.90 a day , accounting for 19% each; and E1-Government expenditure on education, total , accounting for 17%. E2-Government expenditure per student, territory had an average impact, accounting for 14% of the total impact in the group. The least important indicator is E4-Research and development expenditure , accounting for 11%. The behavioural indicators with the greatest impact on the formation of an effective indicator are: B1-Hospital beds , accounting for 21% of the total impact in the group; B2-Immunization, DPT , B3-Immunization, measles , and B0-Life expectancy at birth, total , accounting for 20% each. E1-B4-Risk of catastrophic expenditure for surgical care had an average impact; indicators with no impact were not detected among the behavioral group. We propose that the most influential indicators should be considered in further studies. Disincentives were reduced to a comparable form. After, the input data were standardized . Each country's integral indicators are calculated separately each year , as well as arithmetic mean by year in the context of countries and by country in the context of years. The economic interpretation of the calculations performed for the group of integral social indicators shows that the following countries have the highest average values of integral social indicators according to Table 19: Norway 0.75, the United Kingdom 0.73, Finland 0.67. These values indicate the best states of social indicators that determine the level of health system development in countries. Average values were found for Germany 0.59, France 0.54, and Sweden 0.54. . The lowest, but not critical, values are observed for the Netherlands-0.46; Belgium-0.45; Austria-0.44; and Denmark-0.4, indicating shortcomings in the state of social indicators for these countries, which requires additional attention. For the group of integral demographic indicators that act both as results and as factors influencing the functioning of the health system, the economic interpretation of calculations shows that, according to Table 20, the largest average values are observed for Germany 0.64, Finland 0.62, and Denmark 0.61; these values indicate the best state of demographic indicators that determine the level of health system development in the studied countries. Average values were found for the countries France , Austria , and Sweden , and below average values were found for the Netherlands , Norway , and the United Kingdom . It should be noted that, among these countries, the countries with the highest levels of the integral indicators in recent years were France and Sweden , which indicates a particularly positive trend in these countries. The average values of integral demographic indicators are confirmed by the average values of these indicators in recent years and their relatively positive dynamics: the Netherlands for 2020-0.50; Norway for 2020-0.41. However, this indicator for Austria for 2020 was 0.22, and 0.21 for the United Kingdom thus indicating unstable dynamics and existing problematic aspects. The lowest value was found in Belgium at 0.36, which shows shortcomings in the state of demographic indicators, requiring additional attention. For a group of integral economic indicators that act both as factors of influence and as a result of the functioning of the health system, the economic interpretation of the calculations shows that, according to Table 21, the largest average value of the integral economic indicator is observed for Norway at 1.01. High values are observed in Denmark , Sweden , the United Kingdom , and the Netherlands ; these values indicate the best state of economic indicators that determine the level of health system development in the studied countries. An average value is observed for France , and below average for Austria , Finland , and Germany . The lowest value indicates shortcomings in the state of economic indicators, which requires additional attention. The economic interpretation of the calculations performed for the group of integral behavioral indicators, which act both as results and as factors influencing the functioning of the health system, shows that, according to Table 22, the highest average value of the integral behavioral indicator was found in Austria High values were observed in France , Sweden , Finland , Denmark , and the United Kingdom , which indicates the best state of behavioral indicators that determine the level of healthcare system development in the studied countries. Average values are observed for Germany at 0.58, Belgium at 0.58 . The lowest, but not critical, values are observed for the Netherlands at 0.48 and Norway at 0.46, which indicate shortcomings in the state of social indicators, requiring additional attention. However, we note the positive dynamics for Norway, the highest indicator for 2020 being 0.79. The general integral indicators are derived together for all countries' indicators each year, as well as by the arithmetic mean for years in the context of countries and for countries in the context of years. Thus, the economic interpretation of the calculations performed for complex integral indicators shows that, according to Table 23, the highest average values of complex integral indicators are observed for Norway at 0.61 and Sweden at 0.60, indicating the best state of indicators that define the highest level of healthcare system development in these countries among the selected cluster of countries . Average levels of integral indicators were found in the following countries: France at 0.59, the United Kingdom at 0.58, Denmark at 0.58, Finland at 0.56, Austria at 0.56, Germany at 0.54, and the Netherlands at 0.50. This indicates the good state of indicators that show the level of health system development in these countries. Belgium has the lowest but not a critical value of 0.41; this indicates shortcomings in the state of indicators that determine the level of health system development in the country and requires additional attention. A high level of integral indicators indicates the positive development of the health care system in the country, and a low level of integral indicators for the state is an alarming indicator since this shows a low level of healthcare system development. Therefore, the representatives of healthcare management should regularly, carefully, and continuously monitor the factors that lead to a decrease in integral indicators and take appropriate measures. --- Discussion This study refers to proposals to improve healthcare system by further developing the approach to qualitative and quantitative assessments of health system indicators by developing an integral indicator in the context of behavioral, social, demographic, and economic factors that characterize the level of the health system development in European countries using the selected methods of multidimensional statistical modeling. The steps of this complex scientific study of behavioral and social analysis of the public health system were based on the the work of the authors [90] in the health care field. As a result of this study of the behavioral and social dimensions of the public health systems of the world based on the use of bibliometric analysis, the main scientific categories of the study were determined, the most potential priority areas of policy and strategy formation of the healthcare system were identified, and the territorial component was theoretically determined for further considerations. In addition, the previous works by the authors of [46] used the method of clustering countries into specific groups, which confirmed the appropriateness of the obtained distribution. This technique was applied to group European countries into appropriate clusters for further analysis in the current study. Previous healthcare research by the authors of [47] studied the factors of the healthcare system and their influence on the vulnerability of the population of a certain region; relevant factors are identified. The analysis of literary sources shows the practicality of using the selected types of analysis-descriptive analysis, cluster analysis, canonical analysis, and factor analysis-for research in the healthcare field. Moreover, descriptive analysis allows various relevant indicators available in databases to be combined into appropriate groups. With the help of cluster analysis, it is possible to adequately divide countries into corresponding comparable research groups. Canonical analysis makes it possible to determine the relationships between the component characteristics of the studied groups of indicators and the nature of such relationships. By conducting a factor analysis, the relevant indicators of the studied indicator are determined, and the integrated indicator of the selected indicators is modeled. The authors' contributions to the knowledge of healthcare system include: The determination of the degree and significance of interrelations between groups of behavioral, social, demographic, and economic indicators of the level of healthcare system development in European countries based on the use of canonical analysis in terms of using canonical correlations; The definition of relevant indicators to assess the level of healthcare system development in Europe based on the use of factor analysis in the form of principal component analysis; The construction of integral indicators of the level of healthcare system development in Europe in the context of behavioral, social, demographic, and economic factors based on factor modeling and using the convolution procedure. The authors' approaches to the behavioral and social measurement of the public health system were developed separately. These approaches so not act as one full-fledged integrated approach to assess the level of health system development since the study uses a limited list of indicators selected by the author in the context of behavioral, social, demographic, and economic factors characterizing the state of healthcare systems. However, the developed approach is the best addition to the existing systems for measuring the state of health systems in European countries because this approach: Conducts a statistical assessment of the significance and relationship of the studied characteristics; that is, it conducts a causal analysis of groups of behavioral, social, demographic, and economic indicators of the level of health system development in European countries, based on canonical analysis, which, in contrast to existing approaches, takes into account canonical correlations between groups of indicators; Determines the significance of factors within each group of behavioral, social, demographic, and economic indicators for assessing the level of the European health system development based on factor analysis; the method of analyzing principal components was used to effectively determine relevant indicators in other scientific fields; Identifies integral indicators of the level of health systems development in European countries by groups of behavioral, social, demographic, and economic factors, based on factor modeling, which allows the use of procedures and convolution to quickly determine common general indicators for each group and a common integral indicator, greatly facilitating further analysis. The validity of the results is confirmed by the fact that the chosen research methodologies, namely, descriptive, canonical, and factor analyses, are reasonably suitable for study of the state of European health systems and achieved the set goal of the study. The calculated data obtained correspond to the actual situation and dynamics of the healthcare sector for 2000-2020. --- Conclusions and Recommendations The descriptive analysis made it possible, first, to form and model a multi-aspect array of groups of behavioral, social, demographic, and economic indicators, which are relevant for the further formation of an integral indicator of the level of healthcare system development in European countries. Second, based on cluster analysis, which involves the application of the iterative divisive k-means method, it was possible to determine a group of 10 European countries for the study . The canonical analysis specifies the degree and significance of relations between the constituent features of the studied groups of indicators to establish systems of pairs of features that are most correlated with each other and form an indicator of the level of healthcare system development in European countries. Such indicators and reasons that significantly impact the corresponding groups of indicators are the components of the groups of social and demographic indicators. Considering the results of the canonical analysis research stage, researchers should take into account the most correlated pairs of features to form narrowly concentrated combinations of relationships. At the same time, practitioners should focus on casual and effective characteristics. Thus, it is recommended to consider social characteristics that affect behavioral, economic, and demographic indicators; demographic characteristics that affect economic indicators; and two-way communication between groups of behavioral and economic indicators. The factor analysis, conducted by applying the study of the principal components, made it possible to determine the relevant indicators for evaluating the level of healthcare system development in European countries . The most relevant indicators among the indicators of the social group were Mortality rate , Mortality rate , Birth rate , and Mortality rate . The most relevant indicators among the demographic group were Age dependency ratio, Population ages 15-64, Life expectancy at birth , Population , and Refugee population by country or territory of asylum. Among the economic indicators, the most important were GNI per capita, GDP per capita, and poverty gap at USD 1.90 a day. Finally, the most important indicators of the behavioral group were Hospital beds, Immunization , Immunization , and Life expectancy at birth . Factor analysis allowed for building an integral indicator of the level of healthcare system development of European countries. The highest average values of integral social indicators are observed for the following countries: Norway , the United Kingdom , and Finland ; the highest integral demographic indicators were found in Germany , Finland , and Denmark ; the highest integral economic indicator were found in Norway , Denmark , Sweden , the United Kingdom , and the Netherlands ; the highest integral behavioral indicators were found in Austria , France , Sweden , Finland , Denmark , and the United Kingdom Considering the results of the factor analysis, it is recommended that future studies focus on a deeper study of certain relevant indicators, which have the greatest impact on the group. Therefore, it is recommended that further studies also analyze them separately to determine the factors that affect the formation of these relevant factors to achieve the maximum level of healthcare system development. Furthermore, according to the results of factor analysis, it is recommended to analyze in detail the levels of integral indicators in dynamics in the context of each country. It is first recommended to study the integral indicators that comprehensively cover the overall level of healthcare system development and provide a comprehensive picture of the direction under study. At the same time, specialists are recommended to focus on integral indicators, the levels of which, as indicated in the study, have the lowest values and unstable or negative dynamics. Thus, the results were summarized using the following indicators: the integral indicators for each group in the context of each year and the general integral indicator of the level of healthcare system development of European countries for each year; the arithmetic mean by year in the context of each country and by country in the context of years. Other generalizations are not provided by the proposed model. When constructing the model, we considered explicit hypotheses of the presence of relationships between the indicators of the behavioral and social, behavioral and demographic, behavioral and economic, social and demographic, and economic, demographic, and economic groups. Non-explicit hypotheses were ignored. The need to improve the level of healthcare system development in European countries was confirmed. Shortcomings and possible reserves for potential improvement of the healthcare system were identified based on the statistically significant models and by analyzing relevant factors. Therefore, for the effective development of the healthcare system in the countries of Europe and of the world, it is advisable to review theoretical approaches and practical results of the state of development of the medical system on an ongoing basis, taking into account the dynamic changes in the influencing factors that determine the priorities of this field. The results of this study will help managers and organizers of the public health system of European countries to use the received factual and analyzed data in making managerial decisions; to build strong, substantiated links between the available objective data and the policies of the healthcare system, the level of the healthcare system development in European countries, and positive changes in the health sector. The study's results can help government officials, employees of the healthcare sector, and those providing medical services identify possible reserves for potential improvement of the level of the health system based on developed statistically significant models, as well as by analyzing relevant factors. Based on the research results, state authorities can conduct effective, timely, highquality regulation and adjustment of the regulatory and legislative framework to improve the level of healthcare system development in European countries and the healthcare system. --- Data Availability Statement: Not applicable. ---

Background: The state and prospects of the healthcare industry of a country are among its top priorities because the quality of life and health of its citizens are indicators of its success and competitiveness. The aim of this study is to conduct a theoretical analysis and qualitative and quantitative assessments of indicators by developing an integral indicator in the context of behavioral, social, demographic, and economic factors that characterize the level of healthcare system development in European countries using multivariate statistical modeling methods. Methods: The study was implemented using Statistica 10 and Statistica Portable statistical packages. The statistical base of the study was formed using descriptive analysis; a group of 10 European countries was identified using a cluster analysis based on the application of an iterative divisive k-means method. The degree and significance of the interrelations between the components characterizing the studied groups of indicators were determined using canonical correlations by conducting a canonical analysis. Factor modeling is conducted by applying the analysis of the main components to determine the relevant indicators for assessing the level of healthcare system development to build integral indicators of the level of healthcare system development in European countries. Results: The need to improve the level of healthcare system development in European countries was confirmed. Shortcomings and possible reserves for potential improvement of the healthcare system were identified. Conclusions: The results can help public authorities, officials and employees of the healthcare sector organize and conduct effective, timely, high-quality regulation and adjustment of the regulatory and legislative framework to improve healthcare system development.

marijuana, or inhalants compared to their and non-AI peers . Similarly, other studies indicate that AI youth begin to use substances at very young ages and may progress more rapidly to regular use than non-Indigenous youth . While variability is noted in the literature with respect to substance use rates, research agrees that AI youth suffer disproportionate negative effects associated with substance use . Further, early substance use is associated with higher risk of developing substance use disorders, which are also associated with other mental and physical health problems . For example, similar to other non-Indigenous youth, early alcohol intoxication by Indigenous youth by the age of 14 is related to a number of negative outcomes including higher rates of subsequent use and greater likelihood of a later substance use disorder . AI adolescents also report higher rates of driving while intoxicated , health issues , and negative social consequences due to substance use. Understanding factors associated with increased substance use in Indigenous populations, especially among youth, is of great importance and public health concern. Several factors have been identified as important in Indigenous and non-Indigenous youth, including peer substance use , exposure to stress , parental abuse/neglect and other family factors , and perceived discrimination . Meanwhile, there is a growing awareness of the important role that extracurricular or other activities play in buffering against engagement in substance use among non-Indigenous adolescents . However, there remains a dearth of research focusing on potential alternative reinforcers to substance use, such as alternative activities, with Indigenous adolescents. According to Behavioral Theories of Choice , substance use behaviors are determined by the availability of substances and the availability of alternatives to engaging in substance use . This theory is critical to understanding substance use in this population, as it has long been described that Indigenous youth live in communities that are devoid of alternative reinforcers, and may drink or use substances out of boredom , presumably for the reinforcement that it might bring. Despite the intuitive sense that this makes in congruence with BTC, to the best of our knowledge, there has been little systematic or empirical effort to study activities or alternative reinforcers of youth living in Indigenous communities. Meanwhile, among non-Indigenous samples, reduced substance availability, increased costs of substances, and greater availability of alternative activities have been associated with reduced drug and alcohol use . In one theoretical paper, Spillane and Smith describe how BTC could be adapted in adult Indigenous populations, theorizing that increased disparities in substance use in Indigenous communities could be explained by a lack of availability of alternative substance-free reinforcers, which lead to community members being more likely to rely on substance use for reinforcement. Additionally, some positive reinforcers in these communities may be relatively less contingent on avoiding substance use, so individuals' perception of the costs of use are relatively low . Indeed, this was found to be true in a study of reserve-dwelling FN adults . When compared to middle socioeconomic status Caucasians, the FN group had reduced expectations for access to so-called "Standard Life Reinforcers," or "SLRs," including employment, quality relationships, and sound financial status, and also reported expecting that drinking would not decrease access to SLRs . Though this work has demonstrated the applicability of BTC in adults, the theory has yet to be further adapted to Indigenous adolescents. To be applied to adolescents, the concept of SLRs may need to be modified to be more developmentally appropriate. We use the term Competing Life Reinforcers , defined as things that are consistent with values and inconsistent with substance use among adolescents, and are also available on a FN reserve. We believe that BTC can be modified to help explain some of the variability in substance use among Indigenous youth. For adolescents, having substances available has already been found to be one of the strongest correlates of substance initiation and continued use . Regarding the effect of alternative reinforcers, a core component of BTC, one longitudinal study of non-Indigenous youth found prosocial leisure activities to be protective against substance use . Other activities, such as participation in sports or athletic teams, have shown mixed findings, with studies indicating both increases and decreases in substance use in relation to participation in sports . However, these findings may not necessarily generalize to Indigenous youth living on reserves, who have unique cultural experiences and many experiences of trauma, health, and economic disparities. Existing research has been limited to a few studies examining activities in relation to substance use. For example, among Indigenous populations, higher perceived availability of extracurricular activities, team sports, and playing music, and intensity of participation, have been found to be associated with less substance use . Among non-reserve dwelling FN youth, research has shown that participation in weekly recreational activities was associated with lower frequency of alcohol use and heavy drinking, while fewer school strengths and more tribal strengths were related to greater substance use . With the above mixed findings in mind, the present study aimed to examine the application of BTC to FN adolescent substance use by exploring activities and other culturally and developmentally appropriate alternative reinforcers . We performed qualitative focus groups and individual interviews of FN youth to explore risk factors for substance use, how potential CLRs, including family, peers, community, culture, and availability of alternative reinforcers, appear in their lives, and how the CLRs relate to substance use. These findings can help to inform future research that will focus on the role of alternative reinforcers to substance use among Indigenous youth. --- Method Study Design and Ethical Considerations This is a qualitative study involving semi-structured in-depth focus groups and individual interviews with FN adolescents between the ages of 14-17. In alignment with the tenants of community-based, participatory research , the researchers formed an advisory committee to help guide the study. The committee consisted of band and council members with experience in health and/or mental health, and substance use in adolescents, who assisted with the development of the interview guide for focus groups and identification of strategies to recruit youth in the community within the target age range. In addition, the study project's assistant is a member and resident of the FN community, and the principal investigator and first-author is a band member, though she does not live on the reserve. The semi-structured interview guides were reviewed and approved by the chief, council, and the advisory board. All study procedures were reviewed and approved by the university Institutional Review Board prior to beginning data collection. --- Research Setting The research was conducted in one rural FN community located in Eastern Canada. The qualitative interviews and focus groups were conducted at the Health Center located on the reserve. --- --- Procedure The present study used a modified grounded theory design to develop a semi-structured interview protocol to examine socio-cultural influences on substance use among reserve dwelling FN youth . We conducted 45-60minute semi-structured focus group and individual interviews with Indigenous youth over an 8-month period from October 2012 to May 2013. The interview protocol was created based on the BTC in that participants were asked to identify various aspects, activities, and influences in their environment that are both supportive of and inconsistent with substance use. Grounded theory stresses the importance of the development of a theoretical model and to allow themes and categories to derive from the data as content analysis takes place . A modified grounded theory methodology was used as we aimed to develop culturally appropriate constructs that related to the BTC model. While we utilized predetermined categories based on BTC, we employed practices consistent with grounded theory, including the use of open coding techniques, memo-making, and simultaneous data collection and analysis to generate specific codes and themes within each predetermined category. Using a directed, or deductive, approach for collection of data, we used open ended questions with directed follow-up questions based on the predetermined categories . Interviews, both in focus group and individual formats, allowed the PI to guide the questions asked during interviews , as is appropriate when the behaviors of interest cannot be directly observed by the research team , such as potential adolescent substance use and various activities adolescents engage in. Focus groups and interviews were audiotaped. --- Data Management and Data Analysis Audio recordings from focus group and individual interviews were transcribed by a professional transcribing company and checked by the first author for accuracy as suggested by . The electronic and hard copy of transcripts were retained for analysis. Transcripts of group interviews were then reviewed by the principal investigator for a preliminary identification of preliminary repeated ideas that arose using the interview guide to inform individual participant interviews as indicated by Hays, Wood, Dahl, & Kirk-Jenkins, 2016. Next, based on guidelines of the consensus process set forth by Hill, Thompson, & Williams, 1997, a doctoral student research assistant read all of the transcripts to independently identify broad themes that arose, and coded the data using directed content analysis. Consistent with guidelines by Charmaz , memo-making procedures were utilized, writing analytic notes to elucidate categories and break categories down into their components, at each stage of coding transcripts. As suggested by Elo and Kyngäs , we approached analysis using a predetermined theoretical model, BTC, where we analyzed the content through the identification of general a priori categories. We then identified main codes and themes derived from the data, as suggested for grounded theory and by Auerbach and Silverstein . With this approach, we highlighted/color-coded the relevant text that fell within each of the eight categories, followed by open coding within each category to identify repeating ideas, followed by grouping the repeated ideas into recurring themes and theoretical constructs. Transcripts were then reviewed and analyzed using the same processes described above by a second doctoral student research assistant. Upon completion of the second coder, both research assistants met with the PI to discuss the themes that emerged from the data until consensus was reached . --- Findings Participants' Thoughts about Substance Use Focus-group participants were asked about the types of problems they noticed within their community or for peers their age. When asked this question, a member of the girls' group stated: These are pretty broad questions because there is so much. Stuff like drinking, smoking dope, other drugs, confidence, racism, ignorance. There's just so much. I don't know. You could just elaborate on and on and on, I think. Similarly, a member of the boys' group simply stated: "Drugs." Using a directed approach, the focus groups were asked to elaborate on these responses. Both groups identified alcohol and marijuana use as specific substances which are heavily used by adolescents in their community, with the boys' group additionally identifying cigarette use as a major concern. During both the focus-group sessions and the individual follow-up sessions, several negative consequences of substance use were identified. Specifically, adolescents identified substance use as often leading to school dropout, negative consequences within their families, and substantial health risks. It was further noted that one potential reason for such severe consequences and high rates of use was due to the availability of substances both on, and off, the reserve. Thus, substance availability was identified as another major problem faced by these adolescents. --- Risk Factors Participants identified three major risk factors for youth substance use: 1) peer influences, 2) family/parent influences, and 3) community influences/issues. Peer Influences.-A common theme influencing adolescent initiation of substance use that was identified during the focus-group interviews and individual interviews was peer and social influences and the desire to "fit in" with peers. Specifically, these adolescents indicated that substance use, particularly marijuana, alcohol, and cigarette use, was very common among their peers, both on and off the reserve. One boy stated: If you go to a party and you're the only one that's not there not smoking weed or not smoking or drinking, then you kinda feel outta place and you kinda feel pressurized into doing it. If you feel pressurized, then you're more susceptible to doing it and then that leads to [background noise] that happening, too. Furthermore, one 16-year-old female reported that substance use is common both on the reserve with her Indigenous friends and off the reserve with her non-Indigenous friends from school: My friends, they smoke drugs, like they smoke dope and they do what they do. They can just relate to the same stuff. My friends at school they drink and stuff, but they're not people I hang out with every day…I have my high school people and then I have my at home people. My high school people are different than my home people, but they smoke and stuff too. A male participant echoed the idea that adolescents are exposed to substances in their social environments stating that students often smoke on school grounds as the "no-smoking" policy is not typically enforced. Additionally, members of the boys' focus group described kids first beginning to engage in substance use, such as smoking cigarettes, at very young ages while at school. They stated: "A lotta kids do it in elementary school. They start in the bathroom," and "About more than half the kids that are coming in grade nine from middle school smoke cigarettes and they start smoking dope, start drinking…" What is more, these substances were often easily accessible through their peer networks. When asked who provides substances, adolescents explained: "Who's ever old enough, you just ask them to go…," and "…go tell someone to go pick it up, yeah. You can just, yeah, basically text or something like that, whatever," as well as, "Because it's easy access, people are getting older. They have older friends so they can get it that way." One 16-year-old girl stated: "Yeah, everybody knows. Even little kids know where to get. It's crazy easy. Kids these days know way too much for their age." Family/Parent Influences.-Family and parental influences also were raised as common risk factors for adolescent substance use. It was reported by the majority of participants that youth are often exposed to alcohol and cigarette use, and may even begin using, at very young ages when parents or important family members engage in such behaviors. Moreover, five individual interview participants stated that parents often engage in substance use with their children, supply their children with substances, or that children begin experimenting with substance use after parents or important family members model the behavior. One 16year-old girl recounted: Exactly, as I've grown up with my parents, like my dad, was an alcoholic always. He's always drank. When I was growing up I'd go to parties with him. I've seen everybody. I don't know I just grew up way too quick, I can just say that. I've seen people do this so I thought it was okay to do. When I did do it, it backfired on me. --- Another adolescent explained: You have parents around here getting drunk, walking down the street with a joint in their hands that smoke dope. People around here selling coke and you just know that. If you grow up with a parent or a parental figure doing that, you're going to think that's okay, and that's not okay. Additionally, respondents reported that they felt as if parents often "don't care" if youth are using substances, and feel there is a lack of discipline from parents and family members, as well as a lack of monitoring of children's' behaviors. One girl, aged 15, explained she first began smoking at the age of seven and a half when she "had the house to myself" while her father worked. Interestingly, many participants, including three individual interviewees, reported viewing parents as hypocrites when they do not condone their children's substance use. One participant described how it is not meaningful when adults tell youth to stop smoking: "You can't go telling your kids 'Stop smoking,' or 'Don't smoke,' while you're sitting there puffing away too." At the same time, several adolescents further reported that they do not look up to adults who engage in alcohol or drug use as role models. Community Influences/Issues.-Beyond immediate family and peer influences, adolescents further identified their community as a whole as a potential influence for engaging in substance use while on the reserve. The adolescents reported that many individuals engage in substance use because "There is nothing else to do." At the same time, ten of the 11 individual interviewees endorsed the belief that their community, as whole, does not care if kids are using substances, and that youth do not tend to experience any legal discipline for underage substance use. Moreover, when events are held in the community, engaging in substance use while participating is often the norm. For example, numerous participants reported that smoking cigarettes in public was extremely common, and that when the community engaged in various celebrations, public intoxication was readily occurring. One participant recounted: I've heard it happening on [cultural feast days]. That's the thing, community events, when we were younger, I thought they were awesome. We had so much, like, rides and stuff. Then now, it's like, "Oh, [at a specific community gatheringredacted to maintain confidentiality of the community]. Everyone get drunk tonight. Where's the party?" I never realized what it was about when we were young. Another 15-year-old girl described community events, such as ballgames, involving "everyone" getting "drunk." Substances were reported to also be easy to obtain from adults and because the behavior is normalized through interactions with adults in the community. For instance, one 16-year-old girl stated: I drink and smoke with adults all the time. I mean at first it was weird because I just started and stuff, but now it's just normal. It's just like one of the friends, just gonna go get drunk or high. It's just normal. It's nothing bad, everybody does it. --- Competing Life Reinforcers Participants elaborated on six protective factors against substance use, based on BTC: 1) future goals, 2) peer influences, 3) family/parent influences, 4) community influences/issues, 5) alternative activities, and 6) culture. Future Goals.-During the interviews, the adolescents were asked about their future goals. Many responses focused on goals that would help the participants stay away from substance use, or to not have substance use problems. These youth reported that having supportive adults in their life would help with achieving future goals, with over half of the individual interviewees suggesting ways in which parents and family could provide support for children's futures. More specifically, two individual participants indicated that having supportive adults in their life that specifically checked in with them regarding school attendance and their hopes for the future would be beneficial in helping them obtain their goals, as well as to stay away from substances. This idea of having support in obtaining their goals was largely tied into adolescents' aims and plans to finish their high school education, and for many, to go on to post-secondary education. Furthermore, four individual participants identified having an education as being important in general, and other youth indicated that education was vital in helping them obtain a lucrative job or career. For example, when asked what her goals were for the next five years, a 16-year-old reported: I see myself, I don't know I don't want to be here. I hope I'm not gonna be here in five years. I want to be out getting a job, maybe have my own family in five years. I don't know, I want better for myself. I want to graduate. I want to get a good paying job that I love. When she was further asked how using alcohol fit into this plan, she stated: I hope I'm not into those at all. I think about trying to give them up for Christmas or whatever, but I hope not. Knock on wood that I'm not doing drugs or alcohol in five years. Other than that I don't know. Having a job was identified as a major future goal amongst this group, and being involved with substance use was identified as a potential barrier to achieving that goal. Thus, having goals about the future, specifically regarding education and jobs, likely may serve as a CLR given that adolescents are provided with appropriate support systems. Peer Influences.-While many participants remarked that peer and social influences were often contributing factors to adolescents' use of substances, one participant described her boyfriend encouraging her to quit smoking, stating "I'm trying to quit. My boyfriend's making me. He doesn't do it and he hates it. He hates it with a passion." This description reveals that for some youth, having relationships with peers who do not use substances may serve as an important CLR against starting, or continuing to use, substances. Family/Parent Influences.-Many participants described that for some adolescents, there was a feeling of lack of support or guidance from parents or family, often resulting in youth substance use not being monitored or discouraged. However, six participants noted ways in which their parents and families could be supportive of them, which in turn may be protective against substance use. Specifically, one participant described his mom pushing him to succeed in school: My mom, she was kind of-she's been really hard on me in terms of school because she knew it was so important and stuff. She kind of-when I was going out -was always like education first and everything else behind that. I've been kind of living off of that for my life. Other than that, even other people in my family are like, you got to have your education. You got to go somewhere. You got to have a successful life. Basically, that's what I did… Additionally, extended family members were reported to be helpful when individuals felt they did not have support from their immediate family members. In particular, grandparents, aunts, and uncles, were indicated as especially helpful people to look up to. Although, a common theme about substance use was that adolescents often begin to miss or drop-out of school when using substances, particularly marijuana, these adolescents identified ways in which they would like to receive support. It was suggested that having parents or parental figures that would help them get out of bed to go to school or providing supportive messages while growing up may lead to a decrease in substance use related problems. For example, when asked what could work for prevention, one participant stated: I just see a lot of parents giving up on their kids. You can't give up on your kids… Or just letting them-just let them start sleeping in, start sleeping in, start missing school more and more, then the next thing you know-…Every kid on there needs someone that will make sure he gets up for school every day, and make sure they're up, ready. I don't know, going to school every day. Community Influences/Issues.-Throughout the qualitative interviews, it became apparent that respondents had difficulty identifying positive community influences, including role models, which were useful in protecting against engagement in substance use. However, when the interviewer used guided questioning, participants were able to identify characteristics that they would like to see in an adult role model. Interestingly, but perhaps not surprisingly, a recurring sentiment was that a role model is an adult who does not use substances and has "bettered" themselves. More specifically, a role model is someone who is not a "hypocrite," meaning that not only are they encouraging youth to abstain from substance use, but also are sober themselves, specifically regarding alcohol, marijuana, and other drugs. One 16-year-old female described a role model as: …they didn't do drugs or alcohol or if they did, like if they recovered about it or doing better for themselves. Because I don't know I see that being a role model for me…Yeah, and to stay clean that whole time and did better for themselves…I don't know, it just shows that they can overcome something that was-having a drug addiction is hard. I don't know I just think it's good that they did because it shows how strong they are I guess. These adolescents noted that having positive, caring, role models that provided structure and discipline in their lives would be beneficial and protective against substance use and help with achieving their goals. Potential role models included friends' parents, extended family members, parents, teachers, and elders in the community. While many agreed that role models should be sober, that having used in the past but currently being "clean," demonstrated resilience and could be helpful to youth. At the same time, participants were also able to identify potential activities they would like to see available within their community-activities they believed would help protect against problems with substance use. A recurring theme that arose was the desire for increased community celebrations or activities that are "sober." Interestingly, based on these interviews, there are mixed messages and ideas as to whether tobacco use is appropriate for a role model as well as within the community. Alternative Activities as Reinforcers.-Beyond identifying characteristics of people who can serve as CLRs, the participants were asked to identify various activities that are already in place serving as CLRs to substance use. One of the most cited activities, endorsed by over half of the individual interview participants, was organized sports, particularly hockey, soccer, rugby, and baseball. However, beyond organized sports, many adolescents had difficulty identifying protective activities currently available. Moreover, this sample expressed that they wished there were a greater number and variety of alternative activities available within their community. First, it was suggested that having various organized sports available during the "off-season" would be useful as the climate in this location gets cold and people tend to stay inside, which may lead to substance use. Next, these youth reported, both during the group and individual interviews that organized, age-specific, youth groups and events would provide an alternative to engaging in substance use. Some examples included outdoor/camping trips and an organized recreation program and/or recreation center. During the girls' group, one individual mentioned past recreation trips to amusement parks, and another girl agreed that trips could be protective, stating, "Trips be bomb. That's an amazing idea. I can see how kids would be more interactive and do stuff and stop drugs and stuff." Other adolescents stated that they would enjoy engaging in volunteer opportunities within the community, while some noted that other groups, such as a videogame league, could be a good option. Specifically regarding youth groups, these adolescents indicated that starting organized programs and consistent youth groups at a young age would be a welcomed idea. During her individual interview, a 17-year-old expressed: I think that the youth group, I think if we made that better-like if people stayed committed to that, I think it would keep them from drinking. It's almost like they won't enjoy what they did and stuff. If they make plans, like trips and all, I think it'd be really fun just to get away and it'd keep other people from doing drugs and alcohol. The participants further suggested that adolescents may be more likely to continue to engage in such groups if they were age-specific and provided age-appropriate activities. Two individual interviewees reported that there are activities available through the schools off-reserve, yet it appears that most FN youth within this community do not participate. This further suggests that community based alternative activities to substance use and appropriate influences may be of greater importance to this population than having such resources available off the reserve. Culture.-While describing desired alternative activities, the theme of culturally based activities arose. Both the boys' and girls' focus groups, as well as three individual interviewees, reported feeling a lack of culturally based activities and programming within their community. Participants described having the desire to learn more about their culture, as well as to learn cultural practices such as Indigenous arts including beading, basket weaving, learning their native language, engaging in sweats, dancing and drumming, and other traditions. Regarding cultural traditions, one girl in the focus group mentioned, "I don't think that it's taught. It's not being passed down from parents, but they don't really know either." Moreover, respondents endorsed wanting to learn about these activities and engage in their practice alongside of parents and adults from within the community, including elders. One girl in the group further emphasized this point by indicating she would like to see parents and other adults committing to cultural practices. These qualitative responses reveal that increased cultural traditions and practice within the community would likely act as appropriate CLRs. Of note, while we had hypothesized that stereotyping and discrimination would be a recurrent theme linked to substance use, we found this to not be the case. While some participants mentioned stereotypes and discrimination as occurring from non-Indigenous peers, these factors were not frequently cited as reasons why these youth decide to engage or not engage in substance use. --- Discussion The purpose of the current study was to begin the process of understanding risk and protective factors for substance use and problems for Indigenous youth in order to design prevention programs that are tailored to their unique cultural needs within the framework of BTC. Our results paint a complex picture with multiple factors that likely interact, as we noted sub-themes being brought up in multiple sections. First and foremost, youth identified substance use as a problem for both adults and youth in their community. Within that environment, youth discussed peer, family, and community level factors that they believed places them at risk for substance use. Regarding peer influences, consistent with previous research, there was an overwhelming sense that youth engage in substance use to fit in with their peers . Our results further indicate that because youth are not only using or being exposed to substances in their community, but in school as well, school-based programs may be appropriate. Perhaps feeling connected to the school community may offer an incentive to participate in school activities and thus could serve as a CLR to engaging in substance use, acting as an alternative reinforcer in alignment with BTC. Such school-based programs should be considered in addition to those received within adolescents' immediate community. Other possible interventions, including multilevel interventions may need to be considered that focus on both individual and community factors . Consistent with research suggesting that family management practices such as parental monitoring and limit setting are highly correlated with the extent of adolescent substance use , youth in our sample felt that parents were not setting boundaries around substance use. This led to youth receiving inconsistent messages with regards to acceptability of using substances. When discussing family-based protective factors, one individual stated that having parents who push you in school is a protective factor. Strengthening prosocial family dynamics and adapting/developing familybased prevention programs that maybe include a broad definition of the family structure may be one strategy to implement. Perhaps of more importance is the finding that family members were often the source of substances and often modeled excessive use. This indicates that substances are readily available from multiple sources at times, and consistent with BTC , would suggest that availability is one key determinant in the decision to use substances. Some programs, such as those that focus on alcohol sales, have been effective in targeting alcohol availability through liquor stores , but may not be as effective for these youth and others who report primarily obtaining substances from others in their community. Therefore, our results suggest that prevention programs targeting multiple sources from which adolescents can obtain substances is warranted. Our findings also suggest subtle nuances that have not been captured in other studies of Indigenous substance use. Youth reported that having role models available to them would be an important CLR. When probed into their definition of a role model, it became clear that, while it would be all right if individuals had used substances in the past, these are individuals whom do not currently use substances at all, and are sober. Related to this point, they expressed that parents are seen as permissive in their substance use norms because they did not want to be seen as hypocritical. These are important distinctions that highlight the necessity for those who work with youth , to have awareness of how their own behavior may be perceived. Additionally, increasing opportunities to engage with positive adults identified by youth as role models , is likely to serve as a CLR as it would provide substance-free alternatives within their community. The lack of alternative activities within the community was a prevalent community level factor that youth reported as contributing to the risk of substance use, consistent with principles of BTC . The lack of activities, or experienced boredom, has also been examined in other studies as a reason for the increased substance use rates observed among Indigenous youth . Therefore, a critical substance use prevention strategy could be targeting the lack of CLRs, such as increasing the availability of structured, substance-free, extracurricular or community activities, for youth living in Indigenous communities. Participants were further asked about potential protective factors against substance use. However, individuals had a difficult time coming up with factors in their community that they saw as being protective. This is likely one example of how historical trauma and forced colonization may be related to the perpetuation of substance use in Indigenous communities . The restoration of culture could provide Indigenous communities with healing by offering cultural activities and strengthening an attachment among youth and the community. Indeed, research suggests that adolescents who are high in community attachment show negative associations with cigarettes, alcohol, marijuana, and other drugs . Strengthening community attachment in these youth, perhaps through culturally-based practices and activities, could be a potential prevention strategy given the protective effect it has shown for other groups. For instance, FN communities could be encouraged to increase youth access to, or interest in, valued community activities which could include traditional crafts, powwows, talking circles, sweats, and learning about their culture. Interestingly, there was some overlap in the factors that were ultimately identified: future aspirations, peers, family, community-level factors, alternative activities, and cultural factors. Youth expressed some future aspirations, but these were limited. Some expressed wanting to finish high school, fewer expressed college aspirations, many wanted to be employed with little specifics as to what type of job, or what they would like to be when they grow up. This may reflect the limited opportunities that exist within Indigenous communities , and the sentiment that leaving the community to attend college or find a job is unacceptable. Previous research found college aspirations to be the most influential protective factor against tobacco use in one Indigenous sample of American Indian and Alaskan Natives , and our findings suggest that these Indigenous adolescents may also view academic aspirations as a protective factor against substance use. Based on previous work in Indigenous populations, we anticipated that perceived discrimination would be highlighted as a dominant theme in relation to substance use . Therefore, it was somewhat surprising that we did not find this to be the case. However, this finding is consistent with other research that has not found perceived discrimination to be significantly related to substance use . It may be that perceived discrimination is less likely to be related to substance use for those living in an Indigenous community than for those living outside of reserve/reservation communities, simply because their primary influential social contact may be with others from their community. While the present study provides important knowledge regarding risk and protective factors for substance use and CLRs against substance use for FN youth, they should be considered within the context of the studies limitations. First, because we only sampled from one FN community, findings from the present study cannot be assumed to be generalizable to other communities or populations. Second, the present study consisted of a small sample size, again limiting generalizability. These occurrences are often the case with qualitative research investigations, therefore future studies should aim to replicate findings in other communities. Third, the hypothesized theories derived from this qualitative study need to be complemented by quantitative research to examine the ways in which these themes relate to substance use behavior. In line with the BTC, our sample of youth identified a number of important factors that they would perceive as reinforcing, and that would influence their likelihood of using substances. The results of the present study highlight several important areas of substance use prevention to target among Indigenous groups. These risk and protective factors are particularly important targets for designing prevention strategies given that they were identified by Indigenous youth as contributing factors for and against substance use within their environment. It is likely going to take an effort at multiple levels in numerous settings to decrease substance use in this population.

Indigenous youth are at increased risk of initiating substance use at early ages and suffer greater negative consequences related to substance use as compared to non-Indigenous youth. The present study aimed to investigate risk and protective factors associated with substance use in one group of First Nation adolescents. Using a modified grounded theory approach, the present study conducted qualitative focus groups and individual interviews assessing categories of risk and protective factors based upon Behavioral Theories of Choice. Behavioral Theories of Choice suggests that substance use is contingent on the availability of substances and the availability of alternatives to substance use. Fifteen reserve-dwelling (75% female, M age = 15.2 years) First Nation adolescents identified peer influences, parental/family influences, and community influences and issues as risk and protective factors associated with substance use. Results highlight possible targets of culturally appropriate prevention strategies for Indigenous populations.

INTRODUCTION Intimate partner violence is the most chronic and costly burden the United States has faced, accounting for the deaths of more than 58,139 women between 1980 and 2008, an average of 2,000 women killed per year . In the Brazilian scenario, these data are even more alarming: 13,071 deaths of women between 2009 and 2011, which represents an average of 4,357 deaths per year. The Central-West, Northeast and North Regions had the highest numbers . It is estimated that, in this context, 40,000 Brazilian women seek treatment for problems resulting from violence, representing an annual cost to the Unified Health System of more than five million reais in hospitalizations costs alone . Despite the high burden, this value is still underestimated, since the statistics do not include costs with health demands that do not require hospitalization as well as those related to other sectors such as the social, police and legal . Due to the high mortality and costs generated, marital violence has been the object of study in different parts of the world, mainly focusing on women's perception of this form of abuse . However, including the perceptions of men is essential for proposing strategies to prevent this phenomenon, through spaces that allow for gender reflection among men . This is a perspective supported also in the Maria da Penha Law, a Brazilian public policy to combat violence against women, which highlights the need to include men in recovery programs, in addition to prioritizing the discussion of the gender issue among men involved in criminal actions . It is emphasized that gender is considered a constitutive element of social relations, based on the perceived difference between the sexes. Under this perspective, it is a set of cultural characteristics that dictate what roles men and women should play in each society . In addition, it ultimately confers a hierarchy between these attributes, giving men a position of authority and ownership regarding women, which makes male power socially legitimized, and marital violence often justified . Considering that the process of deconstruction of conjugal violence requires a theoretical deepening of the phenomenon, it is necessary and relevant to value and investigate the male discourse. In this sense, it is questioned what the perception of male defendants in criminal cases is about marital violence. By taking marital violence as a study object, the research adopts as its objective to analyze their perceptions about marital violence. --- METHOD --- Ethical aspects The study was approved by the Research Ethics Committee of the Federal University of Bahia. The purpose of the research, the potential risks, study benefits and the right to refuse participation at any time were explained to the participants. The preservation of the recorded images and the confidentiality of the data generated in both stages were also guaranteed, in compliance with the ethical guidelines of the research with human beings, proposed in Resolution 466/2012. --- Type of study This is a qualitative, exploratory, descriptive study, part of a doctoral dissertation linked to the anchor project 'Re-education of men and women involved in criminal prosecution: a strategy to combat marital violence', developed by the Study and Research Group in Violence and Quality of Life of the UFBA School of Nursing. --- Methodological procedures --- Data source and study scenario The selection of the study population was intentional, consisting of men who were criminally prosecuted for marital violence. The inclusion criteria were: men who experienced pre-trial detention and were responding without deprivation of liberty for criminal prosecution for marital violence. Men who had lawsuits whose cause was based on violence against the woman, other than the conjugal one, were excluded. The locus was the Jurisdiction of Domestic and Family Violence against Women, from the city of Salvador, Bahia, Brazil. Initial contact was made with the help of a social worker, a jurisdiction employee, and later, via telephone, by the researchers. The men were invited to participate in a Reflection Group , which was developed during nine meetings, lasting seven months and with a total workload of approximately 50 hours. This quantitative considers the three face-to-face hours of each meeting, added to others spent on 'dispersion activities', delivered at the end of each meeting and held by the participants until the next face-to-face meeting. In the first meeting, they were informed about how the GR worked and about the current research. Those who agreed to continue to participate in the group, in the research, or in both, signed the Free and Informed Consent Term. The meetings of the GR addressed varied topics such as family, domestic and conjugal violence, gender, honor, and peaceful resolution of conflicts. --- Data collection, organization and analysis of data The data were collected using multimethods, using the techniques of individual interviews and focal groups . The interviews were individual, in a private room of a municipal public school, also the locus of development of the RG, with an average duration of half an hour each. As a data collection instrument, a semi-structured script was used containing the following guiding question: Tell me what you understand by marital violence. The nine members of the GR and another 14 men participated in this phase, making a total of 23 participants. In order to deepen our findings, a focus group was held in the last meeting of the RG , after he completion of all the interviews. For this stage, the same guiding question of the interview was adopted. The research was carried out between May and December 2015, by nurses and nurse-researchers, master's and doctor's candidates, under the supervision of doctors, with extensive experience in this area of knowledge. The interviews and the focus group were recorded, and their contents transcribed in full. In order to ensure rigor in the study, the transcribed material was fully available to all participants in order to verify if it was reliably expressing what they had said. For this strategy, as a support tool -the consolidated criteria for the reporting qualitative research -was adopted. The data collected were initially categorized using the NVIVO® 11 software program, which also enabled the creation of a word cloud, which supports the findings. Next, the data were organized into central ideas and discourses'synthesis, according to the Discourse of the Collective Subject method . Participants were identified by the letter H, followed by numbers corresponding to the order of interviews. The results were discussed and interpreted according to the theoretical basis of violence, gender and masculinities. --- RESULTS The study participants are mostly black, ranging in age from 25 to 62 years old, at basic education level and income between one and two minimum wages. Regarding marital aspects, the relationships ranged from four to 40 years of coexistence, mostly in stable union with children. The collective discourses allowed us to analyze the male perceptions about conjugal violence, organized into the following categories: Central idea 1 -It is inherent in the conjugal relationship Men perceive violence as being part of the conjugal daily life, a reason that arouses resentment and non-understanding of the prison. They also highlight its cyclical and intergenerational aspect, as follows: Fights occur with every couple. There have been several misunderstandings of this and it has always been like a cloud. The cloud would pass, the problem would pass, and the next day it did not look like it had happened. That kind of thing is normal in every relationship. I remember that my parents fought a lot and my father beat my mother. My hatred is because it was not necessary to put me in a cage because this is natural and every couple faces that. Central idea 2 -It is a private problem Men understand that marital violence is private, and should be resolved between the couple, in the domestic environment, without interference from third parties, including the police, as seen in the following discourse: She brought the whole event to the public. I tried to pull her into the house so that we both could work it out, but she became altered and we started to quarrel right there, in the street. There were a lot of people watching. When the policeman arrived by car in my house, I said that I did not want to talk, that it was a family problem, just our problem. I thought it was wrong to be arrested, to end up at the police station because of this, because what happens in the family is kept right there. There was no need for it because it was our problem! --- Central idea 3 -It is reciprocal Another perception was that the aggression started initially from the companion and because the man's action was retaliatory, it was not understood as violence. The discourse also reveals a conduct based on the non-acceptance of subjection of man to woman. She started giving nicknames to me. I did not like it and did the replica of the nicknames. Then she assaulted me, slapped me on the face. I do not think it's right for the man to hit the woman, or for the woman to hit the man. Am I going to be beaten by a woman? No! So I did not think twice: I used two closed-hand slaps and put her things out on the street. I did not hit, I just retaliated! --- Central Idea 4 -It leaves body marks Although the understanding about the different forms of expression of conjugal violence -psychological, moral, sexual and physical -is clear, the collective discourse reveals that, in the perception of men in criminal proceedings, physical aggressions with visible marks are highlighted. There is violence that is more hidden, such as the verbal and the threats, which, despite not including spanking, also hurts. But cursing is normal, it's just offenses, normal discussions between couples. A verbal offense is not important. If it were, everyone would be arrested, because everyone does that. For her to say that I emotionally harass her, she needs to have a medical report that confirms that. Violence also occurs when a person is forced to do [sex] even when he or she does not want to, even if they are married. There is the corporal violence: pushing, hitting, kicking, stabbing and shooting. This can leave bruises, cause bleeding and lead to death. It only becomes violence when the person is beaten, or a weapon or firearm was used. This is violence and cowardice. If I hit a woman, she has to have marks on her body. These men's perceptions of conjugal violence, unveiled in the illustrated categories, are backed by the "cloud of words", whose words express the essence of the central ideas of the study. --- DISCUSSION The naturalized male perception of violence in marital relations, present in the masculine discourse, is related to the transgenerational and cyclical characteristics of the phenomenon. Having witnessed violent relationships between their parents since childhood, children tend to naturalize and reproduce this model in their own marital bonds. This finding is corroborated by a study carried out in Romania, which argues that children of couples living in violent relationships are more likely to repeat this behavior in their future relationships . Because it occurs intergenerationally and is apprehended as inherent in the marital relationship, national and international studies have shown that women, as well as men, understand the violent act as love, which favors its perpetuation . Authors further posit that these aggressive behaviors are used, even if implicitly, as a method of domination, entailing different phases In a study carried out in Brazil, authors describe the cycle of violence as beginning in a phase of accumulation of tension and small misunderstandings, of a more psychological and moral character; in turn, there are brief episodes of lack of control, with the occurrence of physical aggression and / or situations considered more serious; finally, there is the phase of reconciliation and promises of change . The discourse of men also reveals that the fact that the aggravation is cyclical in the relationship, with alternation of violent episodes and peaceful moments, creates the idea that that moment was fleeting. This cyclical and progressive nature could also be evidenced in a study of 1296 women in Nepal, Asia . It is noticed, therefore, that the intergenerational and cyclical characters incite the naturalization of the violence by the couple, the reason why men do not understand the reason for their prison. A study found that men have difficulty in recognizing the author of a violent act and accepting the reasons that led to their arrest , reinforcing the findings of this research. Also corroborating them, other studies indicate that the denial and non-accountability of aggressions by these men are frequent characteristics in the dynamics of conjugal violence . This lack of understanding shifts the responsibility of the fact to the companion, as found in this study, when the man justifies that the happened occurred by way of retaliation to an action initiated by the woman. In relationships permeated by violence, the roles of victim and aggressor alternate between partners, but with different means of aggression. The woman often uses profanity and mild physical violence, such as scratches, whereas the man, by having superior physical strength, tends to cause more serious injuries, which reaffirms his superiority . Still with respect to the retaliation to the woman, the study points out that it is a way for the man to rescue his masculinity, threatened, since he was beaten by a woman. Corroborating that, authors argue that, when a man is violated by his partner, social questioning about the role of the man in the relationship arises, making him assume an aggressor position to show his superiority . This asymmetry is based on relations of power, domination and oppression between the genders, which is related to a patriarchal and phallocentric culture, in which the companion and children are to obey the man, who must be respected . The male's discourse also reveals the understanding that marital problems interest only the couple. This perception is socially shared in popular sayings such as "nobody can do any good between man and wife", thereby clarifying the social understanding that marital problems are intimate, should not be discussed publicly, nor should they be objects of intervention . The findings from the study also confirm those found in a survey conducted in the state of Espírito Santo, Brazil, in which men agreed that marital violence should be resolved in the domestic environment. The authors also affirm that this is a conduct that favors male power over the wife, as well as protects him from possible legal-police involvement . In this discourse on the privatization of conjugal violence, it is possible to perceive that when a woman takes the situation outside the walls, the man tries to bring the problem back to the intimate forum. When analyzing data from the Map of Violence 2015 -Homicide of Women in Brazil, it is observed that the home is the privileged place for non-lethal violence, with 71.9% of records made by women . This finding is opposed to the ideal that affective bonds would make the home a safe and propitious place for the whole family to live in peace and harmony , showing that marital problems need and must be solved in the public context. In this respect, one of the main achievements of the feminist movement concerning these abuses was the judicial interference in the private space, which consists of using the police power of the State to intervene in the relations of the private space . The Maria da Penha Law is the most expressive mechanism of this juridical conception by criminalizing domestic and family violence against women . In addition to criminalization, it has brought a new approach to this type of violence, based on the concept of gender, and typifying the forms of expression of the phenomenon as physical, sexual, psychological, moral and patrimonial . It should be pointed out that the discourse evidenced the masculine perception about various forms of expression of violence listed in the Maria da Penha Law, except for the patrimonial, which may represent a greater difficulty in understanding this form of the offense. The non-comprehension that retention, subtraction, partial and total destruction of personal objects constitutes crimes results in underreporting, and therefore, the percentages of this classification are not significant . Although in a little exploited way, patrimonial violence has been investigated in national and international studies, evidencing its seriousness , since it implies difficulties to provide for one's own and family support. Among the expressions unveiled in this study, the masculine discourse expresses the hidden character of psychological violence, although it recognizes its capacity to leave sequels. Authors found that psychological violence can compromise the self-esteem, well-being and the development of women's psychological and physical health, as well those of the children who witness the offense . Another expression recognized was the sexual one, which occurs when the man forces the sexual act without the will of its companion. A study shows that marital rape suggests the male understanding that it is the woman's obligation to satisfy him sexually . Although the discourse reveals the perception about various forms of expression, the greatest severity is evidenced when conditioned to the presence of apparent physical injuries or those confirmed by health professionals. Studies in Brazil and Uganda 31) corroborate the findings, showing that punches, kicks, burns, strangulation and injuries with a white or firearm are the most perceived forms of violence because they leave visible marks. This fact is in line with current statistics, since international and national studies show ever increasing percentages of physical violence, which is related to its being easily recognizable . This masculine perception of violence as one that generates visible and serious marks allows us to understand that threats, provocations and insults are sometimes denied as violent behavior because they do not measurable marks. It signals, therefore, toward the non-recognition of the gravity of this phenomenon. Scholars point out that this is an understanding that needs to be deconstructed, which may arise from the reflection of men and women, but above all by the proper education of children so that they may act differently in their future relations, breaking the intergenerational cycle of conjugal and family violence . In this context, researchers defend the importance of training professionals working in family health teams to prevent marital violence in the community and school environment . In relation to the word cloud, the size of the letters indicates the relevance of the term in the context in which it is displayed. In this manuscript, the image shows that the following words stand out: 'no', 'violence', 'fault', 'she', 'problem', 'natural', 'beat', 'marks', 'woman'. This reinforces the collective perception that the phenomenon is only understood when there are physical marks. Still, the word 'guilt' corroborates the central idea 3 , in which the retaliation emphasizes the blame on the other as guilty for initiating the problem. --- Limitations of this study The limitation of the study relies on the fact that it is applicable only in societies that maintain the same stereotype of gender and marital relations. Because it is a social phenomenon, marital violence can present different perceptions in realities that have different customs from those of the participants of this study. Because it is a public health problem, it is essential to understand the different perceptions that permeate the imaginary of those involved. This understanding is essential for the process of addressing this phenomenon, since it offers subsidies to think about prevention actions and, consequently, to promote the reduction of cases of conjugal violence and its complications for health. --- Contributions to the area of nursing, health or public policy The preparation of health professionals is deemed as extremely important, in the most diverse spaces. Teams working in primary health care are at a privileged locus, insofar as this is a space focused on the prevention of offenses and diseases, and the promotion of health. In this context, emphasis is placed on the nurses, who are the main managers of these centers and who have a greater link with the community and community health agents, which favors the articulation with neighborhood associations, schools, social welfare reference centers, anonymous alcoholics programs and others, so that the perceptions about violence, as well as the social ideation of the gender roles, can be worked, seeking a respectful solution in the fight against violence. --- CONCLUSION Collective discourses revealed that, in men understand the phenomenon of conjugal violence as a natural conduct, located in the intimate forum of the couple , and which occurs in a reciprocal manner. While acknowledging the most veiled forms of violence, such as insults, they sometimes consider that, in order to characterize violence, it is necessary to prove it, which is done by means of visible marks, thus highlighting the physical forms. The study evidenced gender dissymmetry as a social construct, signaling the need to create spaces for reflection and resignification of men and women from a gender perspective. Concerning the transgenerational character, schools are privileged spaces to break this cycle, and should incite actions that promote equitable relationships between girls and boys, based on mutual respect, which enable the deconstruction of the current patriarchal model. Moreover, they should give visibility to the magnitude of each of the forms of expression of violence, favoring the deconstruction of the idea that it is restricted to physical aggression. It is also necessary a type of education that encourages the peaceful resolution of conflicts, as well as an understanding that retaliation is not a defense, but a form of perpetuation of violence, which must be recognized as such. Furthermore, professionals in the social, judicial, police, educational and healthcare areas must be better prepared to understand this phenomenon of such magnitude and complexity. Therefore, it is essential that the theme be discussed in different scenarios and, in a specialized way, in the core undergraduate curriculum. Moreover, qualification processes are necessary for those who already work in the labor market.

Objective: to analyze male criminals' perception about marital violence. Method: An exploratory, descriptive, qualitative study undertaken with 23 men who were criminally prosecuted for marital violence. A multimethod data collection was conducted, with individual interview and focal group techniques combined, between May and December 2015. The data collected were initially categorized using the NVIVO® 11 software program, and then organized using the Collective Subject Discourse method. Results: the collective discourses reveal that, in the male's perception, conjugal violence is inherent in a marital relationships: it is a private, reciprocal problem that leaves body marks. Conclusion: gender dissymmetry as a social construct is evidenced, signaling the need to create spaces for refl ection and re-signifi cation of men and women, from a gender perspective.

Introduction Climate change is a global threat that affects the planet and an individual's quality of life. It is considered one of the pivotal problems of the 21st century [1]. Scholars and policymakers worldwide are working to lessen the impact of climate change [1][2][3]. In the Intergovernmental Panel on Climate Change report, the scientific community revealed that greenhouse gas emissions have escalated over the past few decades in spite of an increasing number of efforts to solve this issue [4]. The numerous harmful effects of climate change include the melting of ice sheets, increasing sea levels, and dangerous weather events as a result of severe heat waves. Similarly, land degradation, water scarcity and pollution, pose threats to future generations in terms of hunger and food security; thus, urgent attention should be demanded [1,4]. The devastating effects of human beings' patterns of living on the environment cannot be ignored. One significant example is the substantial impact of food choices and consumption patterns on climate change [2,5,6]. Prior studies have shown that dietary choices have a substantial effect on the environment [7] and are considered a key strategy to mitigate climate change [4,8]. In particular, food consumption accounts for a significant amount of GHGEs [3]. Prior studies have also found that food production processes contribute to GHGEs by 20-30% [5,9]. Furthermore, previous studies have demonstrated that minimizing meat consumption by substituting organic and vegetarian food has decreased the GHGEs in Sweden and China [9,10]. This is because meat generates higher emissions per unit of energy due to the energy lost at each trophic level compared with plant-based foods [7]. Hence, the relationship between food intake and climate change are evidenced in prior studies, e.g., [1,2,4,5,[8][9][10][11][12]. Recently, research evidenced that food-related carbon savings come primarily from dietary changes, particularly the adoption of a vegan diet [6]. According to a study that examined individual food choices and measured their potential impact on reducing GHGEs in developed countries, eating a plant-based diet can reduce annual personal emissions by 0.8 t CO 2 e/yr [6]. The environmental impacts of dietary choices can be minimized by decreasing animal product consumption, energy intake, and food waste [4]. The path toward a sustainable society can be pursued through governmental efforts and innovations and the sustainable actions of human beings. Hence, a cultural change is recommended for sustainable development [13]. Concerns over climate change have led to climate-friendly food consumption, involving the entire food consumption supply chain; from selecting, purchasing, cooking, and sorting food to disposing and recycling food waste. Climate-friendly food consumption refers to an individual's voluntary actions limiting dairy and meat product intake to help protect the environment [6]. The extant literature showed that adopting climate-friendly food is among the mitigating strategies for climate change impact [12][13][14]. Prior studies have also demonstrated that individual awareness of food choices and their subsequent impact on the environment is growing [15,16]. A recent study by Jalil et al. [17] investigated the effects of an awareness-raising intervention on meat consumption through a randomized controlled trial. The study found that interventions that advise individuals and support voluntary change can substantially decrease meat consumption [17]. In western countries such as Scotland, Australia, and Finland, the majority of previous research focused on people's awareness of food choices and their environmental impact [2,11,12]. Developing countries, on the other hand, have only conducted a small number of studies. Furthermore, there is still a lack of evidence linking climate change awareness and concern with subsequent mitigation behaviors in developing countries such as Saudi Arabia [18]. This study closes the knowledge gap. This problem is worsening in Saudi Arabia, where dietary products are more prevalent in Saudi individuals' daily food choices. Prior research investigated female food choices in the Eastern region of Saudi Arabia using qualitative methods and found that females are unaware of the impact of their food choices on environmental sustainability [19]. Accordingly, in a developing country such as Saudi Arabia, few studies have examined the understanding of, and concern about, climate change and its association with dietary choices [18]. Hence, this research investigated an individual's understanding of, and concerns over, climate change in Saudi Arabia. The study also examines the associations between sociodemographic characteristics and dietary choices with the understanding of, and concern over, climate change within the Saudi population. --- Materials and Methods The current research is underpinned by the positivist paradigm, a school of thought which believes that only knowledge gained through observation and measurement can be trusted [20]. Studies based on positivism limit the researcher's responsibilities to data collection and objective interpretation. This paradigm assists positivist researchers in better understanding phenomena through empirical methods such as sampling, measurement, and questionnaires. Positivists are primarily associated with quantitative research, since it involves gathering and converting data into numerical form to perform statistical calculations [20]. Hence, the use of a questionnaire as a primary tool of data collection is justifiable. --- Study Population This cross-sectional study included 280 participants between the ages of 18 and 60 years. Study participants were recruited from March to June 2021 in Jeddah City, Saudi Arabia. Recent statistical reports on Saudi Arabia based on Unified National data indicated that the total population in Jeddah in 2019 was 2,867,446 [21]. Therefore, the sample size required to obtain sufficient statistical power is 271 based on a 5% margin of error, 90% confidence level, and response distribution of 50% [22]. The study was approved by the Bioethics Committee of Scientific and Medical Research, University of Jeddah, Saudi Arabia . --- Study Questionnaire A self-administered online questionnaire was used to collect data through a web link shared over email and social media, such as Facebook, Twitter, and WhatsApp. Participants were randomly invited through the official channels of the University of Jeddah and King Abdulaziz University. Google Forms was used to construct the questionnaire, which included closed-ended questions written in Arabic; the questionnaire took less than 5-7 min to complete. In the online survey on the first page, the inclusion criteria of study sample were clearly stated. The inclusion criteria were adults above 18 years of age living in Jeddah city, and it was asked that any person outside of the inclusion criteria not to fill the questionnaire. Information explaining the study objectives and the target population was included on the first page of the questionnaire. The first page of the questionnaire also confirmed voluntary and confidential participation in the study. Signed online consent forms were obtained from all participants prior to data collection. The survey was anonymous, there was no collection of sensitive information, and the participants were able to leave at any point if they felt uncomfortable. The questionnaire was composed of three sections: sociodemographic characteristics of the participants , understanding of, and concern over climate change, and dietary choices. --- Assessment of Understanding of and Concern over Climate Change The second part of the survey included participant understanding and concern regarding climate change. The questionnaire was adapted from Korkala et al. [1] and Hope [23] with slight modifications. The question, "What do you think is meant by climate change?" was used to evaluate participants' understanding of climate change. Five options were provided: "an increase in sunspot activity and solar radiation," "a change in the axial tilt of the Earth," "an increase in population growth, energy consumption, and exploitation of nature," "an increase in the greenhouse gas concentration of the atmosphere due to human actions," and "a natural fluctuation of climate periods on Earth." Based on the IPCC report [24], alternatives 3 and 4 indicated sufficient understanding resulting in a score of 1, whereas alternatives 1, 2, and 5 indicated a poor understanding of climate change resulting in a score of 0. Furthermore, two questions were asked to assess the degree of concern over climate change. The first question was, "How serious of a threat do you think climate change is to humankind?" The choices were "a very serious threat," "quite a serious threat," "not a serious threat," "not a threat at all," and "I do not know." Alternatives 1 and 2 indicated a high level of concern, whereas alternatives 3, 4, and 5 indicated low concern over climate change. The second question was, "What are the possible future effects of climate change in Saudi Arabia?" The choices included "hotter temperatures," "more rain and floods," "colder temperatures," "rise in sea level," "loss in animals and plants," "no effect," and "I do not know." Alternatives 1 to 5 indicated a high level of concern, while alternatives 6 and 7 indicated low concern over climate change. The answers that reflect high levels of concern were given a score of 1 and the sum of scores for the two questions was calculated for all participants. --- Assessment of Dietary Choices The third part of the questionnaire collected information regarding food consumption during the past 12 months via a short food frequency questionnaire with 14 items adapted from a previous study [1]. The food items were selected based on their climatefriendliness; the FFQ included both climate-friendly and non-climate-friendly food items. The climate-friendliness of food items has been defined in previous studies based on their GHGEs. Climate-friendly foods include fresh fruits [25], fresh vegetables/salad/root vegetables [25,26], potatoes [25], vegetable oil [25], margarine [27], soy products [28], and organic foods [29,30]. Non-climate-friendly food items include French fries [31], rice [25], beef/lamb [25,26], poultry [25], milk [25], low-fat cheese, other cheeses [25], and butter [27]. The calculation to determine climate-friendly food consumption involved summing the intake of fresh fruits, fresh vegetables, potatoes , vegetable oil, margarine, soy products , and organic food divided by seven. The calculation for non-climate-friendly food consumption involved summing the intake of French fries, rice, beef/lamb, poultry, milk, low-fat cheese, other cheeses, and butter divided by eight. --- Statistical Analysis All statistical analyses were performed using the statistical analysis software program SPSS version 27. Descriptive statistics, including percentage and frequency distributions, were calculated from the data. The scores for the understanding of, and concern about climate change and food intake are presented as the mean± standard deviation . The score for understating and concerns were stratified to low and high; a high score for understating reflects participants with a score of one, and for concerns reflects participants with a score of two. A regression model was used to determine differences in the understanding and concern scores between participants according to their sociodemographic data adjusted for sex, age group, nationality, marital status, education, occupation, and income. Food scores were also compared with understanding of, and concern about climate change via a linear regression analysis adjusted for sex, age group, nationality, marital status, education, occupation, and income. Statistical significance was set at p ≤ 0.05. --- Results A summary of the participant sociodemographic characteristics is presented in Table 1. Nearly one-third of the study participants were between the ages of 18-29 years of age, while a quarter were between 30 and 39 years of age and a quarter were between 40 and 49 years of age. The majority of the study participants were females , Saudis , married , and employed in the government sector . Almost 61% of the study participants held a bachelor's degree, and 32% had a postgraduate's degree. A total of 36% of the study participants earned less than SAR 3000 monthly, and 21% earned SAR 7000-12,000 monthly. Nearly 87% of study subjects acknowledged that they had heard about climate change, whereas a small percentage said they had never heard about it. Likewise, approximately half of the study participants stated that they understood the term climate change, and 39% said they understood it to some extent. In contrast, only a small percentage said they did not know what climate change meant. In addition, 77% of the participants believe that human activity is largely responsible for climate change, while 10% believe that human activity is not responsible for climate change and a further 13% are unsure whether human activity is responsible or not . Overall, 45% of the study participants demonstrated a sufficient understanding of climate change and 55% exhibited a poor understanding. Approximately 56% of study participants displayed a high level of concern over climate change and 44% exhibited low concern. Climate change understanding and concern scores stratified by sociodemographic characteristics are presented in Table 2. Regarding the climate change understanding score, there were significant differences between males and females , where males displayed a higher understanding score compared with females . There were no significant differences in the climate change understanding score between participants in different age, nationality, marital status, education, occupation, and monthly income groups. Regarding the concern over climate change score, males demonstrated significantly greater concern over climate change scores compared with females . Additionally, participants with a postgraduate degree demonstrated the greatest concern about climate change scores compared with the other two educational groups . There were statistically significant differences in concern over climate change scores between participants in different income and occupational groups . Participants working in the public sector and with a monthly salary between SAR 7000 and 12,000 exhibited the highest level of concern over climate change scores. There were no significant differences in concern over the climate change score between participants in different age, nationality, and marital status groups. Table 3 displays participants' intake of selected food items according to their understanding of the climate change score. The participants were categorized as low and high according to their understanding of the climate change score. There was a significant positive association between understanding of climate change score and vegetable oil intake when comparing participants with high scores to those with low scores . Additionally, participants in the high score group consumed more vegetables compared with participants in the low score group after adjustment . There were no significant differences between the intake of fruits, French fries, potatoes, rice, red meat, poultry, milk, low-fat cheese, other cheeses, butter, margarine, soy products, and organic food, and understanding of climate change score. Participants' intake of selected food items according to their concern over climate change scores is presented in Table 4. Participants were categorized according to their concern over climate change scores into low and high groups. Higher scores for concerns about climate change were negatively associated with the intake of red meat , poultry , margarine , and soy products . The intake of red meat, poultry, margarine, and soy products among participants in the high score group were lower than that in the low score group . There were no significant differences between the intake of fruits, vegetables, French fries, potatoes, rice, milk, low-fat cheese, other cheeses, butter, vegetable oil, and organic food, and concern over climate change score. Overall, the participant intake of non-climate-friendly food was higher than that of climate-friendly food . --- Discussion Climate change is a major threat to public health. It has critically damaged various life support systems and cycles, endangering human lives. Dietary choices play a significant role in reducing climate change and alleviating its environmental impacts [5,14]. The current study investigated the levels of understanding and concern about climate change in Saudi Arabia and examined their associations with sociodemographic characteristics. It also examined the associations between the study participants' levels of understanding and concern about climate change and dietary choices. The results revealed a poor understanding of climate change but high concern among the study participants. In addition, males and medium-high monthly income individuals were associated with higher understanding of, and concern over climate change scores. Similarly, higher education and government employees were associated with higher concern over climate change scores. Furthermore, subjects with a higher understanding of climate change scores exhibited a higher consumption of vegetables and vegetable oils. In addition, subjects who demonstrated higher concern over climate change scores exhibited lower red meat, poultry, margarine, and soy product consumption. Although 87% of the study participants had heard about climate change and 45% admitted that they understood the term climate change, only 45% of study participants demonstrated a sufficient understanding of climate change. A poor understanding of climate change was reported in Bangladesh [32][33][34], whereas a greater understanding of climate change was reported in Finland [1]. In the current study, some participants expressed an understanding of human activities being responsible for the rise in GHGEs ; however, more believed that climate change is a natural fluctuation of climate periods on Earth, which reflects a poor understanding of climate change. In contrast, the study participants exhibited high levels of concern over climate change; nearly 62% of participants believed that climate change is a major threat to humans. A previous study reported that 36% of the Finnish population had high concerns and 47% demonstrated medium concerns about climate change [1]. Several studies have found high levels of concern over climate change [32,34], which is consistent with our findings. This study demonstrated that males exhibited a good understanding and greater concern over climate change than females, even though the number of females participating in the study was higher than that of males . Previous studies have demonstrated a greater female understanding of, and concern over climate change than males [1,23,33]. A previous study in Turkey determined that females were more concerned about climate change than males [33]. Similarly, a study in Finland illustrated that females exhibited a superior understanding and awareness of climate change compared with males [1]. However, a study in Guyana found no significant difference between both sexes in their understanding of climate change [23]. Scientific evidence has indicated sex differences regarding obtaining health knowledge and adopting healthy behaviors since females are more conscientious and more likely to seek reliable health information [35,36]. Our results can be explained by the fact that the males were more educated and older than the females in this study; 40% of males were postgraduate degree holders, whereas only 28% of females held a postgraduate degree. In addition, 39% of males in the study were 40-59 years of age, whereas 35% of females were 18-29 years of age. Thus, since the males in our sample were older and more educated than the females, they may be more knowledgeable about climate change topics and news. Moreover, previous research indicated that the education level is a strong predictor of climate change knowledge and awareness [32,33], which aligns with our findings that participants with higher education levels were highly concerned about climate change. A study from Bangladesh demonstrated that subjects with a sufficient level of education were more aware of climate change [32]. Other studies from the Philippines, Nepal, and China have reported similar results [37][38][39]. Therefore, increasing knowledge about climate change among students is a valuable strategy that can be used to enhance awareness of climate change. Furthermore, the results of this study indicate that a higher income is associated with a greater concern about climate change. One study from China illustrated that low-income individuals were less aware of climate change than those with a high income [39]. This is likely because individuals with higher income levels can afford higher levels of education. The current study results demonstrated that a sufficient understanding of, and higher concern over climate change were associated with a greater intake of vegetables and vegetable oils and a lower intake of red meat, poultry, margarine, and soy products among the study subjects. These results corroborate with those of previous studies, demonstrating that concerns about the environment are associated with sustainable behaviors, such as increasing eco-friendly product consumption [1]. Specific food item consumption and production are a primary cause of GHGEs [40]. Previous research indicated that animal products, such as red meat, poultry, cheese, and butter are associated with high GHGEs, whereas fruits, vegetables, and margarine are associated with low GHGEs and can thus be considered climate-friendly food items [25,31,40]. A study in Finland illustrated that individuals who demonstrated sufficient knowledge about climate change exhibited a higher intake of fruits, vegetables, vegetable oils, organic foods, and soy products. The study also indicated that individuals with a high level of concern over climate change consumed less red meat and French fries; however, they consumed more fruits, vegetables, vegetable oils, organic foods, and soy products [1]. These findings are consistent with our results, except for soy product and organic food intake; the consumption of soy products and organic foods was low in our study. Nearly half of the study subjects reported that they never consumed soy products or consumed them less than once per month in the last 12 months. The consumption of organic foods was also low; 20% of participants admitted that they never bought organic food, and 40% stated that they consumed organic food less than once per month in the last 12 months. One possibility for this finding is the higher prices of these food items in Saudi Arabia, particularly organic food. Food and livestock production is the primary cause of environmental harm, since it typically consists of excess water use and deforestation [4]. For example, the production of meat and dairy products is responsible for 15-24% of GHGEs worldwide, which explains why climate change scientists consider these food items non-climate friendly [4,35]. In the United Kingdom, one study indicated that reducing meat consumption decreased the production of GHGEs by 35%. In addition, eliminating food waste also decreased GHGEs by 12% [41]. Similarly, a study in the United States suggested that replacing meat with plant-based food effectively reduced GHGEs and improved human health [42]. Research demonstrated that vegan and vegetarian diets are highly associated with reduced GHGEs compared with a diet rich in meat [43]. A study in Lebanon indicated that the western diet, which is rich in meat, dairy products, and processed foods, was highly associated with GHGEs. In contrast, the Mediterranean diet, which is rich in vegetables, fruits, and legumes, produced minor amounts of GHGEs [44]. Our results demonstrated that individuals with higher concern over climate change scores exhibited significantly lower red meat and poultry consumption. This implies that the effect of concern on individual behaviors, including environmental behaviors, may be higher than the effect of knowledge on behaviors that has been demonstrated in previous research [1,45]. However, our results also showed that individuals with a higher concern of climate change score had no increase in the intake of vegetables. Indeed, previous studies reported that the population of Saudi Arabia had a generally insufficient intake of fruits and vegetables [46,47], which may be the reason for this finding. Climate-friendly foods can also improve human health and prevent chronic diseases; hence, people may increase their intake of these food items for health purposes instead of climate change mitigation. Numerous studies have demonstrated that reducing the consumption of red meat prevents coronary heart disease, type 2 diabetes, and several types of cancers, in addition to decreasing the production of GHGEs [48,49]. Chronic diseases, such as coronary heart disease, obesity, hypertension, high blood lipids, and type 2 diabetes, are highly prevalent in Saudi Arabia [50]. Saudi Arabia ranked number 84 in the Global Climate Risk Index since it has many environmental challenges that place the Kingdom at great risk. These challenges include air pollution, restricted freshwater sources, coastal flooding, high rates of energy consumption, and high rates of CO 2 emissions per capita [51]. The Kingdom of Saudi Arabia has implemented numerous strategies for climate change mitigation, including green building projects and sustainable transportation, such as light rail transit in Riyadh, Jeddah, Makkah, Madinah, and Dammam, as well as the Riyadh metro [51]. The "Green Saudi initiative" was launched in 2021 as part of the national 2030 vision. The initiative aims to increase vegetation cover and reduce land degradation, air pollution, and CO 2 emissions nationwide [52]. Regardless of the massive efforts of the Saudi government to mitigate climate change, the study indicated poor understanding and medium concern over climate change in the Kingdom. Therefore, enhancing the knowledge and concerns about climate change, increasing the intake of climate-friendly food choices, and reducing or replacing the intake of non-climate-friendly food among the population of Saudi Arabia can simultaneously benefit human and environmental health. --- Limitations and Future Studies The current study has several limitations. The FFQ required study participants to accurately remember their food intake in the last 12 months, introducing some recall bias. In addition, information such as the portion size of the food and the amount of food wasted was absent, which is considered a weakness of this study, since this information is highly related to reducing climate change. Further, the results cannot be generalized to all Saudis, since the study was only conducted in one city. Future studies should include representative samples from all regions of the country. In addition, using an online survey to recruit study participants may introduce self-selection bias and non-probability sampling; however, the online survey was a safe way to collect the data for this study due to the COVID-19 pandemic. Similarly, selection bias may be an issue in this study because participants who were interested in the topic "dietary choices as determinants of the understanding and concerns over climate change in Saudi Arabia" might have been more enthusiastic to complete the survey. Moreover, this study did not assess the participant awareness of the relationship between food choices and climate change issues. Therefore, their consumption of specific food items may be related to managing health instead of climate change mitigation. A previous study in Saudi Arabia reported that females were unaware of the impact of their food choices on the environment [19]. Future studies should also explore the barriers to organic food consumption in Saudi Arabia and examine the Saudi attitudes and behaviors surrounding eco-friendly food consumption. Further research is needed to determine whether the decrease in meat consumption is related to the growing level of concern. This study also exhibits several strengths. This is the first study to examine the associations between the understanding of and concern over climate change and dietary choices in Saudi Arabia to the best of our knowledge. The study included many food items that were considered either climate-friendly or non-climate-friendly food items based on previous research. The findings of the current study offer insight into how individuals of Saudi Arabia understand and believe in climate change issues. It also provides a foundation for future studies to promote healthy dietary choices and mitigate climate change in the country. --- Managerial Implications We proposed the following recommendations based on our results. Public health representatives should increase awareness of the impact of climate change on public health. Universities and schools should also play a pivotal role in protecting the environment. Specific curricula should be dedicated to educating students about the importance of protecting the environment and how sustainable behaviors can mitigate the impact of their consumption on the environment. In particular, initiatives and campaigns that disseminate knowledge about individual dietary habits and their subsequent influence on the environment and public health should be increased. Further efforts should be made by the Ministry of Environment, Water, and Agriculture to increase Saudi population awareness of the benefits of sustainable consumption on the environment and to broaden their knowledge about their responsibility toward the environment. Businesses, as part of their social responsibility, should encourage green products, services, and operations to foster green consumption behaviors. These efforts can be supported by social marketing campaigns that foster and encourage the consumption of green products and services among Saudi consumers. Expanding communication through social media, such as Twitter, Facebook, Instagram, and Snapchat, is the most common approach used by Saudis to disseminate information. Specific campaigns can be directed to Saudi females to increase their knowledge about the negative impact of climate change on the environment and health and encourage their engagement to protect the environment. Governments, businesses, and communities should work together to enhance awareness of the benefits of climate-friendly food choices for climate change mitigation and public health, to encourage sustainable behaviors. --- Conclusions Climate change is a global phenomenon that threatens human health, biodiversity, and the environment. The extent to which human practices and behaviors have an impact on the environment, and specifically climate change, has been documented in the literature; choosing what to eat is one of them. In particular, dietary choices have an enormous impact on the environment and are important strategies to combat climate change. Hence, the current study investigates climate change awareness and concern in Saudi Arabia, as well as the association between these factors, social demographics, and dietary choices. Data were collected for this cross-sectional research using an online questionnaire. We retrieved 280 completed forms; 45% of the study participants had sufficient understanding of climate change, and 56% were concerned about climate change. Participants who understand climate change and are concerned about it are more likely to be male, have a medium-high monthly income, have a high education level, and work for the government. The findings also revealed that participants with a sufficient understanding of climate change ate more vegetables and vegetable oils, while those with a high level of concern for climate change ate less red meat, poultry, margarine, and soy products. Furthermore, the intake of nonclimate-friendly food was typically higher than the intake of climate-friendly food among the study participants. These findings are critical for encouraging people to adopt healthy behaviors and consume climate-friendly food to minimize the risk of climate change and improve public health. The current study contributes to the body of literature about climate change by investigating the relationship between food intake and its subsequent impact on the environment. As far as we are aware, this is the first study of its kind to measure Saudi citizens' awareness of the effects of climate change and its impact on their food choices. The findings of this study shed light on how citizens in Saudi Arabia perceive and believe in climate change. As a result, we have a better understanding of Saudi Arabians' perspective about climate change. It also lays the groundwork for future studies aimed at promoting healthy eating habits and reducing climate change in the country. --- Data Availability Statement: The datasets generated and/or analyzed during the current study are not publicly available because the authors require them for further publication. They are available from the corresponding author upon reasonable request. Signed online consent forms were obtained from all participants prior to data collection. --- Supplementary Materials: The following are available online at https://www.mdpi.com/article/ 10.3390/ijerph182010605/s1, Table S1 Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

Sociodemographic Characteristics and Dietary Choices as Determinants of Climate Change Understanding and Concern in Saudi Arabia. Int. J.

Poor diet is a major contributor to the burden of noncommunicable diseases and, in the UK, costs the National Health Service £6 billion annually . Evidence from the annual rolling National Diet and Nutrition Survey shows that UK adolescents aged 11-18 years have poorer diets than other age groups . Additionally, the Health Survey for England indicates that 23 % of adolescents aged 11-15 years are already obese; a figure that has gradually increased from 14 % in 1995 . Implementing strategies that improve adolescents' dietary behaviours are crucial because a sub-optimal diet in adolescence affects immediate health as well as raising the risk of obesity and non-communicable diseases later in life and in the next generation . Non-alcoholic beverages are the primary source of free sugars in adolescents' diets, most of which are sugary soft drinks and energy drinks . A survey of energy drinks for sale in the UK indicates that their average sugar content was 9•7 g/100 ml, with some drinks containing up to 16 g/100 ml . Approximately half of the energy drinks available also have a serving size of 500 ml meaning a single bottle markedly exceeds the current dietary recommendation for free sugars which is 30 g/d for individuals aged over 11 years . Energy drinks are distinguishable from other soft drinks because they contain large amounts of caffeine and potentially other stimulants such as guarana, taurine and ginseng . The energy drink survey described above identified that the average caffeine content of energy drinks is also high at 31•6 mg/100 ml , equating to 158 mg of caffeine in a 500 ml bottle . The current European caffeine recommendations specify a daily allowance of 3 mg of caffeine/kg body weight . A single serving of these drinks therefore surpasses this recommendation for adolescents with a body weight below 53 kg. Among adolescents energy drink consumption has been linked to several physical symptoms including headaches, stomach aches, hyperactivity and insomnia; these symptoms largely relate to the high caffeine and sugar content of energy drinks . Energy drink sales have grown substantially over the past decade with current UK sales estimated at 680 million l/year . Alarmingly, a European Food Safety Authority report indicated that young people aged 10-17 years are the greatest energy drink consumers . The report's statistics indicate that British adolescents consumed the greatest quantity of energy drinks of all participating European countries, consuming over a litre a month more than the European average of 2 l/month. The report also showed that more older adolescents and boys reported consuming energy drinks than younger adolescents and girls . Increased awareness of the potential dangers that energy drinks pose to young people's health has led several major retailers to impose voluntary bans on the sale of energy drinks to minors under 16 years ; many UK schools have also introduced voluntary bans to prevent students drinking them on school premises . In 2018, the UK Government undertook a consultation on their proposal to introduce legislation to ban the sale of energy drinks to minors; they proposed this would create consistency across retailers and protect young people's health . The House of Commons Science and Technology Committee released an advisory report at the end of 2018 outlining their interpretation of the evidence and recommendations to government. They concluded that there was insufficient evidence to warrant introducing a ban on selling energy drinks to children . The Committee's report acknowledged that energy drinks were consumed disproportionately by disadvantaged groups but noted that evidence of this trend worsening over time or undermining educational or health outcomes was needed for action to be taken. Additionally, insufficient evidence about the impact of voluntary bans was highlighted, with recognition that qualitative evidence from teachers and parents could indicate societal concerns that would provide legitimacy for a statutory ban. Contrary to the Committee's recommendations, the 'Advancing our Health: prevention in the 2020's' green paper, released in 2019, announced that the UK Government intended to introduce a ban on the sale of energy drinks to individuals aged under 16 years . The basis for this ban was largely founded on the rationale that reductions in energy drink consumption would decrease calorie intake and improve diet, thereby helping to lower obesity rates. Providing scientific evidence of these associations would further support government intervention and is necessary because the exact details of this policy are yet to be published. To address existing evidence gaps and provide robust scientific evidence to inform policy change, we conducted a mixed-methods study combining data from a national dietary dataset with qualitative data from interviews with adolescents, parents and teachers. The specific aims were: 1. To determine the prevalence of energy drink consumption among adolescents in the UK and assess how consumption varies by gender and age group. 2. To examine associations between energy drink consumption among adolescents in the UK and deprivation and dietary inequalities. 3. To explore teachers', parents' and adolescents' perceptions of adolescent energy drink consumption and the effectiveness of current voluntary energy drink restrictions in schools and supermarkets. --- Method --- Study design and setting This study adopted a mixed-methods study design. Quantitative data were used to address the first two research aims and qualitative data used to address the third aim. Qualitative and quantitative datasets were then combined to corroborate findings and expand the breadth and depth of interpretation. Quantitative data were taken from the NDNS rolling programme, a repeated cross-sectional survey conducted with a representative sample of the national population. Each year the NDNS programme recruits approximately 500 adults and 500 children aged over 18 months from randomly selected households across the UK. Participants are asked to complete a face-to-face questionnaire about household and individual demographics as well as an estimated food diary . Qualitative data were collected as part of the development work for the Engaging Adolescents in CHanging Behaviour study, a multi-component intervention to support adolescent diet and physical activity . This formative work was conducted in community settings in Hampshire, UK. All elements of this study were conducted according to the Declaration of Helsinki and data protection regulations and were approved by the University of Southampton, Faculty of Medicine Ethics Committee . Quantitative data: National Diet and Nutrition Survey Dietary intake data were derived from food diaries. Participants recorded details of all foods and drinks consumed on up to four consecutive days, with estimated portion sizes, brand names or ingredients for homemade meals. Trained NDNS coders classified the items in the diaries into 154 food groups and assigned energy values . Detailed descriptions of the design and methodology can be found elsewhere . Our analyses were performed on 2587 adolescents aged 11-18 years from the combined survey waves 1-8, from 2008 to 2016. Frequency of energy drink consumption was calculated for each participant, adjusting for the number of diary days completed. As energy drinks are not categorised into their own NDNS food group, the names of all items categorised in the 'Soft drink, not diet' and 'Soft drinks, diet' categories were extracted and reviewed. Energy drinks were defined as drinks containing over 150 mg of caffeine were excluded) in accordance with European Union labelling regulations for high-caffeine products requiring warning labels for children . Energy drinks with low or no sugar were included. Total daily energy intake was calculated for each participant by summing the energy for all the food and drink items consumed and averaging over the number of diary days. A diet quality score was derived for each participant using NDNS data using a published methodology . Diet quality scores were generated using principal component analysis on 139 food groups; vitamins, minerals and artificial sweetener groups were removed. principal component analysis is a commonly used method for generating dietary patterns . The first component of the principal component analysis explained the greatest variance in the dietary data and represented a diet consistent with UK dietary recommendation: higher consumption of fruit, vegetables, wholegrains and lower intake of sugar-sweetened beverages, chips and processed meats. The principal component analysis allocated coefficients to each food group to quantify their contribution to the overall component. The coefficients and reported frequencies of consumption were used to calculate a dietary quality score for each participant. To facilitate interpretation of the results, dietary quality scores were standardised to a mean of zero and a SD of one with higher scores representing better quality diets; dietary scores have been validated against fourteen nutritional biomarkers, including serum folate, homocysteine, total carotenoids and vitamins B 12 , C and D . An equivalised household income variable was developed using total household income reported by the main food provider, adjusted for household size and demands. Index of multiple deprivation , the official measure of relative deprivation for small areas in England, was calculated for each participant based on the household postcode . IMD scores were divided into quintiles and used to determine the neighbourhood deprivation for each household. IMD was not recorded in the NDNS for waves 5 and 6 due to changes in the study protocol. BMI Z-scores were created to adjust for age and sex and categorised according to cut-offs defined from nationally representative surveys with adolescents. Qualitative data: interviews with adolescents, parent and teachers Semi-structured interviews were conducted with parents, teachers and adolescents to learn about adolescents' daily food and physical activity habits and what could support healthier choices. Interviews were conducted with an additional sample of adolescents to explore energy drink consumption in more depth. All interviews were conducted using semi-structured topic guides distinct for each participant group . Participants were not shown the questions in advance. Participants were recruited in 2018 from a secondary school, a community youth club and at a hospital open day. Adolescents were interviewed at their school or youth club. The school was a non-selective mixed secondary school where above-average numbers of students were eligible for free school meals , compared to the national average . The youth club targeted adolescents from disadvantaged backgrounds with low school attendance. Teachers at the school were interviewed during working hours. Parents were interviewed at their workplace or home by telephone or in person at a hospital evening event for parents. Adolescents and teachers were interviewed in either pairs or groups of three to six participants; parents were interviewed individually or in groups containing three participants. All face-to-face interviews were conducted by one researcher with an observer present who took notes ; telephone interviews were conducted by one researcher and with a single participant. Interviews were transcribed verbatim and pooled together into a single NVivo project . Participants did not comment on their transcripts. --- Quantitative data analyses Summary statistics were used to describe NDNS sample characteristics: mean for normally distributed continuous variables and median for non-normally distributed continuous variables. Frequencies are quoted for binary variables. Frequency of energy drink consumption was calculated per participant, adjusting for the fact that 1•8 % of diaries were completed for only three of the 4 d . Energy drink consumption was highly skewed, with 93•0 % of children reporting consuming no energy drinks in their food diaries; these data were therefore analysed as a dichotomous variable . To assess differences in energy drink consumption according to age, gender and neighbourhood deprivation, the proportions of energy drink consumers were calculated across categories of demographic variables. Logistic regression models were fitted with energy drink consumption as the outcome to describe the effects of demographic variables on energy drink consumption. A logistic regression model was fitted with IMD, year of study and the interaction between the two as predictor variables; the interaction term describes whether the effects of IMD differ as the year of study increases. To assess whether energy drink intake related to dietary quality, diet scores were divided into tertiles describing poorer, medium and higher quality diets. Age was divided into two groups, 11-15 and 16-18 years because most adolescents commence secondary school at age 11 and college at age 16. Household income was divided into two categories which is reflective of the UK median household income in 2012, the midpoint for the data time period . Daily energy intake was divided into four groups . Changes in diet quality score are interpreted in terms of the original foods consumed by calculating the equivalent change on the original scale to the change from the median on the Fisher-Yates transformed scale. Weights were provided in the NDNS dataset to adjust for the under-representation of children in households with more than one child and for the cluster identifier . The weights were rescaled to reflect different sample sizes in different waves so all data could be combined. Weighted analyses are presented throughout. --- Qualitative data analysis NVivo queries were used to extract the broad context of any references to 'energy drinks', and popular brands in the UK e.g. 'Red Bull', 'Monster' and 'Rockstar'. 'Lucozade' was also included because brands with lower caffeine levels are colloquially called energy drinks . Quotes were analysed using conventional content analysis following established guidelines . Initial codes were developed by C.V. and S.J. by creating 'nodes' in NVivo as new topics arose. After all transcripts had been coded, 'nodes' were refined with input from S.Sh., S.St. and M.B. and organised into themes and sub-themes. This approach is aligned with a relativist ontological and subjective epistemic position, which purports that reality is a matter of individual perspective and based on personal experience and insight . To ensure the interpretation was an accurate representation of interviewees' views and data analysis decisions were transparent, a rigorous process was adopted in which data were double-coded by pairs of the researchers, and disagreements were resolved in team discussions throughout the coding process. The five researchers involved in the qualitative analysis were all women, their expertise were in nutrition and/or psychology and their ages varied from young adult to middle age. --- Results --- Participant characteristics: quantitative data The quantitative analysis sample comprised all 2587 adolescents, 1305 girls and 1282 boys in waves 1-8 of the NDNS dataset . The majority were aged 11-15 years , of white ethnicity and lived in households with <£27 000/year . The distribution of BMI Z-score was similar by age categories, such that 31 % of those aged 11-15 were classified as overweight or obese, compared to 27 % of those aged 16-18. --- Participant characteristics: qualitative data Of the fifty-seven interviews conducted, twenty-eight were with adolescents , twenty with parents and nine with teachers . Demographic data were not collected from two adolescent group interviews due to time restrictions. Of the adolescent participants who provided demographic data , most were aged 13-14 years and of white ethnicity ; fewer than half were girls . The majority of parents and teachers were women and of white ethnicity ; most parents were aged 40-49 years , while almost threequarters of teachers were aged 20-39 years . --- Aim 1: prevalence of energy drink consumption among adolescents in the UK The NDNS data showed that 7•0 % of adolescents consumed at least one energy drink in a 4 d period. Older adolescents were more likely to consume energy drinks than younger adolescents . A 1-year increase in age was associated with a 21 % increase in the likelihood of energy drink consumption ; P < 0•001). This trend of increased energy drink consumption through adolescence did not decline over time, despite the known increase in public awareness of safety concerns regarding energy drinks . No difference was observed between the proportion of girls and boys consuming energy drinks . Aim 2: associations between energy drink consumption and deprivation and dietary inequalities Adolescents in more deprived areas consumed energy drinks more frequently than those in more affluent areas . A one quintile increase in IMD was associated with a 40 % increased likelihood of consuming energy drinks ; P < 0•001). Similarly, adolescents from lower annual income households were more likely to consume energy drinks compared to those from higher annual income households . A £1000 increase in household income was associated with being 2 % less likely to consume energy drinks ; P < 0•001). Between 2008 and 2016, energy drink consumption among adolescents living in the most deprived areas increased, whilst consumption among those living in the most affluent neighbourhoods decreased . Adolescents' consumption of energy drinks was also associated with poorer dietary quality . A 1 SD increase in dietary quality score was associated with being 54 % less likely to consume energy drinks ; P < 0•001). Changes in diet quality scores can be achieved in many ways; an illustration of 1 SD higher dietary quality score is consuming seven additional portions of nuts and seeds and six additional portions of salad and other raw vegetables/week, plus six fewer portions of chips and six fewer portions of sugar-sweetened carbonated-drinks/week. A 100 kcal increase in daily energy intake was also associated with 4 % increased likelihood of consuming energy drinks ). Additionally, a 1 SD increase in BMI score was associated with 9 % increased likelihood of consuming energy drinks ; P = 0•40). Aim 3: to explore teachers', parents' and adolescents' perceptions of adolescent energy drink consumption and the effectiveness of current voluntary energy drink restrictions in schools and supermarkets Three dominant themes were identified from the qualitative interviews, which are summarised below along with illustrative quotes. Theme 1: a lot of young people drink energy drinksfriends and price are key reasons why Many of the adolescents interviewed mentioned consuming energy drinks weekly or monthly, and a number reported more frequent consumption. For several adolescents, energy drinks were part of their daily routine: Adolescents sometimes struggled to say 'no' to energy drinks when they were offered them by their peers, but some had made a conscious decision to reduce their consumption after learning what the drinks contained. These adolescents expressed confusion when they saw their parents or other adults drinking them: 'If someone buys me one, I have a sip of it, but then give it away : : : I know what's in them now' Parents and teachers were also aware that many adolescents consume energy drinks regularly. Teachers raised concerns about the social desirability of energy drinks among adolescents and most acknowledged that energy drink consumption had become an accepted norm among their students and conformed to the social pressures: 'You can see what they've been buying on this App. And these fruit drinks, which are energy drinks, he bought four in 1 day' 'There's definitely a social pressure. If their friends [say], 'oh I have five energy drinks a day', there is just a constant pressure. I think they're at that point where they're thinking about who they are and who they want to be' Theme 2: energy drinks are not good for health and cluster with unhealthy diets Adolescents largely recognised that energy drinks are not good for their health and some had experienced negative physical side effects from drinking them. Many, however, Adolescents also felt that profits were more important to some businesses than following the voluntary bans to sell energy drinks to minors. These sorts of statements were said with disdain towards the shop owners indicating disapproval of this approach: 'Shops just don't care, as long as they're making their money.' Teachers also reported that voluntary bans in schools had limited effectiveness on reducing energy drink intake. Teachers were aware that students smuggled energy drinks into school and acknowledged that enforcing the school bans were not always easy: 'I know quite a few of them still have Lucozade though and Red Bull : : : . They do, they hide it in their bags very well.' [Teacher interview 13] Some adolescents felt that if energy drinks are detrimental to their health, access to them in stores should be restricted so they were more difficult to buy. Other adolescents, however, were adamant that they would find ways around stricter sales restrictions: 'But then energy drinks, if they're that bad and they've gotta have ID then surely they shouldn't be in the fridge, they should be behind the tills with all the alcohol.' 'We'd get people to get them for us : : : and I'd get it from the shop myself 'cose I know all the shops round here and they all love me.' --- Discussion --- Main findings This mixed-methods study used a nationally representative dietary dataset to characterise inequalities in energy drink consumption and semi-structured interviews with a large sample of adolescents, parents and teachers to provide deeper insight into adolescent energy drink intake and effectiveness of its current regulation. The findings showed that the overall prevalence of adolescents' energy drink consumption over a 4-d period was 7•0 %, and that consumption rates were higher among older adolescents, regardless of gender . Additionally, this trend of greater energy drink consumption with age did not decline over time. This study demonstrated clear associations between adolescent energy drink intake and markers of socio-economic deprivation and dietary inequalities . Adolescents living in more deprived areas and from lower income households were considerably more likely to consume energy drinks than those from more affluent areas and households, and higher energy drink consumption was associated with poorer dietary quality, higher energy intake and greater body mass. Worryingly, inequalities in energy drink consumption by area deprivation increased over the 8 year timeframe of the quantitative dataset, with rates increasing among those from the most deprived areas and decreasing among those most affluent. Three themes were identified from the interviews with adolescents, parents and teachers . First, many adolescents who drink energy drinks do so because of their friends and because the unbranded drinks are cheap. Second, energy drink consumption clusters with other unhealthy eating behaviours and the harmful physical effects of energy drinks have been witnessed by teachers and some parents; yet many adolescents do not know exactly why energy drinks are unhealthy . Third, participants generally felt that voluntary bans in retail outlets, particularly smaller stores, and in schools do not work; many favoured the introduction of legal restrictions on selling energy drinks to minors but some felt they could find ways to circumvent tougher restrictions. --- Comparison with previous research The prevalence estimate of adolescent energy drink consumption from this study seems lower than previous research from a similar point in time, including findings from the World Health Organisations' European Health Behaviour in School-aged Children study which indicates that energy drink consumption rates across countries range from 9 to 24 % . Such differences in prevalence rates may be due to variations in data collection methods. These previous studies asked about energy drink intake within the past week and reported prevalence rates of 15, 21 and 24 % for adolescent consumption at least once a week, and 9 % prevalence for consumption 2-4 times a week. The current study used food diaries of up to 4 d. It is therefore likely that due to this short time frame, our findings offer a more conservative estimate of energy drink consumption compared with other studies and indicate the prevalence of very frequent, or daily, energy drink intake among adolescents in the UK. Teachers and parents perceived that energy drinks were associated with a specific social identity which fuelled their popularity among adolescents. Energy drink consumption has previously been linked to group membership and social identity among young people . In this study, social status acquired from energy drink consumption was not expressed explicitly by adolescent participants and it is unclear how aware they were of their behaviour being influenced by cultural norms. Some adolescents, however, did mention feeling pressured to partake when energy drinks were being circulated by their peers. Adolescents are known to value social acceptance and group membership, but simultaneously strive for autonomy . These somewhat conflicting determinants of behaviour may help to explain a reluctance in revealing or understanding the true motives for their energy drink consumption. Internationally, research has shown that energy drinks are consumed more frequently by older adolescents and by those from more disadvantaged backgrounds . Our findings align with this previous work, showing that each additional year of age increased the likelihood of consuming energy drinks by 21 %, with highest rates among 17 and 18 year olds. This pattern likely reflects the growing levels of independence over food choices that adolescents acquire with age, and challenges the UK Government's proposal to prohibit the sale of energy drinks to those under 16 years of age. Applying the cut-point at 18 years of age would be more consistent with the evidence on energy drink intake and could help protect older adolescents from more disadvantaged backgrounds who appear to be particularly vulnerable to the regular intake of energy drinks. A disturbing pattern of increasing inequalities in energy drink consumption was revealed in our study, whereby intakes among adolescents from the most deprived communities increased over an 8-year period while intakes among those from affluent communities decreased. Clustering of unhealthy behaviours among energy drink consumers was also apparent in both our quantitative and qualitative data results, showing that energy drink consumers had poorer quality diets, higher daily energy intake and larger BMI. Previous research has shown that multiple unhealthy behaviours cluster among young people from disadvantaged backgrounds, particularly low fruit and vegetable intake and high tobacco and alcohol use, as well as low fruit and vegetable intake and low physical activity levels coupled with high sedentary behaviour and high sugary drinks intake . In our study, each additional SD increase in BMI was associated with 9 % greater likelihood of adolescents' consuming energy drinks. Although not statistically significant, this may suggest the simultaneous occurrence of health-compromising behaviours that could accentuate the risk of non-communicable diseases among these young people. This higher risk has implications for themselves, their future off-spring and society. Interventions to reverse entrenched inequalities are likely to be most successful if they target multiple risk behaviours and address social and environmental drivers . --- Implications for policy The findings from this study support the UK Government's plans to introduce legislation to end the sale of energy drinks to minors ; it suggests that voluntary bans in large supermarket chains and schools are not implemented effectively and are undermined by smaller convenience stores who continue to sell these products to adolescents. More deprived neighbourhoods have higher concentrations of convenience stores and poorer in-store environments . Such unhealthy environmental exposures have been shown to exacerbate existing dietary inequalities and may be contributing to the increasing disparity in energy drink consumption between adolescents from more deprived and more affluent areas; legislation may therefore help to address inequalities. Importantly, this study highlights that the proposed legislation would miss the opportunity to reduce consumption among the highest energy drink-consuming adolescents; those aged 16-18 years. The limit of 16 years may be challenging to implement and easier for younger adolescents to work around. Well-established age restrictions on the sale of tobacco and alcohol to those aged under 18 years already exist in the UK. Aligning the limits on the sale of energy drinks with these established legislations would provide a clear message to the public that these drinks are not suitable for adolescents, as well as facilitating consistent enforcement across all retail premises. For the proposed legislation to be maximally effective additional actions could be considered by policymakers, including minimum pricing of energy drinks and positioning them in restricted areas of retail outlets. The cheap price of own-brand energy drinks was identified as a key determinant of their consumption by adolescents, particularly those from disadvantaged backgrounds, in this and previous research . Introducing a minimum pricing of energy drinks could successfully limit intake in a similar way that the introduction of minimum alcohol pricing in Scotland showed immediate impact, reducing alcohol purchases among lower income and higher alcoholpurchasing households . Additionally, adolescents interviewed in this study suggested that placing energy drinks behind counters with tobacco and some alcohol products would clearly indicate a health warning and make them less accessible to young people. There is increasing evidence that product placement influences purchasing patterns and could be used to support health behaviours, including among adolescents . A communications campaigns about the harmful effects of energy drinks may also be warranted. While there is good evidence illustrating the harmful and unpleasant physiological effects of energy drinks , adolescents taking part in this study did not truly understand what made energy drinks so dangerous. Recent evidence indicates the harmful physiological effects of energy drinks on the cardiovascular system occur independently from caffeine, possibly caused by the additional energy-boosting substances such as taurine, guarana and sugar . Overuse of energy drinks has caused sudden cardiac death, poor mental health and hinders academic performance ; these risks need to be appropriately communicated to young people and their families. Future research could: test how labelling strategies, such as warning labels, may help to inform adolescents about the dangers of energy drinks and co-create the design of communication strategies that align with adolescents' values of autonomy and fun while informing them of healthier alternatives to energy drinks . --- Strengths and limitations The use of mixed-methods is a strength of this study because it enables a more nuanced understanding of how energy drinks fit into the lives of young people in the UK. The quantitative analyses used a nationally representative dataset that is representative of, and generalisable to, the UK adolescent population. Self-report dietary assessment methods have been shown to be prone to under-reporting and thus reporting bias may have been possible, particularly among adolescents from more advantaged backgrounds . The qualitative data included views from a range of population groupsadolescents, parents and teachersdifferent genders and individuals living in more disadvantaged areas. The interviews were conducted in pairs or groups which may have affected the responses received due to the dynamics between participants. For example, very close friends being interviewed as a pair may have given more detailed responses than a larger group interview with members from different friendship groups or different genders. Offering only large or smaller groups may have limited the scope of information received from participants. A methodological consideration is that the qualitative data were collected from a single southern county in the UK and that most participants were white. Unlike the quantitative data, the qualitative sample is therefore not representative of adolescents across England; however, recruitment strategies targeting lower income youth clubs and schools aimed to improve representation across the socio-economic spectrum. Interviews with more diverse groups of adolescents from a different area may have produced different information. --- Conclusions This study supports the introduction of legal restrictions on the sale of energy drinks to minors but indicates that prohibiting energy drink sales to those under the age of 16 years would miss the opportunity to reduce consumption among the highest consumers, those aged 16-18 years from disadvantaged backgrounds. Such restrictions would level the playing field between retailers and may be maximumly effective if coupled with minimum-pricing strategies, placement restrictions and a communications campaign detailing their harmful effects.

Objective: To examine energy drink consumption among adolescents in the UK and associations with deprivation and dietary inequalities. Design: Quantitative dietary and demographic data from the National Diet and Nutrition Survey (NDNS) repeated cross-sectional survey were analysed using logistic regression models. Qualitative data from semi-structured interviews were analysed using inductive thematic analysis. Setting: UK. Participants: Quantitative data: nationally representative sample of 2587 adolescents aged 11-18 years. Qualitative data: 20 parents, 9 teachers and 28 adolescents from Hampshire, UK. Results: NDNS data showed adolescents' consumption of energy drinks was associated with poorer dietary quality (OR 0•46 per SD; 95 % CI (0•37, 0•58); P < 0•001). Adolescents from more deprived areas and lower income households were more likely to consume energy drinks than those in more affluent areas and households (OR 1•40; 95 % CI (1•16, 1•69); P < 0•001; OR 0•98 per £1000; 95 % CI (0•96, 0•99); P < 0•001, respectively). Between 2008 and 2016, energy drink consumption among adolescents living in the most deprived areas increased, but decreased among those living in the most affluent neighbourhoods (P = 0•04). Qualitative data identified three themes. First, many adolescents drink energy drinks because of their friends and because the unbranded drinks are cheap. Second, energy drink consumption clusters with other unhealthy eating behaviours and adolescents do not know why energy drinks are unhealthy. Third, adolescents believe voluntary bans in retail outlets and schools do not work. Conclusions: This study supports the introduction of age-dependent legal restrictions on the sale of energy drinks which may help curb existing socio-economic disparities in adolescents' energy drink intake.

Introduction Over the past decade, with some exceptions, accumulating research has found that the neighborhood food environment, specifically the types of food outlets available and food products offered, is associated with dietary intake and obesity risk . Research has shown that low-income and African-American neighborhoods have fewer supermarkets and more liquor stores and convenience stores than higher income and White neighborhoods, respectively . Fewer healthy food options and lower quality foods, even after accounting for store type, in low-income and African-American neighborhoods have also been documented . Thus, residents of African-American and low-income neighborhoods tend to face more environmental barriers to healthy eating than residents of other neighborhoods. While much of this research has been quantitative, qualitative studies on food shopping and influences on dietary behaviors have recently emerged the include perceptions of neighborhood food environments . Similar to quantitative studies, many of these studies have found that lack of physical access to supermarkets and high-quality, reasonably priced healthy foods are perceived barriers to healthy eating. However, few of these studies have explored environmental factors in depth or included substantial numbers of African-Americans, especially urban African-Americans . Furthermore, little is known about food acquisition behaviors among individuals living in neighborhoods with restricted food environments . Understanding perceived environmental influences on food acquisition in neighborhoods with few food resources is critical to inform environmental and policy interventions to expand access to healthy food and promote healthy eating. The purpose of this qualitative study was to describe perceptions of the food environment among low-income African-American women residing in an urban community with limited food resources, and strategies they use to acquire food. Given the disproportionate burden of obesity and diet-related diseases among African-American women and that the prevalence of obesity is highest among women in large Midwestern urban centers , it is important to gain greater insights into the perspectives and experiences of urban African-American women in the Midwest. --- Methods --- Setting The study took place in Greater Englewood, a low-income, African-American community in Chicago, Illinois. Greater Englewood is comprised of Englewood and West Englewood, two of the 77 officially designated Community Areas in the City of Chicago . In 2000, Englewood and West Englewood were almost exclusively African-American and 32-44% of individuals had family incomes below the federal poverty line. Both communities experience a high burden of chronic diet-related diseases. Prolonged economic disinvestment from Greater Englewood is evident in aspects of the physical and social environment, including the food environment. Based on a 2006 inperson audit of 398 food stores in southwest Chicago including 66 stores in Greater Englewood, Greater Englewood had no full-service chain supermarket and only seven small grocery stores for over 85,000 residents . Stores were much less likely to carry healthy food options as compared with less healthy food options, though no consistent pattern was found for food prices . Likewise, suggesting dissatisfaction with neighborhood food options, a 2005 market analysis report indicated that an estimated $10.74 million is annually spent outside the community on groceries by Greater Englewood residents . --- Approach and Sample This study drew upon semi-structured, in-depth interviews with 30 African-American women conducted in 2006-2007. Inclusion criteria were women who identified as African-American, between the ages of 21 and 45, had a child less than age 18 years, and resided in Englewood or West Englewood. Women were recruited from the Englewood Neighborhood Health Center, one of five comprehensive health clinics operated by the City of Chicago, through flyers and on-site by African-American research staff. Five women enrolled through snowball sampling. Table 1 shows demographic and other characteristics of the study sample. The research was conducted by a partnership of health center staff with knowledge of the population and academic researchers with substantive and methodological expertise. The team collaborated at each stage of the research: design, data collection, data analysis, and interpretation of findings. --- Interviews The semi-structured interview guide was based on the food environment literature and our prior work. Interview topics included perceptions of the neighborhood food environment, process used to obtain food, environmental barriers and facilitators to food acquisition, and retail food outlet preferences and concerns. The interview guide encouraged interviewer flexibility and enabled participants to raise issues, describe experiences, and share stories that were relevant to them. This included the use of standard probes to elicit more detail, such as "tell me about what happened," "what happened next," and "can you tell me more about that" . Table 2 provides examples of major interview questions and content-related probes. To better understand where they acquired food, in one section of the interview guide, women were asked to identify the name and location of each retail store where they normally shop for food. Each person was individually interviewed once by an interviewer matched on race/ethnicity and conducted at a location of her choice, including her own home, the health center, or another community site. Consistent with semi-structured interviewing he length of the interviews-including any interruptions-ranged , but the average interview lasted about an hour. The number and length of stories told by participants contributed to variation in interview length. Following the interview, participants were asked to complete a brief demographic questionnaire. Each woman received a $25 gift certificate to a local discount grocery store to compensate them for their time. All interviews were audiotaped and transcribed verbatim; the transcripts checked against the audiotapes for accuracy. Institutional review boards at the University of Illinois at Chicago and Chicago Department of Public Health approved the research. --- Data Analysis Qualitative data analysis was guided by conventional qualitative content analysis . An inductive approach, qualitative content analysis uses a systematic process of open coding, category creation, and abstraction to condense and interpret raw data. Specifically, in qualitative content analysis, codes are generated from the data; that is, data relevant to the research question are extracted and coded . Data are further reduced by combining similar codes into overarching themes. Utilizing this approach, academic members of the research team began data analysis by conducting a review of five transcripts to gain a better understanding of data content and develop a preliminary guide for coding. Using an iterative process of coding, review, and discussion, the transcripts were coded line by line, including breaking down transcripts into quotations and labeling these quotations according to their meaning. The preliminary list of codes was expanded as new codes emerged. This process generated descriptive codes that were entered into ATLAS.ti , a computer software qualitative data management program, and used to code remaining data. All transcripts were coded independently by two research team members who met at least once every five transcripts to compare coding, resolve discrepancies by consensus, and review code definitions. Summaries of themes were also presented to health center staff to contextualize and refine themes and to identify potential implications for practice and local community action. In addition to identifying thematic codes in the data, we also identified each store identified by study participants including its precise street address, by using telephone directories and online searches. We then geocoded the stores along with the participants' homes using ArcGIS 9.1 and calculated the street network distances between each participant's home and the stores where she shopped using ArcGIS Network Analyst . Based on these data, we generated descriptive statistics, such as mean number of stores and mean distance to the stores where shopped, using SPSS 14.0 . --- Findings Environmental Barriers Data analysis revealed numerous environmental barriers to acquiring desired food in an acceptable setting. We classified emergent themes into three categories: material, economic, and social-interactional. Women discussed barriers that existed when shopping both inside and outside the neighborhood. Detailed findings for each are discussed below. Material-Women described several material barriers to food acquisition. These material barriers were related to store availability and upkeep and food product availability and quality. First, with regard to store availability, several women indicated that lack of a fullservice supermarket in the neighborhood was an obstacle in obtaining food; they wanted a supermarket that was convenient and within walking distance. This was particularly true for women without an automobile. When asked about the availability of grocery stores in the community, one woman replied: Over here, just one and that's [Discount Grocery]. For me it is fine because it is closer but it is not like for other people that have to walk…in the community there could be about two or three more grocery stores where they wouldn't have to walk so far. Poor upkeep was another material barrier to acquiring food. Women associated poor upkeep with poor quality food. Poor upkeep was particularly raised in reference to stores in the neighborhood and included lack of cleanliness, disorganized shelves and aisles, and poorly maintained shopping carts. With respect to cleanliness, women reported that foul odors; dirty, un-mopped floors; and cockroaches and rodents, turned them off. Besides these obvious signs, women also judged cleanliness based on whether they saw employees cleaning or attending to customer spills promptly. A couple of women explained that they determined store cleanliness based on bathroom sanitation: If it's dirty I won't shop there. That's usually the first thing because I'm pregnant and so I've always got to go to the bathroom. So that's the first thing that I do is go to the bathroom and then I go grocery shopping. If it's dirty in there then I'm like 'I ain't going, not today.' Next, related to food products, women expressed concerns about lack of availability and variety of some foods at neighborhood retailers. This included but was not limited to healthy foods. Fresh produce was commonly among the foods identified as missing from the neighborhood, but finding baby food and food products that were low fat, low sodium, organic, and soy was also challenging. Many felt that food options were particularly limited when compared with other types of neighborhoods, even among stores of the same type, and expressed that they should have access to the same choices. When desired foods were stocked, women reported that stores often ran out or it was difficult to locate healthier options, due to their placement and marketing within stores. In contrast, one woman reported that at stores in other areas of the city: You see the vegetables when you first go in. You see the fruit when you first go in. You're not looking at the Flaming Hots and all that stuff which I can't stand…I see myself just going into different grocery stores especially in the African American community that [the media] is the key. It's the cake, it's the chips, it's the soda… then you have to hunt for the fruits, the vegetables, the bottled water, and things like that. Of the foods available in the neighborhood, poor quality was another material impediment to obtaining food, especially for fresh foods but sometimes packaged foods as well. Women described withered fresh fruits and vegetables, rotting "green" fresh meats, and expired canned and packaged foods. One woman reported: Healthy foods are not really available [in neighborhood] like I would like them. Different vegetables they usually don't have it or they might have it for a day. I would definitely say it influences you…and the things that are healthy are sometimes old and outdated. Economic-Another category of environmental barriers to obtaining food was economic, specifically high food prices at both small local stores and supermarkets. With respect to neighborhood corner and convenience stores, women proposed multiple explanations for what they perceived as inflated prices. Some recognized that high prices may be due to the inability of these stores to purchase foods in large enough quantities. Yet, others felt that local stores were taking advantage of local residents without transportation who depended on the stores. Explaining that these stores were owned by "Arabs" or "Caucasians," several women thought that these owners were "overcharging" and getting rich off the African-American clientele. A couple reported that stores "jacked up" prices because they knew customers receiving food assistance relied on their stores. When asked whether she could get the foods she wanted in the neighborhood, one participant explained: No, you basically get the basic type of food and the only place you can get it cheap is [Discount Grocer] and everywhere else they jack it up a little bit because they know that a lot of customers are Link customers. They can't charge taxes. So, they jack-up the regular price of the food so that they can make their money that way. While they generally were satisfied with food variety and quality, many women thought the prices at full-service supermarkets outside the neighborhood were too high, to the point of being "ridiculous." Social-interactional-Women identified multiple social-interactional features of stores that hampered their ability to obtain desirable food in an acceptable environment, including safety concerns, poor customer service or treatment, crowding, and unsupportive sales practices. First, lack of safety was identified as a major social-interactional deterrent to food acquisition at local stores. Many safety concerns stemmed from problems with people hanging out in front of stores, panhandling, soliciting drugs, and harassing shoppers. One woman explained, I don't really like going certain places…cause I just don't feel safe. But not only that, say if I go to a grocery store and say a guy try to talk to you…in front of the store, if you don't talk back to them they will spit on you. The proximity of liquor stores and a strip club to some stores was seen as contributing to the problem. Second, several women described poor customer service or treatment as another socialinteractional barrier to food acquisition that was encountered both inside and outside the neighborhood. Among commonly reported grievances were employees' "surly" or "snotty" attitudes and lack of basic courtesy such as not asking if they may help you, saying "thank you," and counting back change. Women also identified inappropriate employee behaviors such as smoking at checkout, cursing, flirting with customers, and watching "like you're going to steal something." Some women attributed these problems to owners or employees being of a different race/ethnicity, from outside the neighborhood , or young. Crowding was a third social-interactional impediment to food acquisition. In addition to weekends and evenings when more people shopped, women reported that stores were particularly crowded at the times of the month when food assistance benefits are distributed. Women described long lines and aisles so congested it was difficult to pass. Fourth, sales practices that women perceived as unsupportive were another barrier to obtaining food. Women objected to some local stores selling cigarettes and alcohol to minors and not accepting food assistance benefits. Failure of retailers to provide food on credit or accept food assistance benefits were also viewed by some women as a barrier to obtaining food. Women also described use of deceptive sales practices, specifically use of plastic wrap to hide spoilage of fresh meat and produce at local corner stores: It [meat] was wrapped and rewrapped and rewrapped on top of that. It was like the wrapping was taking away from you getting a chance to see the clarity of the actual meat because there was so much wrapping on it. --- Adaptive Strategies Data analysis revealed that women adopted several strategies to manage or change these environmental barriers. We grouped emergent themes into four categories: optimizing, settling, being proactive, and advocating. We discuss each category below. Optimizing-When resources such as time and transportation allowed, women optimized to get the foods they wanted, seeking the highest quality products at the lowest prices in desirable stores. Women engaged in two optimizing strategies: shopping at multiple retailers and "traveling for it." First, on average, women shopped at 4.3 different food retailers, ranging from 2 to 9 stores. In their use of multiple retailers, women employed one of two general approaches. In one approach, women described frequenting a different store on each shopping trip , with store selection dependent on which store had the lowest prices that week based on sales or other promotions. In a second approach, women routinely purchased some kinds of foods at one store and other kinds at a different store. A typical pattern was purchasing lower priced canned and packaged goods at discount grocers and buying fresh meat and produce at supermarkets or specialty stores, which were perceived as having better selection and quality. While some women traveled from store to store in a single shopping trip, others spread out visits to these distinct stores over a set period of time . "Traveling for it" was a second optimizing strategy, with many women journeying to other neighborhoods, and sometimes to the suburbs, to obtain foods at the price or quality they wanted and in an acceptable environment. On average, stores frequented by the women in the sample were 2.3 miles from their home. Whereas half the women frequented at least one store within 0.5 mile of their home, one-third traveled more than five miles to reach at least one store where they shopped. Some observed that the variety and quality of foods was better in predominately White neighborhoods, even among stores of the same type: You go all the way out to the suburbs where the white people live at and you find everything in the thrift stores out there. It's even a better variety in [discount grocers] and [supermarkets] when you go to their stores. There's a difference. So, I will go out farther to travel and get better quality and stuff, yes. Settling-When they lacked resources some women "settled" to get foods they needed . When they did not have transportation or time to reach preferred stores, some felt they had no choice but to shop at local convenience or corner stores. This often meant paying higher prices or selecting other foods, such as junk food, when healthy foods were preferred. One participant explained: At that particular time it might be late and I don't feel like cooking, so I might settle for what they [local stores] have at that particular point in time. Other than that, if I don't have to [settle] I don't…I have to travel out of my way to get certain kinds of foods that are healthy for me and my son. When forced to shop at stores of questionable quality, another way women settled was to purchase packaged items. Women avoided purchasing fresh meat and produce and limited their shopping to canned goods, bottled drinks, and snacks. According to one participant, "If it ain't canned up or bottled up I don't want it." Another described: The shelves are dirty. The items that are on the shelves are dusty. I've had a situation onetime when I bought some of that instant oatmeal and there were worms in the package. That was some years ago…So, I don't buy anything like that out of there. The most I will buy out of there is a pop, a juice, or something I don't have to eat. Being proactive-To avoid or minimize problems, participants engaged in several proactive strategies: changing the timing of shopping, modifying their demeanor while shopping, and leaving or refusing to shop at stores. As a first proactive tactic, some women adjusted their shopping timing. Some would only shop at local stores during daylight due to safety concerns: Me, I wouldn't go late at night. The latest I would go would be seven o'clock… There are weird people out and a lot of drunks and they're babbling and people have to kick them out of the stores. Then I've got two kids and I would have to carry them with me. Because her son was tempted by unhealthy food items placed in the front of the store, one woman limited shopping to times while her son was in school. Another shopped during the day when stores were staffed by older employees in order to get better customer service. Others timed their shopping to avoid busy times of the month when people received food assistance benefits. Second, women modified their demeanor to avoid problems. When anticipating safety concerns, women got "in and out" of stores quickly, going straight to what they were looking for and not stopping to look around. Some described "staying alert" and paying attention to their surroundings. Some women sought good customer service by being aware of how they "carried" themselves and purposefully "respecting" store employees. Leaving or refusing to shop at stores if they had a bad experience was a third proactive strategy. This strategy was frequently in response to lack of cleanliness, long lines, rude service, and poor quality foods. Some women felt strongly that they would not spend their hard-earned money at "nasty" stores: I walked in the store and it was just like nasty. It was cockroaches running on the floor and as soon as I saw that I called my mama on the phone like, 'Look Ma, we're not fixing to get nothing from up out of here because they've got roaches and the floor is filthy dirty. I'm gone.' Advocating-Women also engaged in advocacy, seeking to bring about changes related to the store environment and food products. Women most commonly reported problems or concerns directly to store owners or employees, but some contacted regulatory agencies such as the local health department. With respect to the store environment, women advocated for enhanced upkeep and safety. With respect to food products, women advocated to increase availability of food products they wanted and especially to improve food quality or safety. One participant found the mere threat of contacting regulatory agencies brought about desired change related to food quality: I ran into a problem where there was a fly in my ground beef…and then I had bought some turkey tails before and it had mold on it. So that was two different complaints he had from me and I said, 'I'm going to call the health department,' but because of me he had bought all new coolers and I was happy. He remodeled that store when he really was scared. He thought I was going to health department for real, which I actually did but I never got through to them. Their advocacy efforts were not always successful in bringing about desired changes in the store environment or food products. According to one participant, in response to her complaints about safety, a store owner explained that he had tried to address safety issues around stores, but could not get the cooperation of the local police department. --- Discussion Our findings yield new insights into food acquisition practices among low-income African-American women residing in a community with few food resources. As found in prior quantitative and qualitative studies on the food environment, these low-income women desired a wide selection of reasonably priced foods, though not just healthy foods, in a pleasing environment. Yet, they perceived multiple environmental barriers to obtaining food, extending beyond the types of stores and food options nearby to the physical and social environments of stores. In the face of these challenges, women adopted multiple strategies to acquire food, sometimes adjusting their tactics depending on resources available at the time. --- Environmental Barriers Economic and material threats related to store availability and food product characteristics have been the most commonly reported environmental barriers in previous qualitative studies with African-Americans as well as other populations . These factors are the focus of most quantitative studies and the most common targets of environmental intervention efforts to date . Our findings are consistent with prior qualitative studies in which participants identified lack of a supermarket, limited variety of foods, poor food quality, and high food prices, particularly at small neighborhood stores, as environmental barriers to food acquisition and healthy eating . One striking similarity to a study with African-Americans in New York City was reports of deceptive food packaging to hide poor food quality . Yet, much less commonly identified in previous studies, we found that the challenges women identified in the neighborhood food environment extended to the store physical and social environments. Like Cummins and colleagues in Scotland , we found that poor upkeep was a material concern related to the physical environment of stores. Women also identified multiple negative social-interactional features of stores that hindered food acquisition. Of the social-interactional features we identified, crowding and poor customer service have been identified as concerns in prior studies on the food environment . However, less attention has focused on safety and unfair treatment in research on the food environment . Interestingly, in an Australian study , participants mentioned traffic-related safety concerns when walking to stores, whereas crime-related safety concerns were described by participants in our study. Crime-related safety was a particular problem for our participants because children often accompanied them to the store. While a study on shopping experiences of African-Americans in New York City and Philadelphia found that participants were more likely to report poor treatment at stores in White neighborhoods than in African-American neighborhoods , women in our sample identified unfair treatment as a problem at stores owned by individuals of a different race/ethnicity both inside and outside their neighborhood. Both poor upkeep and social-interactional concerns were frequently discussed in connection with the race/ethnicity of the store owner or employees, highlighting previously documented tensions between White and immigrant owners and employees and local African-American clientele . The implications of widespread ownership of food stores by non-African-Americans for food acquisition practices and health outcomes of African-Americans could be explored in more depth in future studies. Overall, our findings underscore the relevance of not only economic and material obstacles that are frequently reported in previous qualitative and quantitative studies but also physical and social environmental impediments to food acquisition in low-income African American neighborhoods. Future observational and intervention research on the neighborhood food environment should consider these elements as well. --- Adaptive Strategies Confronted with a restricted food environment, women in our sample adopted several tactics to cope with unsupportive food environments. Our findings highlight the fluidity of their approach, depending on the resources available to them at the time. When they had sufficient resources, women optimized to obtain foods they wanted by shopping at multiple retailers and traveling outside the neighborhood. In two previous U.S. studies-one with an African-American sample in New York City and another with a majority Latino sample in Austin, Texas-participants mentioned similar strategies . Nonetheless when resources were lacking, women in our sample settled for what they needed at local stores. In a qualitative study with a predominately Latina sample, women also described frequenting local stores only in "emergencies" and for everyday items . Taken together, these findings challenge the assumption apparent in most quantitative studies on that low-income racial/ethnic minority persons are confined to food sources in their residential neighborhood. Nonetheless, as illustrated in prior studies, especially among those without reliable transportation, additional and prolonged efforts to reach food sources outside the neighborhood comes with costs including time, money, limited flexibility in scheduling, compromised food choices, feelings of uncertainty and lack of control, and missed opportunities . Thus, ensuring that low-income African-American neighborhoods have supportive food environments could alleviate these burdens. Women in the sample adopted proactive strategies to cope with environmental threats. In addition to changing the timing of their shopping to avoid particularly crowded times as also found by Clifton , women also adjusted when they shopped to feel safe, enhance the likelihood of receiving good customer service, and minimize children's exposure to marketing of unhealthy food products and unsafe situations. Intense and targeted marketing of foods high in fat and sugar to children may negatively impact children's dietary quality and body weight and may be especially pronounced in African-American and low-income neighborhoods . Other proactive strategies included being attentive to how they "carried" themselves and going out of their way to "respect" store employees to obtain good service. These strategies reflect those identified in a study of food shopping by Lee . In a sample of urban African-Americans, Lee found that participants consciously "wore" their class, including dressing up, carrying expensive accessories, and using certain mannerisms and speech, to show that they belonged at stores and to avoid negative treatment. Similar to Lee , we also found that some women avoided stores where they had bad experiences. Finally, women advocated for improvements in the food environment. In a prior study , an African-American female participant described lobbying her local food store for organic products without success. In this study, women identified multiple targets of advocacy efforts, not only changes in product mix but also food quality and store sanitation and safety. As found by Munoz-Plaza , women felt compelled to take these actions, incensed by what they perceived as a socially unjust food environment. --- Implications for Health Our findings suggest multiple pathways by which environmental barriers and adaptive strategies may affect the health of African-American women and their children living in low-income neighborhoods. First, drawing on empirical evidence in prior studies, lack of availability, high prices, and poor quality of healthy foods in the neighborhood may negatively impact dietary quality and increase obesity risk among women and their children . Obesity is a public health crisis, with particularly high rates among African-American women and children . Children who are obese are more likely to become obese adults . Poor diet and obesity are major risk factors for developing type 2 diabetes, cardiovascular disease, and some cancers . Second, our findings highlight several sources of chronic psychosocial stress in the food environment, such as unfair treatment, deteriorated conditions, and lack of safety at stores. Chronic stress may contribute to obesity, especially viscerally, through alternations in the hypothalamic-pituitary-adrenal axis functioning and triggering high-fat, high-sugar food intake . Chronic stress also contributes to mental distress and depressive symptoms . Third, confronted with multiple environmental barriers, many women engaged in prolonged and high-effort coping to obtain food, which may lead to hypertension and generally more wear and tear on the body systems . This may be particularly true for those with few socioeconomic resources. Fourth, safety concerns around stores may make it especially difficult for older children, who may be going to the store alone, to obtain food. Finally, because it can lead to business closures and further divestment, the extent to which barriers in the local food environment force women to shop outside the neighborhood further weakens economic conditions in the neighborhood, with negative repercussions for the social and physical environment . --- Implications for Intervention Our findings have several implications for interventions to support food acquisition among residents in under-resourced neighborhoods. First, the findings suggest the need to eliminate environmental barriers through environmental change such as attracting supermarkets, enhancing existing local stores, and supporting local food production . Attracting supermarkets and increasing healthy foods at existing stores in low-income communities is a strategy that is gaining traction in the U.S. through programs such as Fresh Food Financing Initiative. However, as illustrated by our findings, these strategies may not be successful in improving nutrition among residents of low-income neighborhoods if not accompanied by efforts to make foods more affordable. Further, promoting local ownership and employment at stores may be important to enhance local residents' treatment and comfort. Efforts aimed at transforming existing local stores should not only address food supply characteristics but also the broader store social and physical environment including upkeep, safety, and customer service. That few women primarily selected stores based on the availability of healthy food products substantiates the importance of addressing these other aspects of the food environment. Investment in local food production including urban agriculture and community gardens may also improve the food environment in under-resourced communities. Second, intervention efforts could facilitate adaptive strategies among local residents through economic development in low-income communities to increase income, economic subsidies for healthy food options to make them more affordable, and enhanced transportation options to help residents reach food sources outside the communities. --- Implications for Future Research The consistency of our findings on environmental barriers and adaptive strategies with constructs of stress and coping suggests that studying the food acquisition through a stress process lens may assist in advancing understanding of food acquisition practices in neighborhoods with restricted food resources, identifying health consequences, and pinpointing multiple points for intervention. As suggested earlier, psychosocial stress and high-effort coping are under-studied pathways by which the food environment may affect the health of residents in low-income neighborhoods. We recommend developing and testing stress process models for food acquisition. --- Limitations This study has limitations. First, our sample was restricted to 30 participants. Enhancing the credibility of our findings, we did achieve saturation of our codes, reaching a point in the analysis in which no new codes or new information regarding our codes emerged . Nonetheless, it is possible that a larger sample may have yielded new concepts had we financial resources to increase our sample size beyond 30 participants. Second, we focused only on food procurement at stores. Though also important components of the food environment and food acquisition, we did not consider restaurants or purchase of prepared foods, respectively. Third, while embedded in some of our findings, our study may not adequately reflect the complex interplay between person factors and environmental factors in shaping food acquisition due to our interview guide's environmental emphasis. Despite these limitations, this study provides important new insights into perceptions of the food environment and strategies used to obtain food among African-American women in a low-income community with restricted food resources. Engagement of health center partners who work with the population of interest during all phases of the research augments the credibility of our findings. --- Conclusion Although there is strong interest in identifying social inequities in neighborhood food environments and their implications for health disparities, few studies have focused on understanding the perspectives of persons who live in neighborhoods with few food resources. Our data from 30 urban low-income African-American women show that women faced with restricted neighborhood food environments identified multiple environmental barriers-material, economic, and social-interactional-to obtaining food. Yet they were resourceful and had developed a multitude of adaptive strategies to cope with these challenges. While environmental change as part of a multilevel approach is needed, to enhance the likelihood that these efforts are successful, it is important that we first gain a deeper appreciation of food acquisition practices and factors that influence it. In supporting women's food acquisition, our findings suggest that addressing stores' physical and social environments may be a necessary accompaniment to improvements in the food supply.

This qualitative study sought to understand food acquisition behaviors and environmental factors that influence those behaviors among women in a low-income African American community with limited food resources. We drew upon in-depth interviews with 30 women ages 21 to 45 recruited from a community health center in Chicago, Illinois. Data were analyzed using qualitative content analysis. Emergent themes revealed that women identified multiple environmental barriersmaterial, economic, and social-interactional-to acquiring food in an acceptable setting. In response, they engaged in several adaptive strategies to manage or alter these challenges including optimizing, settling, being proactive, and advocating. These findings indicate that efforts to improve neighborhood food environments should address not only food availability and prices, but also the physical and social environments of stores as well.

Introduction By July 2022, the COVID-19 pandemic had infected over 88 million people in the United States and caused over a million deaths [1]. The Lancet's COVID-19 Commission on Mental Health Task Force concluded that there was clear evidence that psychological distress increased during the early months of COVID-19 and that the pandemic was harming mental health [2]. Vahratian and colleagues at the National Center for Health Statistics at the CDC, using cross-sectional surveys from almost 800,00 respondents, documented a 14% increase in the number of US adults experiencing symptoms of anxiety or depression in the seven days prior to its surveys [3]. However, the existing research has not convincingly identified the distinct pathways through which COVID-induced stressors trigger mental distress nor disentangled the causal relationships among them. Most research has treated the pandemic as an undifferentiated whole, showing for example that indicators of mental distress were higher in locations [4] or at times with higher infection rates [5][6][7] or among specific groups of people, such as healthcare professionals [8]. While this type of research demonstrates that the pandemic was associated with increases in mental distress, it rarely differentiates distinct stressors associated with the pandemic and how they influence mental distress. A small number of studies have attempted to differentiate the influence of distinct stressors associated with the pandemic, such as risks of disease and death, unemployment and loss of income, and social isolation resulting from stay-at-home policies and individual choices, and even fewer have attempted to examine the impact of these stressors simultaneously. We are aware only of recent research by Ka ¨mpfen et al [9], who used a large national probability survey of US adults conducted for three weeks in March 2020 to examine the extent to which disease and financial or social stressors predicted changes in symptoms of anxiety and depression. The stressors respectively were respondents' perceived risk of getting infected and dying from Covid-19, their concerns that they would run out of money, and self-reported reductions in their social activities. They found that all three of these stressors predicted worse anxiety and depression outcomes, as measured by higher PHQ-4 scores [10] after controlling for relevant demographic variables, including sex, age, educational, race, and marital status. Alimoradi et al [11] found that sleep problems appear to have been common during the COVID-19 pandemic and were associated with higher levels of psychological distress among the general population, healthcare professionals, and COVID-19 patients. Although an excellent start, this research has important limitations that undercut the conclusion that these stressors cause increases in anxiety and depression. Perhaps the most important are the related problems of endogeneity, common method bias, and reverse causation. Both the stressors and the mental health outcome were measured via respondents' self-reports. Therefore, it is plausible that people who had higher levels of generalized anxiety and depression also perceived greater risk and had greater anxiety from the specific stressors the survey targeted. That is, respondents' generalized mental distress may have led them to perceive delphi.github.io/delphi-epidata/api/covidcast.html). These data come from multiple sources, with data licensing handled separately for each source. The de-identified survey data are available to researchers associated with universities or nonprofit organizations. Researchers who want access to the survey data should submit an information request on Facebook's COVID-19 Symptom Survey -Request for Data Access page higher risks independent of their objective risk. Similarly, those with higher levels of generalized anxiety and depression may have been more likely to practice social distancing. The main substantive goal of our research is to examine the causal impact of distinct pandemic-related stressors on mental health. We examine the disease, financial, and social stressors identified by Ka ¨mpfen et al [9]. Our methodological goal is to reduce threats to causal interpretation by combining evidence of objective pandemic-related stressors with selfreported survey data and using mediation analysis to examine the extent to which the objective stressors influence mental health by influencing individual respondents' behavior and fears. In contrast to most previous research, we examine the relationship between changes in pandemic-related stressors and mental health not just at the beginning of the pandemic but over a long, 8-month period and collect population-weighted data from over 11.5 million US adult respondents. A simplified path model is presented in Fig 1 summarizing our hypotheses about how objective community-level stressors predicted mental distress, mediated by individual respondents' social isolation and worries about disease and finances. We hypothesize that the pandemic could plausibly harm mental health through three distinct routes. First, the pandemic could increase mental distress by increasing fears of getting the disease [12]. Second, pandemic-induced social distancing, a result of both public health recommendations and individual decisions to limit exposure, could influence mental distress in a more complicated way. On the one hand, the hypothesis that social distancing would increase mental distress is based on decades of research demonstrating that social contact is associated with better physical and mental health and that loneliness and social isolation are associated with increased depression and mortality [13][14][15]. On the other hand, social distancing could also reduce people's exposure to disease, which in turn could reduce their fears about getting ill and their overall mental distress. In addition, social distancing could also reduce employment opportunities for some people, such as restaurant workers, but increase employment for other occupations, such as warehouse workers or delivery drivers, or lower commuting and other work-related expenses for others, such as white- collar workers. Thus, to better understand the impact of social distancing policies and norms, we hypothesize that county-level social distancing can also influence mental distress by influencing personal social contact, illness worries, and financial worries. Third, the pandemic could lead to financial hardships and fears about them caused by economic slowdowns, which in turn could cause mental distress [16]. The solid lines labeled 'A' represent the degree to which county-level distancing and stressors influence respondents' social contact and their individual worries, and the solid lines labeled 'B' represent the association between respondents' social contact and their individual worries, and their mental distress. The dotted lines labeled 'C' represent the direct pathway between the county-level stressors and respondents' mental distress. The product of 'A' and 'B' represents indirect effects of the county-level stressors on distress, which are mediated by their effects on respondents' social contact and their individual worries about the illness and household finances. --- Methods --- Study design and data collection We used time-series data from the COVID-19 Trends and Impact Survey [17], a collaborative project between Facebook and academics to support COVID-19 research. Each day Facebook invited a random sample of users in the United States at least 18 years old to take a survey designed and collected by Carnegie Mellon University's Delphi Group by placing a notification at the top of their News Feed. The survey was anonymous and did not collect any personally identifiable information. The current paper relies on 11,974,779 survey responses from 239 cross-sectional samples gathered daily from April 6 to November 30, 2020. Although some respondents may have taken the survey more than once, because of the anonymous nature of the data collection we cannot identify surveys completed by the same person, and we therefore treat them as independent. Each survey response was weighted to adjust for non-response and coverage biases so that the distribution of age, gender, and county of residence in the survey samples were representative of the general population of the United States. . The demographic characteristics of the weighted sample closely matches data from the 2019 American Community Survey , except for an overrepresentation of highly educated respondents . The survey asked respondents questions about COVID-19 symptoms they and other household members had. It also asked questions about the depression, anxiety, in-person social contact, and COVID-related stressors respondents were experiencing, the focus of this paper. Respondents also described their demographic characteristics, including their household composition, their gender, and their approximate age. The survey data included respondents' Federal Information Processing System county code, which allowed responses to be joined with county-level data from multiple sources describing daily and cumulative infection rates of COVID-19 in the county [17], unemployment rates [18], and the time county residents spent outside of the household as estimated from mobile devices [19]. We also estimated from the survey data daily county-level worries about illness and finances and county-level social contact by first removing the respondent's data and then calculating the 2-week moving average surrounding the respondent's survey date. These county-level variables are treated as potential causes that could influence mental distress directly or indirectly, by influencing the respondent-level predictors of interest, including social contact and worries about disease and finances. --- Measures Table 1 below describes the measures of all variables used in the analyses. --- Analysis logic We used structural equation modeling, done with the Stata SEM package [20], to implement the mediation analysis represented in Fig 1's path diagram. The maximum likelihood estimation was used in the analysis. The mediation analysis examines the potential causal pathways through which day-to-day variation in objective, county-level disease threat, financial threat, and social distancing could influence respondents' mental distress either directly or mediated by respondents' individual social contact and worries about disease and finances. To control for static characteristics of respondents' locations, we first centered each variable by the county-identification FIPS code, which removes all fixed effects associated with that geographic area, such as its size, economic prosperity, demographics, and other unmeasured static differences. What remains is the day-to-day variability in respondents' mental distress, disease and financial worries, and county-level stressors. The use of both respondent-level variables collected via the survey and county-level ones from multiple sources reduces many threats to assessing causation from observational data. Because the variation in county-level stressors and social distancing are outside of any single respondent's control, we can treat them as exogenous variables that can directly influence respondent-level variables but not be caused by them, eliminating possibilities of reverse causation. For example, changes in county-level disease threat and financial threat are exogenous variables that could influence respondents' mental distress directly or indirectly through their worries about getting ill or their concerns about household finances. Similarly, changes in the time residents of a county spent outside their home, reflecting both government regulations and evolving local norms, are exogenous variables that could influence a respondent's mental distress both directly or indirectly through its effect on their social distancing behavior and their worries about disease and finances. The multiple levels of analysis reduce the likelihood that unobservable variables, like respondents' socio-economic status, work-status, or disability, jointly influence their social contact and their mental distress. The multiple levels of analysis also reduce common-method bias, in which associations are inflated because potential causes and consequence are measured using similar measures from a single source [21]. --- Results Tables 2 and3 below show descriptive statistics and correlations among the variables. Fig 2 shows how self-reported mental distress , county-level predictors and mediators varied over time. In addition to these time-varying variables, analyses reported below included several static covariates: respondents' self-reported gender, approximate age, and whether the respondent lived alone or with others in the household. Table 4 and Fig 3 summarize the mediation analysis, showing how county-level social distancing and disease and financial threats predict respondents' mental distress both directly and indirectly through their influence on respondents' social contacts with people outside their household and the worries they report having about getting ill and household finances. finances. The three coefficients on the dotted lines respectively represent the total effect, the direct effect, and the indirect effect of county-level variables on mental distress. Note, all coefficients in Fig 3 are highly significantly different from zero, with all p-values < .0001. --- Effects of covariates Women, younger respondents, and respondents living alone reported greater mental distress compared to men, older respondents and those living with others respectively. The associations of mental distress with these demographic characteristics are all consistent with prior research. For example, Salk et al's meta-analysis revealed that women are substantially more likely to be diagnosed with depression and show depressive symptoms across multiple cultures [24]. Abundant research also demonstrates the links between social integration and both physical and mental health [25]. For example, people who live alone are almost twice as likely to report symptoms of depression compared to those who live with others in their household [26]. Although not the focus of the current project, survey findings showing less mental distress among respondents in households with other adults or children are consistent with one of our core hypotheses: social contact is a preventative for mental distress. However, because household composition is something that people choose, and people who are predisposed to mental distress may be more likely to choose to live alone, the association of household composition and mental distress is not itself strong evidence of a causal relationship between social contact and mental health. In contrast, an association of social distancing at the county level with mental distress is stronger causal evidence of the role of social contact, because it is unlikely that respondents with greater than average mental distress choose to live in a county during a period in which social distancing is greater than average. --- Effects of disease threat, social distancing, and financial threat on respondents' mental health Disease threat. The mediation analysis in Table 4 shows that overall greater threat of disease in an area is associated with more mental distress . Because the county-level disease threat is associated with individual respondents' worries that they or a family member would get ill from the disease , and these worries about the disease are associated with their mental distress , nearly 65% of the total effect of county-level disease threat is mediated by individual worries about disease /.013). This mediation result suggests that objective risks of illness have their effects on mental distress to a large extent by elevating individual worries about becoming ill. Social distancing. Overall, social distancing at the county level is associated with increased mental distress . Because county-level social distancing is associated with individual respondents' having less social contact outside the home , more disease worries , and more financial worries and because these individual level behaviors and worries are associated with mental distress , the mediation analysis suggests that social distancing in a county affects respondents' mental distress to a large extent by reducing their contact with others outside their homes, as well as increasing their worries about disease and finances. Approximately 63% of the total effect of county-level social mobility on mental distress is indirect and mediated by respondents' self-reported reductions in social contact outside of their households, and disease and financial worries + + )/.011 = .628). The total effect of county-level social distancing on mental distress is small but practically important because it is a policy lever at the disposal of government authorities, and because of the many millions of people whose mental health might be affected by social distancing policies and norms. The small effect size may be the result of other factors that influence respondents' social mobility besides objective social distancing policies and norms, such as whether they are employed outside the home, their gender, or their household composition, which can also influence their mental distress. In addition, lock-down orders and other reductions in opportunities for social contact outside the household may cause people to spend more time interacting with others in their household and thus compensate for the impact of social distancing on mental health. That is, for people who live with others, the greater social contact they have within the home may compensate for reductions in social contacts outside it. To examine this possibility, we tested whether the mental health benefits of greater county-level social mobility were greater for respondents living alone than for those living with another in their household. We added an interaction term between social distancing and live with someone to the SEM model. S2 Table shows the results. As a reminder, 76% of respondents lived with at least another adult or a child and 24% lived alone. The lack of a statistical interaction between county-level social distancing and living with others suggests that social distancing was not more harmful in terms of increasing mental distress among people who live alone . The marginal analysis shows that a standard deviation increase in county-level social distancing was associated with a .0044 standard deviation increase in mental distress both among those who lived alone and those living with another person. Financial threat. Overall, financial threat at the county level was associated with more mental distress . This result is consistent with Witteveen and Velthorst's findings in six European countries showing a "positive relationship between instantaneous economic hardships during the COVID-19 lockdown and expressing feelings of depression and health anxiety" [16]. A systematic review of research on COVID-19-related fear and anxiety and job-related outcomes also shows that fear of COVID-19 was associated with increased future career anxiety, decreased job satisfaction, and perceived job insecurity [27]. Because county-level financial threats were associated with respondents worrying more about household finances , and respondent-level financial worries are in turn associated with greater mental distress , the mediation analysis suggests that county-level financial threat affects respondents' mental distress partially by increasing their personal worry about household finances . Surprisingly, though, the direct effect of county-level financial threats was to reduce mental distress . To rule out the possibilities of multicollinearity due to a correlation between social distancing and county-level financial threats , we conducted an additional analysis excluding social mobility. The result shows a robust negative effect of county-level financial threats on mental distress . If county-level financial threats raised personal financial concerns which in turn increased mental distress, why was the direct effect of county-level financial threats to reduce mental distress? It may be that even though unemployment and concerns about finances in the county exacerbated mental distress by raising personal worries about finances, the 2020 Coronavirus Aid, Relief, and Economic Security Act and other government stimulus programs reduced the actual financial pain associated with the pandemic, but these effects of government stimulus programs were not reflected in the county-level employment data we had available. Moreover, considering the overrepresentation of adults with higher education in the survey samples, those highly educated individuals might have been in white collar occupations less subject to the economic hardships caused by the pandemic. --- Discussion This research provides evidence consistent with the thesis that the COVID-19 pandemic harmed the mental well-being of adults in the United States and identifies specific stressors associated with the pandemic that seem responsible for increasing mental distress. The current study distinguished objective stressors from respondents' perceptions of stress, thereby reducing common method biases that have inflated the associations between stressors and mental distress in earlier research. Note that mental distress correlates ten times more highly with these measures of disease and finances worries and social contact, all of which were measured by self-report at the respondent level , than with parallel measures of disease and financial threat and social distancing measured at the county level . This substantial difference in strength of association is consistent with the speculation that Ka ¨mpfen et al's results [9] were inflated by common method variance. The analyses show that objective disease stressors outside of respondents' control, as measured by county-level COVID-19 infection rates and the likelihood of other county residents knowing someone with COVID symptoms and being worried about getting ill, increased individuals' mental distress in part by increasing their own worries that they or other family members would get ill. Overall objective financial stressors, as measured by county-level unemployment rates and county-level perceptions that the pandemic was harming household finances, were associated with greater mental distress, and these effects were mediated by the extent to which these financial stressors caused respondents to become worried about harm to their own household's finances. However, the direct effect of the financial stressors seemed to be to lower mental distress. Future research is needed to examine the mechanism for this direct effect; for example, did federal government stimulus programs reduce the actual financial pain and associated mental distress during times of high unemployment, and what role did sociodemographic variables play? The reduction in social contact caused by the pandemic is especially interesting. Reductions in social contact outside of the household, which were partially caused by official lock-down orders and informal norms in a county, were associated with greater mental distress. Authorities issued shutdowns and stay-at-home orders and people voluntarily reduced outside social contact to reduce their risk of becoming infected with the disease, and to the extent that these actions reduced people's worries about getting COVID, they also reduced mental distress. However, to the extent that these efforts also reduced people's social contact outside the home, they had the undesirable side effect of increasing mental distress. Surprisingly, the harmful effects of social distancing policies and behavioral norms in increasing mental distress applied equally to those who lived alone and those who lived with others. This latter result is consistent with previous research showing benefits from social interaction with coworkers, acquaintances, and other weak ties even among people who have greater than average strong-tie interactions [28] and benefits from social interactions in social spaces outside the home [29]. We believe one can balance the benefits of reduced social contact to slow the spread of disease with the mental health harms to social isolation. For example, having social interactions online, through text chats, emails, phone calls, and video sessions may successfully substitute for inperson social interactions. Very little research has examined the impact that modality of communication has on mental well-being [30]. This study has several methodological limitations that should be considered when interpreting the findings. Respondents' mental distress was measured by two questions assessing depression and anxiety. Follow-up research should use more robust and clinically validated measures of psychological distress. While the survey data were representative of US adults in terms of age, gender and region, there was a sampling bias associated with education; the survey respondents were more educated than average US citizens. Additionally, follow-up research should examine how community-level predictors, like poverty and social inequality, and individual-level ones, like occupational status, moderate the stresses associated with the pandemic. Despite these limitations, this research allows us to make stronger causal claims than possible with more conventional, respondent-level survey research about the impact of COVIDrelated stressors on mental health, because it examines pathways through which pandemicrelated reductions in social mobility and increases in disease and financial stressors, measured at the county level and therefore out of respondents' control, influence respondent-level social contacts and worries, which in turn lead to increases in mental distress. Although the focus of this research was to understand how pandemic-related stressors were influencing mental health during the COVID-19 pandemic, it also extends our theoretical understanding of how social support works. Decades of research have provided strong and consistent evidence that social ties and social support improve many aspects of personal health, including all-cause mortality [31,32], physical health [33,34] and mental health [35], but the mechanisms are still murky [25]. It is unclear whether the component of support that is most valuable is the perception that support will be available when needed , the explicit exchange of support during times of stress, especially from strong ties, or merely the accumulation of everyday social interactions [25,[36][37][38]. Results of the current research are consistent with the thesis that mundane social interactions can lead to well-being. Weekto-week changes in the frequency of social contacts in the community seem to lead to changes in respondents' mental distress, suggesting that to some extent it is social interactions that people actually engage in outside the home that confer benefits, rather than slower-to-change perceived social support. While our data show that people who are living with others have less mental distress, they also show that social contact outside of the household, and presumably with less intimate ties, also confers benefits over and above social contact within the home. --- Data sharing Most of the data reported in this paper are publicly available in the Epidata API, maintained by the Delphi research group at Carnegie Mellon University and available through R and Python clients. These data come from multiple sources, with data licensing handled separately for each source. The de-identified survey data are available to researchers associated with universities or non-profit organizations. Researchers who want access to the survey data should submit an information request on Facebook's COVID-19 Symptom Survey-Request for Data Access page [39]. --- Most of the data reported in this paper are publicly available at a Github repository maintained by the Delphi research group at Carnegie Mellon University and available through R and python APIs (https://cmu- --- Conclusion This research provides evidence consistent with the thesis that the COVID-19 pandemic harmed the mental well-being of adults in the United States and identifies specific stressors associated with the pandemic that are responsible for increasing mental distress. to collect the data. Kraut had no role in data collection and as part of the data-use agreement was not allowed direct access to the data. --- Ethics statement The Carnegie Mellon University Institutional Review Board reviewed the research plan and granted approval under exempt review on 7/10/2020, . . Characteristics of the study sample, compared to 2019 American community survey supplemental estimates. --- Supporting information --- S1 Table --- S2 Table. Mediation analysis predicting mental distress from county-level and respondentlevel variables, including the interaction between Social distancing and Live with someone. ---

Although research shows that the Covid-19 pandemic has led to declines in mental health, the existing research has not identified the pathways through which this decline happens.The current study identifies the distinct pathways through which COVID-induced stressors (i.e., social distancing, disease risk, and financial stressors) trigger mental distress and examines the causal impact of these stressors on mental distress.We combined evidence of objective pandemic-related stressors collected at the county level (e.g., lack of social contact, infection rates, and unemployment rates) with self-reported survey data from over 11.5 million adult respondents in the United States collected daily for eight months. We used mediation analysis to examine the extent to which the objective stressors influenced mental health by influencing individual respondents' behavior and fears.County-level, day-to-day social distancing predicted significantly greater mental distress, both directly and indirectly through its effects on individual social contacts, worries about getting ill, and concerns about finances. Economic hardships were indirectly linked to increased mental distress by elevating people's concerns about their household's finances. Disease threats were both directly linked to mental distress and indirectly through its effects on individual worries about getting ill. Although one might expect that social distancing from people outside the home would have a greater influence on people who live alone, sub-analyses based on household composition do not support this expectation.

Background Urban AI adolescent girls reported greater sexual risk behaviors, other risk behaviors , and pregnancy compared to reservation AIs and other racial groups . Rutman et al. concluded that urban AI adolescent girls were at a twofold increased risk for sexual risk behavior as well as for violence at school, drug use, rape, assault, and pregnancy and a threefold increased risk of suicide, feeling unsafe at school, and involvement in fights that required medical care. Similarly, Gruber et al. found that urban-based AIs, particularly girls, were more likely to engage in risk behavior, including substance use, physical violence, and early initiation of sexual behavior, compared to their Black, White, and reservation based AI counterparts. In addition, of the studies conducted with urban AI adolescents that focus on sexual risk behavior few were guided by a culturally informed theoretical model. American Indians are not just different racially, but also politically and historically, and this can affect the research perspective . Although multiple theoretical models have been developed for AIs by health researchers, these theories tend to focus on a specific tribe, adult populations, reservation based AIs, and make assumptions about previous life experiences . This diversity highlights the need for a culturally specific theory to frame research with the urban AI adolescent girl population. The purpose of this grounded theory study was to explore how individual, family, environmental, community, tribal, and national factors and processes influence urban adolescent AI girls' sexual risk behavior. Theoretical Guide Glaser's grounded theory methodology guided this study. In addition, symbolic interactionism and Bronfenbrenner's ecological model shaped the project design, including the guides for the talking circles, interviews and event history calendars . Symbolic interactionism provided focus on the social interactions of the adolescents in the context of the larger society. Bronfenbrenner's ecological model facilitated exploration of the AI adolescent girls' sexual risk behavior by examining the social contexts of the sexual risk behaviors and interactions of AI adolescent girls. --- Method Sample and Setting Access for this study was granted by the director of an American Indian health and community center and approval by the University institutional review board. A certificate of confidentiality was obtained from the National Institute of Nursing Research. Twenty 15-19 year old participants were primarily recruited from the AI health and community center located in a large metropolitan area in the Midwestern United States. Participants primarily self referred after seeing flyers posted throughout the center although many were referred from the youth group and by the medical staff. Those living outside of the service area were referred by staff in their own community who received notification about the project from the PI and the staff. Adolescent girls were eligible to participate in the study if they were: between 15-19 years of age, self-identified as urban AI, had parental permission to participate in the research study , and were able to speak, read, and write English. The twenty AI girls in this study ranged in age from 15 to 19 years old; most were full time students, lived with either one or two parents, were eligible for subsidized lunch, and were on Medicaid . Nine of the participants denied any history of sexual activity and 11 reported oral sex, vaginal sex, or both . Participants were able to identify multiple tribal affiliations and reported connections with tribes from across the U.S., with most participants having representation in tribes from the upper Midwest. All participants currently lived in non-reservation areas within a large urban or suburban area. --- Data Collection and Recording Informed consent/assent was received from the participants and the parents of minors participating in the study. Participants were given a gift card to a local store for participating in the initial study and follow up interviews. The girls and their family members were also offered a full meal during the study. Family members and participants were invited to eat and socialize while consent/assent was obtained and prior to data collection beginning. Data collection included completion of demographic information, an event history calendar , and talking circle or individual interview participation. Prior to beginning the talking circle or individual interview, adolescents individually completed a demographic form and an EHC in an area that provided privacy and confidentiality. The EHC is based upon previous life history calendar research with adolescents as well as themes that Martyn and colleagues derived qualitatively . The EHC helped prepare the adolescent for the talking circles and interviews by providing an opportunity to chronicle their life events over a three year period and reflect on the interaction between life events, relationships, living situation, sexual activity, and other risk behaviors . The EHC also provides a column for a fourth year so that adolescents can note future goals or plans . The current study also utilized the EHC to gain valuable historical contextual information from the adolescents that was not revealed in the talking circles or individual interviews. After completion of the EHC, the girls participated in a talking circle or individual interview that explored the psychosocial and contextual factors that influenced AI adolescent girl sexual behavior. Talking circle and interview questions were developed using Bronfenbrenner's ecological model and symbolic interactionism as a guide. Questions were developed and reviewed by an AI advisor and experienced researcher. After initial approval, the questions were reviewed by the staff at the data collection site for appropriateness and cultural sensitivity. Questions were revised after feedback from the recruitment site . Initially, talking circles were planned as the primary data collection method. However, based upon the requests of the AI girls in the community, individual interviews were added to respect each individual's right to confidentiality. Talking circles are a traditional method of group communication in AI society that allows all participants to speak and to be heard. This culturally appropriate method of conducting focus groups has been successfully used in other urban and reservation AI research projects . During the talking circle, everyone was given the opportunity to talk and share their story. Unlike focus groups, the interaction between participants is not as important as allowing each member to share their personal experience on the topic. In talking circles, each person's voice is equal and each member has equal opportunity to address the question. An object is used during talking circles to show which person currently is given the right to share their story. In this study, a shell was passed from one participant to the next and the person with the shell was the person who had the floor to talk. Once the participant finished speaking, they passed the shell to the next person in the circle. The talking circles and interviews were audio-recorded. A professional transcriptionist transcribed all the talking circle and interview data, yielding 478 pages of data for analysis. Immediately following the talking circles and interviews, the researcher debriefed with a colleague experienced in the grounded theory method and recorded memos of impressions and observations. In addition, to enhance cultural sensitivity in data analysis, an AI research assistant reviewed the transcripts and offered impressions of influences on sexual risk behavior that were incorporated into memos. Seventy four pages of memos from the primary author and AI research assistant supplemented the data transcripts. --- Data Analysis The constant comparative method of data analysis was used simultaneously with data collection to enhance validity . The EHCs, transcripts, and memos were analyzed using three levels of coding. Open coding of the data involved line by line analysis of the EHCs and transcribed data from the talking circles and individual interviews in order to identify processes and contextual factors in the data relevant to urban AI adolescent girls' perceptions of sexual risk behavior . During the research project, these processes/contextual factors or substantive codes were compared with other data, including the memos by the PI and research assistant, and assigned to categories . The categories were compared to other categories to ensure that they were mutually exclusive . Reduction of the number of categories occurred in order to identify the primary social processes or core variables that explained the social scene . Conceptualization of the relationship among the three levels of codes occurred through development of the more theoretical Level III codes . --- Results Ten girls participated in three talking circle groups, of those four were sexually active. The other ten participants opted to participate in individual interviews. Recruitment ended when data saturation was reached . Eight participants were selected to return for a follow up interview for member checking, clarification, and further exploration of data and for peer validation of the data analysis. The eight participants who returned for follow up interviews were selected because they expressed interest in their initial interview to meet again with the PI and/or the ideas and themes they discussed in the initial meeting resonated with the preliminary research results. Using the methods described above the generated theory, Framing Sexual Risk Behavior, emerged. --- Framing Sexual Risk Behavior: A Grounded Theory Two assumptions underlie the developed grounded theory model. The first assumption is that reciprocal interactions between the systems of the model influence how each urban AI adolescent girl views sexual risk behavior. The second assumption is the form, content, and strength of the processes affecting the urban AI adolescent varies depending on individual factors and environmental surroundings. American Indian girls' sexual risk behavior in this study was most influenced by the groups and organizations in their environment. In this study, the basic social process for the urban AI adolescent girls, regardless of their social, economic, or tribal status, focuses on the exposure to messages about sexual behavior from both social and structural influences. These are positive and negative messages that influence how the adolescent reacts to and negotiates her own sexual behavior. In addition, for the urban AI girls in this study the strength and content of the messages they receive effects their perceptions about sexual risk behavior. The generated theory, Framing Sexual Risk Behavior, emerged and was consistent with Bronfenbrenner's ecological model . --- Microsystem The urban AI adolescent girl's sexual risk behavior was influenced by her social and structural systems. The microsystem, including long term goals, identification of being a normal teenager, and cultural identity, helped the participants determine who they are and influenced them to abstain from sex, have safe sex, or have unsafe sex. Being normal-Participants believed that they were normal adolescents who lived lives similar to other urban dwelling adolescents. All the participants had friends who were not AI and most had family members who were not AI. Yet, despite the interracial company the girls kept, they could not see a difference between themselves and adolescents from these other racial and ethnic groups. The girls felt that their day to day lives were no different than others nor were their decisions about sexual behavior. However, although AI adolescents felt normal, they also had a sense of what it meant to be an AI woman. The girls in this study remarked on their intentions to become "strong Native women." The idea of being strong resonated with many of the girls, particularly those who were not sexually active. These girls in particular spoke of making their people proud by pursuing their goals, particularly finishing college and becoming a role model for other AI youth. Having goals-The significance of having long term goals emerged from the girls' event history calendars, interviews and talking circles. The girls who specified long term goals reported less risky sexual behaviors and had a clear plan to complete their goals. In addition, the goals of those reporting fewer risk behaviors tended to be more academic. Girls in this study saw the consequences of sexual risk behavior, particularly early childbearing, as an impediment to achievement of their goals and future success. They were aware of the negative effects early child bearing could have on goals from observing their parents, aunts, sisters, and friends. Some were children of teen parents and as an 18 year old who was not sexually active said, "My mom had me at a young age and it was hard for her to take care of us, not having an education and not having a good job." She was graduating from high school and had already been accepted into four different colleges. She explained, "I will be like the first on my mom's side to go to college…so I don't want to take the risk of having sex and getting pregnant. I want to finish college." Those with future plans felt they were extremely important in how each identified herself. When participants spoke of their goals, they spoke of their life, the meaning of the goals and the rationale for their goals. Even those who had unrealistic goals spoke of their goals as imperative to their life story. Cultural identity-Cultural identity emerged as a critical component in how participants "defined or described" themselves. This identity formation helped the girls in this study determine who they were and what they wanted to be. Subsequently, this identity influenced their decisions about sexual behavior. Those who identified strongly with being AI reported less sexual risk behavior than those who were not connected to their culture. The majority of participants stated that they were of mixed racial and ethnic heritage. However, most described being AI as integral to who they were as individuals. A 17 year old participant said, "It's really weird because I feel like really connected to my Native culture but I'm not necessarily a part of it, so I don't know why I feel so connected." Another participant, age 16 said, "I say I'm Native because I think that's basically what I am. I know some languages and some other culture and stuff." Girls felt that their AI heritage was a key part of their identity. --- Mesosystem Six components of the mesosystem were identified by participants as influencing sexual behavior. The mesosystem, particularly family and friends, emerged as powerful influences on the adolescents in this study. Adolescents are aware of the various messages, both positive and negative, from social and structural systems surrounding them. These messages are interpreted by the adolescent in the context of their life and influence their sexual behavior. Family-Family was an important influence on AI adolescent girls' sexual behavior and knowledge about safe sex. Girls in this study cited the family as the most important influence on their sexual behavior. Three important themes emerged related to family influence: 1) networks of family influences; 2) talking about sex with at least one family member, usually another female; and 3) mixed messages about sexual behavior from different family members, including those who discouraged and those who encouraged sex. Girls in this study described a network of family members that included mothers, fathers, grandmothers, sisters, aunts, and cousins who influenced their sexual behavior. For example, one 15 year old participant identified her cousins as her primary sources of sexual information, while an 18 year old identified her father and grandmother as people who influenced her decision to abstain from sexual activity. In addition to having a wide network of family members available who influenced sexual behavior, all of the participants in this study reported at least one female family member that they could openly discuss sex with. These family members included mom, aunts, grandmothers, sisters, and cousins. However, even though girls reported having family members available to discuss sex, they often received mixed messages about sex. Girls in this study were more likely to receive messages discouraging sex from their elders and messages encouraging sex from those family members close to their own age . One participant, age 17 said, "I did it because all my sisters were doing it. Now it's just like I have already done it. When I was younger I guess I just wanted to be like my sisters." Overall, girls in this study felt that their family, regardless of the messages they received from them, were highly influential in their sexual behavior. Friends-In this study, the influence of friends on sexual behavior was most commonly identified after family influence. Three important themes emerged related to friend influence: 1) friends discourage sexual risk behavior; 2) friends encourage sex; and 3) friends are often family members. Many participants in this study, particularly those who were not sexually active, cited their friends as an important influence for avoiding sexual risk behavior. Having friends who were not engaging in sexual activity helped participants feel comfortable with their own decision to abstain. A 16 year old who was not sexually active stated "my friends don't have sex." However, friends also encouraged sexual behaviors. Many girls felt pressure to have sex to fit in with their friends or for acceptance from their partners or boys in school. Multiple participants also reflected on how their decision to initiate sex in early adolescence was shaped by friend influence. An 18 year old with four sexual partners over a three year period stated that friends were a primary influence in her decision to have sex. She said, "I made a lot of bad decisions like who I chose to hang around…I just gave into all the peer pressure when I was younger." Finally, although participants identified friends from school and their neighborhood, many of the girls in this study reported considerable overlap between their friendship groups and their family. Many participants identified their sisters and cousins as their friends and therefore the influence of friends and family were not mutually exclusive. This lack of exclusiveness blurs the lines between where the sphere of family influence ends and where the friend influence begins. Therefore, it is important to consider the two in tandem rather than separately. Neighborhood-In this grounded theory study, neighborhood was noted as an influence on sexual behavior by participants although participants described family and friends as more influential. The majority saw some connection between their sexual behavior and their neighborhood. Those who grew up in "suburban" neighborhoods felt that this influenced them to abstain from sexual activity. Participants residing in "suburban" regions who were sexually active felt that their actions conflicted with the values of their community or neighborhood. Those who lived in "inner-city" areas responded in two distinct ways regarding sexual behavior. One reaction by participants was to follow the normative sexual behaviors of the community to fit in and feel accepted. The second reaction was to ignore common sexual behaviors and make decisions based upon a desire to exit the neighborhood and lifestyle. When girls accepted the neighborhood's values as their own, the girls felt that they were part of the neighborhood and therefore protected. Those who chose to ignore the normative behavior of others in their neighborhood used their desire for better opportunities as their reason to abstain from sex or have safe sex. Many participants pointed to their siblings and cousins who had babies as teenagers and were now "stuck" in their neighborhood. One participant, age 17 said, "I don't want to live in the hood and all that…my sisters are stuck there because they had babies. That isn't gonna happen to me." School-School emerged as an influence similar to that of the neighborhood. Three major themes emerged related to school: 1) belief that most teens in schools are having sex; 2) sex education courses are not enough for an adolescent's understanding of sexual risk behavior; and 3) out of school organized youth groups are needed to supplement school based sex education programs. In this study, participants overwhelmingly cited the school as a place where sexual behavior was on display and where introductory learning about reproduction, sexual consequences, contraception, and abstinence occurred. One non-sexually active 16 year old felt that school was a major factor that influenced sexual behavior and said, "I think its [school] got a big influence. No matter what school you go to, poor or rich….it's the same in every school. Peer pressure about sex and everyone is having it." In addition, many of the girls believed that the school environment helped influence their own decisions about sexual behavior although most stated that their sexual education was inadequate. For example, a 15 year old who was sexually active said that her official sex education course had just started two months prior to the interview. She had already been sexually active for a year when her school based sex education course took place. Mass media-One issue that arose from the school and neighborhood questions was the influence of the mass media and popular culture on sexual behavior. The girls in this study believed that media, particularly TV shows, influence AI adolescent sexual behavior. Current shows such as "16 and Pregnant," "Jersey Shore," and "Teen Mom" arose in the interviews and talking circles as media that teens watched regularly. The majority of participants admitted to watching reality shows and felt that TV was one way that they learned about sexual behavior. One participant, age 18 who was sexually active and was pregnant at the follow up interview felt that TV shows were a significant influence on sexual behavior in adolescents. Shows like "Teen Mom" sent messages to adolescents about the acceptability of sexual behavior. She explained, "Because you see all these teen moms having babies and it looks like they're doing okay, so that influence you to have sex." Health care-Health care emerged as an influence on sexual behavior. This study revealed two themes for urban adolescent AIs with regards to health care: 1) trusting the health care providers; and 2) access to health care services. The majority of participants trusted their health care provider and the larger medical system. Participants felt that health care providers had their best interests in mind and believed that the girls' safety was of utmost importance. In addition, all participants said that health care access was important for receiving health care information and practicing safe sex. Girls in this study believed that health care access was necessary for good sexual health. A 17 year old sexually active participant said, "Having access to health care makes it easier to have safe sex…They [the doctors] could help me, teach me, have the doctors tell how to practice safe sex." Another 17 year old who was also sexually active believed that having low cost, accessible services was a necessity for good health. --- Macrosystem Although federal policy drives support for many AI services and the environment in which they lived , adolescents did not identify a link between policy and their own personal lives. Within the ecological model, it is logical to conceptualize that them acrosystem would influence the other systems surrounding the adolescent . Federal and state policies towards AIs trickle down to the individual in a number of forms, such as health care and government assistance. Given the age and development of the participants, the connections between government policy and their daily lives may not be immediately obvious or relevant for them. --- Discussion and Recommendations Framing Sexual Risk Behavior, the theoretical model that evolved from the study data, has the potential to assist both clinicians and researcher's understanding of sexual behavior in urban adolescent AI girls. Similar to other racial/ethnic groups, factors that influence the urban AI adolescent population's sexual risk behaviors are consistent with Bronfenbrenner's ecological model . Other findings from this study are consistent with research with urban adolescent girls that indicates parental communication and sexual risk behaviors have an inverse relationship, emphasizing the importance of family in modifying sexual risk behavior in adolescents . The urban AI adolescent girls described many similarities with other racial/ethnic groups such as the high value placed on family and peer opinion and relationships , the role of parental expectations in their decision to abstain from sex or practice safe sex, and the influence of messages about sexual behavior received from their family members and friends . Distinct differences emerged between AI urban families and non-AI urban families, including the importance of the large network of family members and openness to talking about sex with at least one female family member. In addition, contrary to previous literature with AI populations , this study revealed that urban adolescent AI girls trusted their health care provider and believed that health care access was imperative to their personal well-being. According to Shafii and Burstein , adolescence is a critical time to support patients' sexual health. Health care providers are uniquely positioned to provide resources and education to adolescents about safe sexual practices in a safe, confidential setting . The similarities between factors that influence the sexual behavior of AI adolescent girls and non-AI adolescent girls can be used by both clinicians and researchers to develop interventions and clinical plans for AI adolescent girls. The unique culture of urban adolescent AI girls offers clinicians the opportunity to develop with the community culturally aware interventions to reduce sexual risk behavior. These interventions should consider including a female family member into the health care visitor identifying cultural health care beliefs that could enhance treatment or adherence. Clinicians should also consider formulating personal goals with each patient and taking time to review how health promoting behavior and healthy sexual choices will help the patient meet their long-term and short-term goals. Additionally, because there are many similarities between urban AI youth and those non-AI youth living in urban areas, previous interventions that focused on reducing unintended pregnancies and STIs with non-AI urban dwelling adolescents should be considered for modification, adaptation, implementation and evaluation. However, it would be important for researchers modifying interventions for the urban AI population to consider the differences among the various tribes in urban populations and ensure that the modifications meet the needs of a diverse group of urban AI adolescents. Strategies clinicians can consider include attending culturally responsive training as well as taking time to learn about AI culture, particularly the history of tribes in their local area. In addition, clinicians should be experts not only on clinical care, but also on connecting urban AI adolescent girls to community based programs that emphasize the importance of culture and sexual health. Clinicians must build relationships with other providers who can collaborate with one another to provide community based interventions to reduce sexual risk behaviors. These health care collaborations should be in association with the larger AI community and involve both AI elders and AI community leaders. --- Future Research Recommendations The grounded theory developed from the findings of this study provides direction for future research. The current literature on urban AI adolescent sexual risk behavior is limited; therefore, using the Framing Sexual Risk Behavior model to investigate known influences on sexual risk behavior could be important to the health of the urban AI adolescent girl population. Future research should also focus on the male adolescent as well as comparison of urban AI adolescents to reservation AI adolescents. Replication of the current study on reservations could confirm any similarities or differences between the two groups. Similarly, replicating the study with male adolescents could provide valuable insight into how adolescent AI boys regard sexual behavior and what they believe to be the primary influences on sexual behavior. Framing Sexual Risk Behavior can be used to guide future research and efforts to reduce sexual risk behaviors among urban AI adolescent girls. Understanding AI culture and heritage as well as recognizing the urban AI girls' unique influences described by the girls in this study is necessary for reducing teenage pregnancy among AI adolescents. --- Interview Questions Variables Topic One: Knowledge and Influences --- 1. Tell me what you know about having sex. --- 2. Tell me how you feel about having sex. --- 3. Tell me what influences you having/not having sex. --- 4. Tell me who influences you to have/not have sex. ---

Purpose-American Indian (AI) adolescent girls have higher rates of sexual activity, births and STIs compared to the national average. The purpose of this study was to explore factors that influence urban adolescent AI girls' sexual risk behavior (SRB). Design-A qualitative study was conducted using grounded theory methodology to reveal factors and processes that influence SRB. Methods-Talking circles, individual interviews, and event history calendars were used with 20 urban AI 15-19 year old girls to explore influences on their sexual behavior. Findings-The generated theory, Framing Sexual Risk Behavior, describes both social and structural factors and processes that influenced the girls' sexual behaviors. The theory extends Bronfenbrenner's ecological model by identifying microsystem, mesosystem, and macrosystem influences on sexual behavior, including: Microsystem: Being "Normal," Native, and Having

Introduction According to Ministry of Unification [1], in 2018, an estimated 32,476 North Korean refugees had settled in South Korea, about 40% of which were children and young adults aged 10 to 29. Scholarly interest in NKRs has increased along with their growing numbers during the past 10 years, but there is scant research on them, particularly North Korean Refugee Youths . NKRs are likely to have had traumatic experiences, such as compulsory confinement, arrests and detainments, witnessing people die of starvation, witnessing public executions or accidents, or being deported to North Korea [2]. NKRYs have reported a variety of traumatic experiences while they were in North Korea and on their way to South Korea [3]. NKRYs often feel a sense of guilt and loss about family members that were separated from them during their escape, and they have fears about others' knowledge of them as refugees [3,4]. NKRYs often suffer from post-traumatic stress disorder , depression, or anxiety because of these traumatic events [5]. In particular, depression, which is a psychological symptom of maladjustment, is a key indicator used to assess the mental health of immigrants and refugees [6], and it is one of the most common maladjustment problems of NKRs [7]. Because childhood depression might cause psychosocial and other problems in adulthood, it might be associated with a huge social cost [8]. Therefore, it is important to relieve the depression experienced by NKRYs and prevent their childhood problems from affecting their adult lives. Adolescence is usually a vulnerable stage in the life course when physical, interpersonal, cognitive, environmental, and stress problems can negatively influence mental health [9]. NKRYs are particularly vulnerable to internal problems, such as anxiety and depression, and their depression is likely to increase over time after they arrive in South Korea [2,10]. However, resilience theory proposes that the developmental outcomes of adolescents who spent their childhoods in stressful environments, such as poverty or abuse, or those who experienced adverse events, are not necessarily negative [11][12][13][14]. Consequently, researchers also consider protective factors. Protective factors are expected to reduce the likelihood of dysfunction or illness after life experiences that might cause vulnerability and/or stress [15]. Adolescent developmental protective factors [16][17][18] are classified as personal characteristics and internal factors , positive responses to others, and cognitive factors; social supporters or adults who warmly care for and supervise youths; and adult support systems, social supports, adult role models, and service institutions that link youths to their communities. Therefore, clarifying the personal and environmental factors associated with change in depression is important to realizing effective interventions. Many studies on NKRYs' mental health have focused on psychopathology, such as suicidal ideation, depression, anxiety, and PTSD, and the associated risk factors. However, little research has been conducted on the protective factors, such as positive mental health, character strength, and social support. Adaptation to a new culture in South Korea places constant demands on every aspect of NKRYs' lives, and, because their lives are dynamic, it is important to conduct longitudinal analyses to examine changes in mental health. Based on the previous studies about these youths and their mental health, this study examined changes in depression levels and the related protective factors and risk factors in a sample of NKRYs to obtain insight for effective interventions in accordance with the results of the current study. --- Materials and Methods --- --- Variables and Measurement --- Sociodemographic Characteristics Gender, age, birthplace, parental education level, and type of household were the personal characteristics used in the study's analysis. --- Potential Risk of Depression The Center for Epidemiologic Studies Depression Scale was developed to measure depressive symptoms in the general population [19]. It has four positive items and sixteen negative items . The response options are on a four-point scale where 0 = rarely or none of the time , 1 = some or a little of the time , 2 = occasionally or a moderate amount of time , and 3 = most or all of the time . The four positive items were reverse-coded; and, then, the responses were summed. The total scores ranged from zero to 60, 16 through 25 points was classified as mild depression and more than 25 points was classified as clinically significant major depression [20]. This classification was based on the usual 16-point cut-off used in primary care [21]. For the analysis, depression levels were low = zero to 15 and high = 16 or higher. --- Psychological Characteristics Three psychological characteristics were measured. The Brief Resilience Scale measured resilience defined as the process of, or capacity for, successful adaptation after exposure to trauma or severe stress [22,23]. The scale has three positive items and three negative items . The response options are on a five-point scale where 1 = strongly disagree through 5 = strongly agree. The negative items were reverse-coded, and the scores were then summed for a composite score, which ranged from six to 30, with higher scores indicating more resilience. The Emotion Regulation Questionnaire measured cognitive reappraisal and expressive suppression , which are two emotional regulation strategies [24]. The response options were on a five-point scale where 1 = strongly disagree through 5 = strongly agree. Higher scores indicated that the use of more strategies to control emotions by changing their thoughts or suppressing emotions. The Rosenberg Self-Esteem Scale was used to assess self-esteem [25]. It has six positive items and four negative items . The response options were on a five-point scale where 1 = strongly disagree through 5 = strongly agree. The responses were summed after reverse-coding the negative items. Total scores ranged from 10 to 50, with higher scores indicating higher self-esteem. --- Social Support Two items were used to measure social support as psychological or practical support received from others. Psychological support was measured by responses to the question: "How much psychological support do you currently receive from your family, relatives, friends, and others around you?" Practical support was measured by responses to the question: "How much practical support do you currently receive from your family, relatives, friends, and others around you?" Both items' response options were on a 10-point scale where 1 = none at all through 10 = enough. --- Statistical Analyses First, descriptive statistics were generated on all the variables. We then compared the two groups to see if their baseline scores differed. A multinomial logistic regression analysis was performed to identify the variables significantly related to change in depression by comparing T2 to T1 data. Odds ratios and 95% confidence intervals were calculated using the group factor as the outcome variable, and sociodemographic, personal, and psychological variables were predictors. The outcome variable was based on the CES-D cut-off score of 16. Depression change was categorized using the CES-D scores at T1 and T2: stable low , alleviated , deteriorated , and prolonged . All statistical analyses were performed using SPSS 20.0 , and the statistical significance cut-off level was p < 0.05. --- Results The sample comprised 66 female and 42 male NKRYs aged 13 to 26 years old with a mean age of 17.84 . Table 1 presents the descriptive statistics. Twelve of the 66 respondents who scored high on depression symptoms at T1 had lower scores at T2 . Fifty-four of the 66 respondents who scored high on depressive symptoms at T1 also had high depression scores at T2 , and 20 of the 42 respondents with low depression scores at T1 had higher scores at T2 . There was no significant difference in socio-demographic variables in the four depression change groups. When comparing baseline scores between the follow-up group and the group without follow-ups, there was a significant difference in mean age . There was no significant difference in gender . There were no significant differences in baseline scores on the CES-D, BRS, RSES, or ERQ . There was no significant difference in psychological support , but there was a significant difference in practical support . Table 2 presents the results of the multinomial logistic regression analysis of the predictors of change in depression. The alleviated depression group had significantly higher odds than the stable low depression group regarding expressive suppression and tended to have low self-esteem at T1. The deteriorated depression group was more likely than the stable low depression group to have low resilience and low cognitive reappraisal at T1. The respondents with prolonged depression were more likely than the stable low group to have low resilience, low self-esteem, and perceive low practical support at T1. The stable low depression group was treated as the reference; AOR, adjusted odds ratio; adjusting for all variables in Table 2; CI, confidence interval. --- Discussion This study investigated factors related to change in the potential risk of depression among NKRYs focusing on the progression, maintenance, and alleviation of depression. The NKRYs whose depression was alleviated between T1 and T2 had significantly higher T1 expressive suppression scores and tended to have lower T1 self-esteem scores than those in the stable low group. Low self-esteem and expressive suppression are two features of depression [24,[26][27][28]. Therefore, the relatively low self-esteem and relatively high expressive suppression scores of the respondents in the alleviated depression group seem to reflect their high baseline depression scores rather than that these factors alleviated their depression. These results imply that programs to promote self-esteem and emotional expression might be effective interventions for depressed NKRYs. The respondents in the deteriorated depression group had significantly lower resilience and lower cognitive reappraisal scores at T1 than those who were in the stable low group. Resilience is a protective factor previously associated with subjective health status and low depression and anxiety among NKRYs [29]. Resilience theory proposes that personal characteristics and internal factors classified as protective factors reduce the likelihood of dysfunction among those with life experiences that could cause vulnerability or stress [15]. The ways that NKRYs perceive, interpret, and accept traumatic experiences or acculturation stress seems to be important. Considered together, low resilience and low cognitive reappraisal seemed to create a propensity to be vulnerable that increased the risk of depression among the respondents, which implies that depression prevention programs for NKRYs should focus on promoting resilience and enhancing healthy emotional regulation strategies. This study's prolonged depression group had significantly lower resilience, practical social support, and self-esteem scores at T1 than those in the stable low group. In addition to low resilience and self-esteem, which are historically considered central factors in depression [26][27][28], lack of practical social support seemed to have a significant role in depression maintenance. The relationships between depression and low self-esteem and social support could be bidirectional. Individuals with depression may be more likely to have low self-esteem [30] and feel socially isolated and as though they have a lack of social support [31]. These feelings of low self-esteem and insufficient social support, in turn, may be a risk factor for developing more severe depression [26][27][28][30][31][32]. The psychological and practical support received from family members, friends, and others were previously associated with NKRYs' mental health [33,34]. These are protective factors in resilience theory because, through social support, individuals obtain knowledge and advice that helps them to adapt to their environment, improve their adaptability skills, and cope with change and stress [35]. In particular, practical support functions to adequately provide resources and services necessary for youths, thereby improving mental health by reducing stress and helping with environmental adaptation [33][34][35]. However, a previous study indicated that the average number per NKRYs of individuals providing practical, informational, and emotional assistance was 2.1 per person, and about 12% of the youth had no social supporters [33]. Those who lack social support are expected to be relatively vulnerable to mental health problems caused by stress. To the best our knowledge, this is the first longitudinal study on change in the potential risk of depression among NKRYs. The findings provide insights into the variation in depression among NKRYs. First, relatively low resilience at T1 related to increased depression at T2, suggesting that resilience is a risk factor for deteriorated depression. Second, because self-esteem was significantly lower in the T1 high depression group, low self-esteem seems to be important to the initial state of depression. Third, low practical social support seems to be a factor that contributes to maintaining a high level of depression. These results will help develop programs to improve mental health among NKRYs and inform experts on depression. Further studies are needed on larger and representative samples, and the protective effects of family characteristics should be analyzed to verify our results. Despite this study's important findings, it has several limitations. First, the sample was small, with only 12 to 50 people per depression change group, which might have influenced the external validity of the results. Second, social support was measured with two single items. Further research is needed that uses a validated scale to distinguish among social supports received from family members, friends, and others. Third, we did not collect any information on treatment for depression, which could have affected changes in depression during the follow-up period. Finally, this study revealed factors associated with change in depression among NKRYs, but it did not explore the ways that these factors might relate to alleviation, deterioration, or maintenance of depression. Longitudinal studies of longer duration, with more follow-ups, and that use statistical analyses, such as temporal mediation or moderation, would help to reveal the relevant mechanisms. --- Conclusions This study examined the factors associated with change in the potential risk of depression and those that affect the progression, maintenance, and alleviation of depression among NKRYs. Twelve of the 66 respondents who scored high on depression symptoms at T1 had lower scores at T2 . A total of 54 participants scored high on depressive symptoms at T1/2 --- Author Contributions: Conceptualization, S.P.; methodology, J.Y.J. and S.P.; formal analysis, E.-S.L.; investigation, S.P. and J.Y.J.; writing-original draft preparation, S.P., S.Y.K. and E.-S.L.; writing-review and editing, S.Y.K. and S.P.; funding acquisition, S.P. ---

This study investigated change in depression and revealed factors related to change using one-year follow-up data. A sample of 108 North Korean Refugee Youths (NKRYs) aged 13 to 26 years (66 females) was recruited from two alternative schools for NKRYs in South Korea. Based on the Center for Epidemiologic Studies Depression Scale cut-off score of 16, respondents were grouped based on change in depression score after one year as stable low, alleviated, deteriorated, or prolonged. Multinomial logistic regression assessed the influence of baseline psychological scores (resilience, emotional regulation strategy, and self-esteem), and reported social support (psychological/practical) on the odds of group classification. With the stable low group as the reference category, those with alleviated depression at Time 2 had significantly higher odds of expressive suppression and tended to have lower self-esteem at Time 1. The deteriorated depression group was more likely than the stable low group to have lower resilience and cognitive appraisal scores. Those with prolonged high depression were more likely than the stable low group to have lower resilience, less practical social support, and lower self-esteem. Psychological interventions, particularly those focused on increasing self-esteem and resilience, could be helpful for NKRYs with potential risk of depression. In addition, practical support should be provided on an as-needed basis to prevent chronic depression among NKRYs.

November 2023 employ a variety of mechanisms such as questionnaires, interviews, diaries, field notes, and reflections over some time. The process of research always encompasses feedback to improve the situation and bring about some changes modifications or redefinitions. Action research is all about researching own practice or the people involved together rather than people out there. It is participatory and emergent. It can also be useful for real problem-solving. It is situation-based and theory-building from the practice. Moreover, it deals with individuals or groups of people who have a common purpose to improve their practice involving analysis, evaluation and reflection. Action Research Processes Many studies have given various stages/procedures for the participatory action research method of research. Particularly it is known as a cyclical/spiral process in which a complete cycle completes and is repeated time and again. One cycle has four stages: the planning stage, the acting stage, the developing stage and the reflection stage. Figure 1 Stages of Action Research Action research involves recurring stages of planning, observation, action and reflection along with the evaluation. These stages are recursive in almost all the action research process. The influence of Lewin's original ideas continues to organize action research works in the spiral of stages that comprises observation, reflection, action, evaluation, and modification . These cyclical stages are recurring even in another cycle. Reviewing many research and research reports through an action research approach reports a common framework for participatory action research that undergoes a "cyclical process of fact-finding, action, reflection, leading to further inquiry and action for change" . The contributory writers on participatory action research, Kemmis and McGaraat also emphasized the recursive steps in PAR such as plan, act, observe and reflect and repeat the same process of plan, act, observe and reflect until the situation is improved. Likewise, Kelly suggests that the beginning of action research is followed by collaboration with the community partners in three cycles: planning, acting, and reviewing. In the same line, Valsa Koshy suggested a list of stages to be followed in the conduction of participatory action research. These states are identification of topic and context setting, review of related literature, emphasizing the topic research question or hypothesis, careful planning of the activities, collecting required data, analyzing the data and fixing the problems, implementing the plan, reflecting on the results and reporting the changes. In the literature on action research, many action researchers often mention the basic common four phases involved in action research assessment, planning, action, and reflection. Among the processes mentioned and suggested by the previous studies, Clark et al. provided clear steps for conducting action research in the educational setting. These steps are almost similar to many other scholars such as topic identification in a particular educational context, literature review, revision of the topic, construction of research questions, planning of research activities, collecting data, analysing them, doing real action, reflection, reporting, sharing and documenting. These processes can be useful for conducting action research in the classroom setting as well. Aligning these steps of action research to the rigorous process of educational research, these steps can help the researchers. Participatory Action Research as a Research Methodology Pain et al. provided the participatory action research toolkit for conducting PAR as an approach to learning, research and action. They have defined it as "collaborative research, education and action used to gather information to use for change on social or environmental issues. It involves people who are concerned about or affected by an issue taking a leading role in producing and using knowledge about it. . PAR is different from other traditional research approaches in the sense that it is initiated by participants at workplaces rather than an outsider, funders or academicians. Moreover, it offers a democratic and practical model of producing, taking ownership, and using the knowledge produced themselves it is collaborative at every stage in nature that involves discussions, reflections and applications intending to bring about changes or improvements in the issues researched. Since PAR is a research approach to explore and improve the practices with a set of principles and practices for identifying issues, designing plans, conducting activities, analyzing and acting, it can also be used as a research methodology. It is not a single method but an integration of multiple methods such as group discussion, interviews, observations, videos, diagramming, and photography. It has a typical and cyclical stage of action and reflection from the beginning to the end of any PAR project. In the toolkit offered by Pain et al. , it is said to include a set of questions at every stage of PAR. For example, they said to include various questions for collaboration , knowledge , power , ethicalities , theory generation Vol. VI November 2023 the findings of the research? Who is involved in the meaning-making process and what does that mean? What outputs will we expect from the research?), taking action , and researchers' wellbeing and emotions (Is the topic of the research relevant on which the people care passionately or directly affects their well-being? How will we make sure that our workplace is comfortable and hospitable for participants? How can we manage the negative emotions of the participants in the meetings? How might the results of the research affect the outsiders in the participatory action research? Do we have alternative strategies to overcome such problems that arise during the implementation of the research results? These toolkits could be utilized to guide the research methodology through PAR. Lewin stated, "You cannot understand a system until you try to change it". As expressed by Lewin, only the talk, exploration, and discussion may not be possible to bring about changes in the existing situation. PAR as a research methodology can be an alternative qualitative approach to improve/solve practical problems. The main aim of qualitative research is to describe and understand the phenomena rather than to predict and control them . PAR is considered a subset of action research which is the "systematic collection and analysis of data to take action and make change" by generating practical knowledge . Action research embeds myriads of other terminologies such as participatory action research, participatory research, community-based participatory research, participatory inquiry, practitioner's research, and classroombased research which might be confusing for novice researchers to distinguish and conduct action research . The common purpose of all research is to bring social change with a specific action as the ultimate goal . By involving researchers and community members who desire to improve their situation, action research often opts for social change The philosophical underpinning of participatory action research is the change-oriented action that is value-laden and morally committed . Therefore, participatory action researchers try to understand themselves and the phenomena being intervened concerning other individuals in social contexts along with the epistemological assumptions underlying action. Participatory action research also aims to create knowledge as an active process, knowledge being uncertain and the object of the enquiry . Action researchers believe that the philosophical underpinnings of participatory action research are similar to "postmodern tradition that embraces a dialectical of shifting understandings whereas objectivity is almost impossible and multiple or shared realities exist" . The philosophy of PAR embodies the idea that the people in the community must have the right to determine their development and participate meaningfully in the process of analyzing the results or solutions by recognizing the needs of local people for sustainable development . In participatory action research, the role of participants remains the co-researchers since they engage in the research process from the beginning to the end for co-constructing the knowledge. Guiding Principles for Action Research The theory of participatory action research is guided by two reasons: the first one is that it is an effective way of imparting knowledge acquired from the experience of participants in the workplace . McTaggart , further, states that the guiding principles are descriptive as well as prescriptive, whereas, in the second reason, the recipients should perform an educative function. Lewinian approach to cyclic action research emphasizes the need for an action plan to be flexible and responsive. Two works were substantive in Lewin's work: group decisions and commitment to improvement. Participation means taking ownership of the knowledge. Tandon identified many determinants of actual participation in research. These determinants were listed as participants' active role in setting the agenda of research, their participation in the process of data collection and analysis, and their dominance over the utilization of the results and the entire research process. It is visible from the literature that PAR engages participants from the academic fields and workplace with unique relationships. Participatory action research is democratic, equitable, liberating, and life-enhancing because it selects the participants based on the criteria given with equal access to them and helps them to transform through action. McTaggart outlined 16 tenets of PAR such as the active approach to improve social practices, real participation of the individuals; collaborative self-reflective learning communities; and involvement of practitioners for theory building, record-keeping, making critical analysis, political, initiated from small cycles and groups. Likewise, De Oliveira identified seven components that characterize participatory action research such as originating from the problem in the community, oriented to a drastic change of social reality and improvements in the lives of participants, full and active participation of the community, engagement of a range of powerless groups of individuals, creating greater awareness in individuals and mobilizing them for self-reliant development, and making selfdetermined participants, initiators, facilitators and learners during the process. Participatory action research shapes the identity of the individual and groups through the collective project which improves their work and the way it is understood . Furthermore, it increases the collaboration with the individuals within their institution and beyond for understanding the situation, solving the problems and developing their own professional space. It attempts not only to change the individuals but also the culture of the groups, institutions, and societies where they belong, bringing changes in the ongoing discourses, practices and organizational context from the perspective of the distribution of power, unifying the intellectuals and the project, engaging the politics of research and action . --- Strengths of Action Research The PAR always identifies and values the people as social beings within the broader social, political, and economic context. It also seeks to address the issue of significance concerning humans and their communities. In participatory action research, participants are not only treated as the subject of study rather they are treated as active participants and contributors to the research. It attempts to rebuild the participants' capacity as creative actors in the world, engage them in the decision-making process and empower them by being involved in the research process. Since it as a collective inquiry, develops the ownership of the participants in the research and its outcomes. Moreover, it empowers oppressed individuals to partner the social change. It also provides the opportunity to collaborate the individuals with diverse knowledge, skills and expertise during the process of research. In this research design, individuals learn by doing. The process in PAR is transformative, empowering, liberating, and consciousness-raising for its participants. Furthermore, it provides critical understanding and selfreflection to the researcher and participants. PAR enhances the collective consciousness and the democratization of the participants . Applications and Benefits of Action Research Action research has been useful in understanding the problem and improving it directly being involved in it since it is the 'systematic inquiry into one's practice' . In the field of education, it is the process which supports teachers to study their classrooms and improve the quality or effectiveness of teaching-learning. Mertler provided six ways of making PAR and teacher inquiry critical in any profession. They are constructing teachers' knowledge base, developing skills, enhancing Journal of NELTA Gandaki Vol. VI November 2023 teachers' agency, teacher empowerment, improvement of educational practices and professional growth Among them, Vaughan and Mertler highlighted teacher empowerment, the improvement of educational practice and professional growth as the important ones. The first application of action research is directly concerned to lead to the improvement of educational practices because the researchers or educators study their practice by critically examining and reflecting on their problems related to their contexts. The action researchers identify their problems, collect the data and finally engage in the process of data informed and practical decision-making. Professionals, teachers and teacher educators get the solutions to their presenting issues at the workplaces and solve them through the process of action research. Similarly, through action research or teacher inquiry, teachers can grow themselves successfully in their profession. . The application of action research has become the alternative to professional grown for many teachers and teacher educators. Acton research has been considered one of the major means of in-service teachers' professional development in education. For example, in school education in Nepal, the provision of granting one mark for one action research each year has been made just for promotion. In this regard, Oliver contended that in-service teachers benefit from action research as a key component of professional development since it promotes the culture of posing questions and findings solutions to solve their immediate problems. Action research and teacher research can be highly effective tools for teachers' empowerment. When teachers engage themselves in the process of research-identifying issues, collecting data by using various tools, making subsequent decisions based on the data and taking necessary interventions for the action and change, they experience, get knowledge and empowerment. That also helps them to innovate, create and apply to their education contexts. The whole process becomes truly empowering themselves. The studies suggested various benefits of participatory action research in education such as empowerment, collaboration, engagement, change, professional community building, and emancipation . There are various advantages to using action research as a method of research. MacDonald provides five characteristics/benefits of action research. First, it is open to all the competing possibilities in the educational context because it rejects the positivistic notion of objectivity, rationality and truth. Second, it invites the practitioner's reflective and interpretive subjectivity and develops localized theory and pedagogy. Third, it provides opportunities for educators to self-realize and understand their practices by exploring and analysing the existing situation. Fourth, it links reflection and action encouraging the educators or researchers to overcome the problems for pedagogical changes through the systematic exploration into the educational context. Finally, it involves deep consideration of theory and practice and also demonstrates critically reflective action by developing and organizing knowledge with the practice. Sample Studies on Action Research Many dissertations and articles through participatory action research are available online and offline repositories. Journals, such as the Journal of Teacher Action Research, Action Research, and Educational Action Research publish articles based on participatory action research. For example, one recent study on action research: exploring the teaching of English and academic writing as a social practice in a British Malaysian University by Alison Abraham at the College of Education, Victoria University, Melbourne, Australia in 2016 followed the PAR as research methodology. The purpose of that study was to analyze and improve English for academic purposes in the Malaysian university setting. Taking an academic literacies perspective, the study attempted to capture the complexities of teaching and learning academic writing within a tertiary classroom. The researcher used post-method pedagogy to guide a teacher while implementing the action plans. The researcher used action research with 117 voluntary students in six cycles over two years and collected data from various sources such as teacher diaries, interviews with colleagues and students, students' letters, email exchanges, and assignments. In the study, the researcher's journey of becoming a critically reflective teacher alongside the student's growth as academic writers has presented the findings. The study reports the findings that power mismatches can be reduced through negotiated interactions, students' autonomy was increased after the knowledge gained from the study, and students were engaged in learning after ensuring the relevance of social and cultural context . The researcher engaged in teaching the students for two years long time and kept records of all the documents, analyzed and presented in the form of a dissertation. The analysis of the power conditions, knowledge conditions, and socio-cultural conditions have been developed as the main themes/results of the study in the narrative form. It shows that action research can be applied along with narrative inquiry. Many studies have also applied participatory action research as a research methodology for completing their formal university degrees. Campbell's study uses PAR methods for the professional learning community to investigate trauma-informed practices with six co-researchers also used participatory action research as a method to explore the experiences of bilingual teachers at an elementary school in the professional learning community. The study found that the participants in the professional learning community enjoyed the safest spaces for learning, group work and reflection. Participatory action research methods in the field of social sciences and education were found for the participants' engagement, knowledge construction and immediate use of the research findings in the practice. Misconceptions and Criticisms of Participatory Action Research Participatory action research is not what academics and workers normally think about. It is more systematic and collaborative in gathering the data on which to base the reflection and plan change. It is not only problem-solving. It is also problem posing where it finds the values and plans realized by the work in real-life situations . It is oriented by the quest to improve and understand the problems by getting involved in it and making some changes. PAR is not research conducted by outsiders but research by practitioners on their practices. It treats the people as independent, responsible change agents who can solve their problems themselves, make their histories and construct knowledge. It never makes the people subject of study but encourages them to engage in the research and improve the existing situation. It is also not the method or technique for policy analysis and implementation because it never accepts the truths created by outsiders. Moreover, it is not the scientific method of any social work because it does not test hypotheses using hard data. It further works in the natural setting. It is systematically evolving, a living process changing through living dialectics of researcher and research . Kemmis and McGarrat illustrated four types of myths, misinterpretations and mistakes in critical participatory action research. They grouped them into four clusters: "… exaggerated assumptions about how empowerment might be achieved through action research, confusions about the role of those helping others to learn how to conduct action research, the problem of facilitation, and the illusion of neutrality, the falsity of a supposed research-activism dualism, with research seen as dispassionate, informed, and rationales and with activities seen as passionate, intuitive, and weakly theorized. An understatement of the role of collective and Journal of NELTA Gandaki Vol. VI November 2023 how it might be conceptualized in conducting the research and in formulating action in the project and its engagement with the public spare in all facets of institutional and social life" . Similarly, Clark et al. stated three criticisms commonly occurred in action research practices. The major criticisms they discussed were the lack of rigour and trustworthiness in comparison to other research methodologies; the generalizability of the findings to other contexts and the deficit model as its basis . As they explained in the article, these criticisms can be minimized by maintaining rigor throughout the research process from selecting issues to collecting and reporting. Challenges in Doing Participatory Action Research There are several challenges, for example, diversity in meanings of PAR and interchangeable use of terms such as action research, participatory action research, practitioners' research, and novice researchers might get confused. Since there is a lack of a comprehensive and balanced way to learn about the diverse origins, theories, methods, motives and problems associated with the related field , the researchers may remain in dilemmas about whether to follow PAR as a research methodology. Another challenge can be the inclusion of community members in the research team because they may have problems maintaining commitment throughout the research since PAR requires time, knowledge and sensitivities on the part of researchers to participants' agenda. Moreover, there may be a divergence of perspectives, values and abilities among the members . The next challenge can be the balance of power and establishing the relationship in PAR. Issues of power imbalances and the establishment of egalitarian relationships must be addressed before initiating PAR research . There may be misunderstanding among the people involved, lack of agreement, wrong perceptions, directions and questions resulting in irrelevant data . While using PAR as a methodology, the researchers need to be sensitive because the researchers may have to prove its legitimacy to others. Those conventional researchers who are not used to openended research designs might criticize it. The most criticized aspect of PAR from a scientific perspective is that it is a soft method of research . Therefore, other researchers might challenge it for employing as a research methodology as it emphasizes "voice and everyday experiences" and not hard data . --- Conclusion and Implications Participatory action research as it aims to transform the existing situation and emancipate the research participants, has been widely applied in the field of social sciences and education for exploring workplace issues and overcoming them through collaboration, participation and action. Its cyclical and transformative nature has also fascinated many emerging researchers to adapt it in their research as a methodology. Moreover, the critical review of its origin, features, and practices shows that participatory action research can bridge the gap between theory and practice as it is always oriented to generate practical knowledge and also to practice the knowledge created in the local context. Furthermore, participatory action research engages the community people in the process of research and takes ownership of the knowledge or change that occurs. Although it is often criticized for being loosely designed and not systematically/scientifically conducted to produce true scholarship, scholars have suggested ethical considerations and quality standards for its rigour. Its popularity has tremendously increased as the qualitative approach to coping with local issues and theorizing the knowledge produced by the practitioners. This paper might be helpful to understand and apply participatory action research in the field of social sciences and education as a research methodology. Moreover, this can be insightful to the teachers, researchers and policy makers for taking into practice.

Participatory action research, as other qualitative methods. like phenomenology, ethnography, narrative inquiry, autoethnography, and case studies, has emerged as a distinct field of study and established itself as a research design in the field of social sciences and education. This methodological conceptual paper presents a review of participatory action research papers highlighting their meaning, purpose and use in research along with their definitions, the process of conducting research through participatory action research as a methodology, its guiding principles, strengths, weaknesses and challenges, applications, misconceptions and analysis of previous studies through participatory action research in various disciplines and contexts. This paper also highlights how participatory action research elevates the marginalized communities involved in the research process, solves their workplace problems and transforms their identities throughout the research by reviewing a few sample studies through participatory action research. The findings show that participatory action research has been immensely used in the social sciences and educational research for creating new knowledge as well as improving the existing situation. This paper might provide some significant insights into understanding and employing participatory action research to the teachers, teacher educators, and researchers who opt for using research as part of their academic degrees.

INTRODUCTION The Amazon Rainforest, colloquially called "the lungs of the Earth," is an ecosystem of incalculable global ecological value. This unique ecosystem is threatened by various human activities, most notably traditional and industrial mining, both legal and illegal. The growing mining expansion in the Amazon region is of grave concern, mainly due to the potential harm to surrounding communities and the sustainability of this fragile ecosystem. This situation mirrors critical challenges in sustainable development and environmental justice. When attempting to implement land-use change policies, the inherent ecological fragility of the Amazon region poses significant challenges. Historically, land use planning and zoning decisions have favoured economic gains over environmental and social welfare in these delicate ecosystems. While industrialisation may spur economic development, it also carries severe environmental and social repercussions that must be understood from various perspectives. This study aims to explore and understand the ramifications of gold mining on communities near extraction sites. Specifically, it focuses on the daily life of communities near areas where illegal gold mining is practised, following years of legal exploitation with government permits. Within the framework of sustainable development, anticipating the legacy that mining will leave in communities after its closure is vital as it constitutes a crucial element of its planning . The goal is to provide key insights that aid in planning land transformation and crafting policies for sustainable land use. The community of Yutzupino, in the Napo province of Ecuador, serves as the focal point of this research. Through exploring the experiences of this community, we aspire to amplify our comprehension of the socio-economic interplay and challenges they face in the aftermath of official mining activities. Notably, this study posits the creation of a new category within spatial planning explicitly tailored for territories previously subjected to mining. A qualitative methodology encompassing comprehensive interviews and observational studies was employed to fulfil this objective. The findings of this article contribute theoretical, empirical, and practical insights relevant to territorial planners, policymakers, and local communities. In addition, the study provides an essential understanding of the needs, challenges, and goals of the communities impacted by mining, which can inform and steer both sustainable development strategies and initiatives led by the community itself. The article's structure unfolds as follows: Section 2 provides the study's theoretical framework, focusing on the aftermath of mining following the termination of concession contracts. Section 3 outlines the methodology and approaches used in the research. The results and their corresponding analysis are presented in Section 4, divided into five subsections. The paper ends with a set of concluding remarks derived from the study. --- THEORETICAL BACKGROUND One of the main threats facing the Amazonian ecosystem is industrial and traditional mining activities. The expansion of mining poses concerns about the potential destruction of surrounding communities and the sustainability of particularly fragile ecosystems worldwide . This Sustainability in Debate -Brasília, v. 14, n.3, p. 219-233, dez/2023 ISSN-e 2179-9067 theoretical review explores the socio-environmental implications of gold mining in the Amazon and its consequences for local communities. Land use zoning is a tool for regulating activities in a specific geographical area. It allows authorities to categorise lands for various purposes, such as agriculture, conservation, infrastructure, and industrial development . In the Amazon case, zoning favouring industrial mining has prioritised economic gains over environmental and social welfare . The expansion of industrial mining brings with it the destruction of forests and loss of habitats, impacting communities that depend on these resources for their livelihood and cultural identity, thereby exacerbating inequality and social conflicts . Concurrently, the release of toxic chemicals into water bodies, such as mercury and cyanide, threatens biological diversity and disrupts the natural cycles of the ecosystem . This negatively affects flora, fauna, and vital ecosystem services such as climate regulation, water purification, and food provision. The interconnection of the different ecosystem components like rivers, forests, and soils requires a holistic approach to land use management. Deforestation, frequently spanning across borders , often results from clearing forests to accommodate mining activities. This leads directly to extensive habitat loss and biodiversity displacement . Also, the extraction of minerals and the associated infrastructure construction disrupt natural hydrological cycles, resulting in notable changes in water availability, heightened incidence of flooding, and exacerbated soil erosion . Much like other mining activities, gold mining plays a substantial role in the Amazon's environmental degradation. Celi Sangurima and Velastegui-Montoya et al. underscore the connection between gold mining and forest loss, changes in land cover and use patterns, and decreasing biodiversity. Also, Pérez et al. scrutinise the detrimental effects on water quality and likewise link gold mining with long-term biodiversity loss. Furthermore, by its very nature, gold mining requires substantial displacement of soil and rock, a factor that invariably instigates soil erosion. This erosion affects slope stability, undermines soil fertility, and hinders the ecosystem's innate regenerative abilities . Comprehensive research, such as the study conducted by Balaka Opiyo et al. in Kenya, demonstrates that gold mining precipitates the degradation of vegetation cover and the depletion of fertile soil, posing substantial threats to agricultural productivity. --- THE IMPACT ON SURROUNDING COMMUNITIES Driven by the rising global demand , the Amazon has seen a surge in gold mining, leading to significant land cover changes. Swenson et al. highlighted how this increased gold demand, local resource utilisation, and growing populations in communities around the mines have reshaped the Peruvian Amazon's environment. This demographic growth in mining areas pushes forests to be converted into agricultural land. López and Maldonado emphasise that while this land cover transition does not always spike overall deforestation rates, it notably diminishes successional forests and exacerbates water quality issues. The health consequences of gold mining for Amazonian communities are notably alarming. The employment of hazardous substances like mercury and cyanide in gold extraction processes severely threatens human well-being . Specifically, mercury contamination of fish and water sources has been associated with neurological and developmental disorders among communities along the Brazilian Amazon's riverbanks . Social disruptions are also of primary concern . The social impact of mining projects in Amazon communities is complex, marked by anticipation and conflict during various stages of mining operations . In early phases, companies must obtain social consent to operate, leading to high expectations and sometimes resistance or division within communities. Attempts to secure local consent may involve harmful practices such as co-opting leaders and corruption. Once mining is underway, challenges include mismatches between expectations and reality, inequalities, dependency on the company, social changes, and erosion of trust in public institutions. These dynamics, along with land rights conflicts , underscore the multifaceted social impacts of mining in the region. The literature has broadly examined the environmental and health consequences faced by communities surrounding gold mining territories in the Amazon. Much of this focus has been directed towards concession contracts for industrial exploitation, particularly emphasising the stages prior to and during the concession phases. However, a noticeable gap persists in understanding the social conflicts that arise post-concession. This underexplored area highlights a need for further investigation to comprehensively address the full spectrum of social impacts associated with gold mining in the region. --- EMERGING APPROACHES TO MINING CONCESSIONS Addressing the destructive consequences of mining in the Amazon requires a fundamental shift in land use zoning and resource management strategies. This includes encouraging responsible mining practices, utilising cleaner technologies, and enforcing stringent environmental regulations to reduce the ecological footprint of mining operations . Moreover, facilitating the temporal coexistence of legally concessioned mining by industrial means with traditional mining practices has been identified as an approach to decrease social conflict between concessioned firms and local communities. This idea, supported by Loor and Evans and Roy , illustrates the ongoing interaction between formal and informal spheres in the Global South, highlighting the potential for sustainable solutions that balance ecological integrity and social harmony. Managing the challenges of mining concessions in the Amazon may also be addressed through strategic incentives. Barroso and Campos emphasise the crucial role of economic incentives, such as certification schemes and fair-trade initiatives, in promoting responsible gold mining practices. By offering financial rewards tied to sustainability, these incentives not only encourage miners to employ environmentally friendly techniques but also actively promote the restoration of areas that have been degraded. Land tenure regularisation is another approach to tackle the challenge. According to Bernal Dávalos , unrestrained mining exploitation in Bolivia has been driven by the separation of indigenous communities from their ancestral territories, leading to new mining settlements and consequent land ownership disputes. For indigenous peoples, land is more than a physical entity; it is a vital part of their cultural identity, providing wealth, comfort, security, and stability. Regularising land tenure and establishing clear ownership and rights can be a protective measure . This approach could help prevent illegal mining activities, create a legal framework for sustainable land use, and preserve the delicate balance between economic growth and the conservation of culture and the environment. Recognising and empowering indigenous communities in decision-making related to mining is also crucial. Indigenous territorial organisation and self-management play a vital role in conserving Amazonian ecosystems and protecting indigenous rights. Martin et al. emphasise the importance of land rights and indigenous management practices for achieving conservation and social goals. Indigenous communities possess traditional knowledge associated with sustainable practices that can help mitigate the negative impacts of gold mining and promote alternative livelihoods based on traditional resource use and cultural preservation. Based on the literature review, a discernible gap in research has been identified in understanding the social conflicts that arise post-concession of gold mines. This unexplored aspect necessitates further investigation to provide a comprehensive understanding of the impacts of gold mining in the region. Moreover, little attention has been paid to understanding what it is like to live and subsist daily while economically depending on nearby gold mining. A comprehensive insight into these subtleties can pave the way for targeted solutions that balance economic growth with environmental stewardship. --- METHODOLOGY AND METHODS What is the social context of communities proximal to gold deposits, which are still subject to traditional and illegal mining operations in the Amazon after the end of official concessions? To tackle this research question, this study employs a qualitative and descriptive case study approach . The study aims for evidence-based insights into how the transition of gold mining concessions unfolds, emphasising the complex interplay between traditional mining practices and illegal operations. The community of Yutzupino, located near Tena City in Napo Province within the Ecuadorian Amazon region, is the case selected for this study. Yutzupino is of interest because it encompasses various intersecting factors. Within this community, the interplay between traditional mining practices, industrial mining companies, and indigenous land connections forms a complex landscape. This combination yields unique challenges and insights into how mining influences the inhabitants, their lifestyles, and the surrounding environment. The specific circumstances in Yutzupino contribute to a broader understanding of the complex issues related to mining in the Amazon, marking it as an invaluable area for exploration. As part of this research, primary data were collected through detailed interviews and on-site observations, while secondary data were derived from recent censuses conducted by the Risk Secretariat of Ecuador and relevant media content. The subsequent sections delineate the case's characteristics and the data collection and analysis methods. --- THE CASE The community of Yutzupino, situated 14 Kilometers away from the parish of Puerto Napo and nestled in the heart of the Ecuadorian Amazon in Napo Province, is today home to 327 Kichwaspeaking residents living in 65 dwellings and families. Despite its modest size, the community showcases a substantial demographic variety, with pregnant women, persons with disabilities, and older adults. The houses are entwined with this biodiverse region's vibrant flora and fauna. At first glance, it may seem idyllic, yet Yutzupino faces a series of challenges threatening the life and safety of its inhabitants. Homes in Yutzupino, traditionally constructed, are perpetually endangered due to their proximity to the Jatunyacu River, a tributary of the Napo River, meaning "big river". These houses are in a high floodrisk area, constantly threatening the safety and lives of their inhabitants. Land tenure issues and the scarcity of relocation alternatives limit residents' options to move away from this hazard zone. The community's economy is rooted in agriculture, with crops like cassava, banana, and cacao as staples. However, the people have also turned to traditional mining as a vital supplement to their income, supporting their local economy. The simple yet effective act of miners shaking pans in the water to extract gold has become a symbol of daily life in Yutzupino, reflecting both their ingenuity and their connection to the land. Over the last two decades, the landscape of Yutzupino has been profoundly transformed by the concession of mining rights to private firms for industrial gold extraction. The Ecuadorian government These concessions have transformed the everyday life of local miners, who perform the extraction while dodging heavy machinery and excavators, a perilous reality that has woven itself into their routine. As the situation moved into the post-concession phase, it has further deteriorated. The blend of illegal industrial extraction, outsider traditional miners, and local traditional miners has ignited tensions and social conflicts. This mix has accelerated environmental degradation, heightened community vulnerability, and added complexity and risk to the mining practice. --- DATA COLLECTION AND ANALYSIS The primary data collection process unfolded as follows. Between April and May 2023, in-depth interviews were conducted with 18 heads of households, focusing on those involved in traditional gold mining. These hour-long interviews took place in the participants' homes, detailing their everyday lives, challenges, and relationships with illegal mining. Ethical considerations were paramount, with informed consent sought for all interviews and observations. The selection of participants was carried out randomly during on-site observations between November 2022 and May 2023. Initially triggered by the interest of the Municipality of Tena, the capital city of Napo Province, to address the presence of illegal miners-a situation that escalated to become the subject of a hearing in the Ecuadorian National Assembly-the observations evolved in scope and focus. The research began with unsystematic observations to map the area and the communities affected by mining, later moving to a more structured approach. This focused on the houses, materials that sustain everyday life, and travel patterns to everyday places. Photographs were taken, and a diary was maintained to capture these observations. Analysing the data involved content analysis and hand-coding. In-depth interviews were transcribed and organised by key themes and categories, forming the backbone for a narrative description of the community's daily experiences. This qualitative data was then linked to observations and secondary sources, allowing for triangulation and a more nuanced understanding of the area's complex, often tense, social dynamics. The researchers were mindful of the dangers and tensions in this area arising from the intersecting interests of locals, outsiders, and newcomers involved with illegal mining. --- FINDINGS AND DISCUSSION The findings unfold an unsettling reality faced by the Indigenous Amazonian community of Yutzupino. Historically engaged in rudimentary practices of gold mining as one of their diverse sources of income, these inhabitants now find themselves at a complex intersection of challenges. Their struggle to preserve their traditional way of life increasingly clashes with the need for conservation and personal safety. The current context presents a web of socio-economic, environmental, and security challenges that weave together, demanding immediate and effective intervention to untangle and resolve. The following paragraphs are organised into five subsections. The end of mining concessions affecting the study area is reported in the first subsection, revealing their impact on the local community. The second subsection delves into traditional gold mining, elucidating its practices and significance within the community. Next, the focus shifts to the living conditions in the third subsection, where a portrayal of the houses and limited access to essential services is given. The fourth subsection uncovers the physical vulnerabilities of Yutzupino's inhabitants, highlighting the prominent risks and challenges. The fifth section identifies governmental initiatives aiming to address the main issues. --- THE END OF MINING CONCESSIONS During the mining concession's active period, a balance of exploitation was forged between the concession beneficiary, particularly Terraearth Resources, and Yutzupino's local traditional miners. The community members coincide that this balance allowed a harmonious coexistence, with the company often employing local miners on a daily wage basis for various gold extraction tasks, including machinery maintenance. However, this cooperative relationship abruptly ended with the concession's suspension in October 2020 . In the aftermath of the suspension, illegal miners unfamiliar with the community rapidly invaded the area, wielding heavy machinery and aggressively competing with local miners. This dramatic shift has disrupted the previously established dynamics, creating tensions for Yutzupino's mining practices. Yutzupino is now among the areas most severely impacted by rampant illegal gold mining. As reported in May 2021 by a technical analyst from the Ecuadorian Institute of Geological and Energy Research, citizen groups "Napo Loves Life" and "Napo Resists" exposed unlicensed gold extraction by four backhoes on the Jatunyacu river's beaches in November 2021. This illegal mining has been conducted using industrial machinery and without compliance with basic environmental standards. A report from the Andean Amazon Monitoring Project further confirmed this, highlighting the illegal miners' swift takeover of the area. Maap issued its initial alarm report in October 2021, identifying less than one hectare of affected land. Shockingly, by December, this damage had ballooned to 61 hectares. According to a journalism report, EcoCiencia spokespersons who participated in Maap's analysis pointed out that "87.5% of the illegal mining expansion occurred in December." By January 2022, the devastated area had expanded another six hectares . This alarming rate of mining activity expansion underscores the urgent need for intervention. --- TRADITIONAL MINING In the community of Yutzupino, traditional mining is viewed as a secondary activity, supplemental to their primary occupation of farming and selling local products like cassava, banana, and cocoa. In interviews, Yutzupino miners explained that gold mining typically occurs at night, continuing until about 3 in the morning. Community members, including men, women, and young people, embark on a 30-minute walk along a gravel road to reach the gold extraction area. There, heavy machinery is observed excavating and forming embankments. Describing their hands-on process, miners shared how they collect material from the base of the embankment using shovels. After removing larger rocks, they wash the material with gentle pan movements, leaving only small sediments at the pan's bottom. These sediments may or may not contain gold. They emphasised that the success of this endeavour depends on the miner's skill, with each load taking approximately 5 minutes to process. The miners also described an adaptation of traditional gold mining techniques through a less conventional tool: a homemade version of a washing machine commonly used in small-scale mining. As explained by the miners, the device consists of a wooden ramp covered with a piece of cloth and a metal grid. The process begins with the miners pouring material onto the ramp with a shovel and then The socio-environmental aftermath of gold mining in the Amazon: the case of Yutzupino in Napo,Ecuador 226 Sustainability in Debate -Brasília, v. 14, n.3, p. 219-233, dez/2023 ISSN-e 2179-9067 adding water to filter the material through the cloth and grid. After all the material has been filtered, they remove the cloth, and in the centre, sediments remain where gold may be present. These descriptions vividly show how traditional methods are being fused with innovative techniques to maximise their gold extraction efforts. Figure 1 offers a visual representation of a miner using the pan. In Yutzupino, traditional mining practices occur in dark and hazardous areas where machinery operators dig. The poor visibility increases the risk of traditional miners being struck by excavators. Furthermore, the community's digging activities at the base of the embankment undermine its stability, leading to frequent collapses that pose serious dangers to those working below. Yutzupino miners have also voiced concerns about pollution and the authorities' responses to gold mining in the area. Recent military operations to combat illegal mining have led to the confiscation of their traditional mining tools and gold, further igniting dissatisfaction within the community. One resident emotionally reflected, "At least the Chinese miners gave us work; we had breakfast, lunch, and dinner for our children," recalling a time when the concession was still active. Concerning pollution, they describe the pollutants in nearby bodies of water. They often find deposits of oils, fats, and metallic waste, formerly components of the mining machinery. They have observed that the bodies of water near the community are contaminated with sediments, which decreases water quality, exterminates aquatic life, and affects people's health. These issues, aligning with Martin et al. , are viewed as an affront to indigenous land rights. However, the impact of gold mining in Yutzupino extends beyond environmental degradation. The lure of gold has attracted outside miners, leading to clandestine businesses and tolerance zones. This influx has fostered an environment marked by excessive alcohol consumption and occasional aggression, disrupting community peace. Additionally, reports of prostitution and violence during protests further underline the negative social consequences of mining within the community. The problems the Yutzupino community is facing are complex, involving their traditional way of living, taking care of the environment, and getting along with each other. What is happening in Yutzupino might not be unique to just their community. The experiences and concerns shared by the people there show that we must look deeper into these issues. More research is needed to see if similar things are happening in other places where gold mining occurs, especially after the official permissions for mining end. This will help us understand the broader effects of mining on local communities and their environment. --- HOUSING Houses of Yutzupino, erected on wooden pillars and chains without formal technical design, also symbolise the precarious living conditions and the ongoing struggle for survival faced by their inhabitants. The durability of the wood elements is particularly poor, making them highly vulnerable to the extreme weather conditions common to the Amazon region. The walls of these houses are made of vertically arranged wooden planks. Occasionally, cement blocks can be observed, denoting an attempt to incorporate more durable materials, but it also highlights inequality in resource access. As a result, the structures require frequent maintenance and reinforcement to ensure their integrity and to provide enough protection for those who live within them. The roofs of the houses are made of zinc sheets. While these roofs are lightweight and resistant to heavy rain, they create a hot and overwhelming internal environment that is hardly conducive to the well-being of its inhabitants. Often covered with plastic sheets, windows provide an ephemeral barrier against the exterior environment and lack the security and durability of a conventional window. Figure 2 displays two houses with typical features of the community. The socio-environmental aftermath of gold mining in the Amazon: the case of Yutzupino in Napo, Ecuador The poverty situation in Yutzupino is further reflected in the shortcomings of its essential public services and facilities. Access to clean water is persistently challenging, largely due to the complexities of land subdivision, an administrative and legal process that divides properties into smaller lots with individual registration. This practice, vital for clarifying land use rights and maximising property value, is hampered by the need for proper land tenure regularisation to prevent misuses such as illegal mining, as Hänggli et al. emphasised. In addition to water issues, the community faces problems with electricity access. Though available throughout Yutzupino, the electricity supply is often unreliable and insufficient to meet everyday needs. Education in Yutzupino is limited to a basic level. The daily commute to Puerto Napo, necessary for young people aspiring to obtain a high school education, is emblematic of the broader challenges faced by the community. This burden not only hinders their academic development but is a manifestation of the systemic weaknesses in the area, which adds to the unreliable utilities and the need for frequent housing maintenance. Figure 3 illustrates the daily route students use between Yutzupino and Puerto Napo, a visual representation of the interconnected challenges that obstruct educational advancement and overall progress within the community. In Yutzupino, the precarious state of housing, coupled with the lack of dependable utilities and constrained access to education, creates a vivid portrait of the challenges endemic to this Amazonian community. This complex situation does not merely reflect material hardship; it underscores a broader narrative of poverty and vulnerability. It is a call to action, emphasising the need for thoughtful intervention and support to address these multifaceted issues and empower the community. --- THE PHYSICAL VULNERABILITIES OF YUTZUPINO INHABITANTS Yutzupino is close to the river, which defines the area's appearance but also makes it vulnerable. The people there enjoy the rich natural resources but face constant threats to their safety because of the location. Flooding is common, especially when it rains heavily. The residents recall times when the floods were so strong that they washed away weak homes on the riverbanks, destroying important belongings and crops. The people believe that gold mining is making things worse, changing the river's flow and washing away the banks. This makes flooding more likely and puts the homes near the river in danger. In addition to flooding, residents of Yutzupino mention feeling small earthquakes at least once a month. While they have become accustomed to these low-magnitude tremors, the experience is always unsettling and scary. These regular quakes have revealed cracks in the houses and throughout the community, adding to ongoing concerns for the inhabitants' safety. The inability of the structures to withstand even these minor quakes underscores the precariousness of living conditions in the area and keeps the fear of a more significant disaster. Yutzupino susceptibility to house fires also stands out as a critical concern. The residents identify poor electrical installations and the use of highly flammable construction materials like wood as the primary causes. Such conditions allow fires to ignite and spread rapidly, posing an ever-present danger to both life and property. The community also fears the force of strong winds, a common occurrence in the area. These windstorms have the power to tear off roofs and damage crops, causing chaos in the population's livelihoods and essential infrastructure. In the face of these environmental challenges, Yutzupino finds itself in a ceaseless battle with nature. The combined threats of flooding, earthquakes, fires, and windstorms weave a tapestry of physical vulnerability exacerbated by a lack of resources and proper planning. This precarious situation perpetuates a cycle of poverty and exposure to environmental risks, underscoring the imperative need to mitigate these threats. --- GOVERNMENT INTERVENTIONS In addition to the vulnerabilities mentioned above, Yutzupino faces land regularisation and tenure security challenges. Here, 89 plots are dangerously located within the risk zone of the Jatunyacu River and do not qualify for regularisation. The Tena municipal government has played a crucial role in responding to these challenges. It has been confirmed that the lands belong to the heirs or relatives of the original owners, recognised by regulatory institutions such as the National Institute of Agrarian Development and the Ecuadorian Institute of Agrarian Reform and Colonization . However, instability persists due to the environmental risk that constantly imposes the threat of relocation. To counteract these challenges, the municipality has acquired 2.35 hectares of land in the upper part of the community to relocate the endangered residents. The area was subsequently parcelled, and the parcel plan was approved and legalised. It fell to the community to take the final step to secure ownership of the individualised lands: registering them in their name at the Tena Property Registry. However, a lack of management and resources has thwarted this process, leaving the residents in an even deeper situation of vulnerability and uncertainty. In these plans, Yutzupino is categorised as a forest conservation area with minimal agricultural uses destined for sustainable forest utilisation. However, according to the map of conservation areas of the Tena canton, Yutzupino is not classified under any conservation category. On the contrary, it is identified as a metal extraction zone on the Mining Types -Mining Concessions map, which aligns with the mining concession granted to Terraearth Resources S.A. Company to explore and exploit a vast territory, including the community area. This evidences a conflict in the classification of land use in the canton. --- CONCLUSION This research sought to investigate the socio-environmental consequences of gold mining in Amazonian communities, particularly after the ending of official mining concessions. The core question revolved around the effects of mining activities, specifically how the cessation of formal concessions gave rise to an upsurge in illicit mining activities and its impact on local communities and their environment. This study's theoretical contribution lies in a nuanced understanding of the dynamics of mining exploitation in Amazonian communities. During the active lifespan of a mining concession, a delicate equilibrium is observed to coexist between traditional and industrial exploitation, where environmental degradation occurs gradually. However, this equilibrium can be disrupted at the end of the official mining concession, marking a shift towards an anarchic state. In this phase, illegal exploitation, encompassing both traditional means and heavy machinery, overexploits resources, leading to exponential degradation. This understanding constitutes significant insights into the transitional phases of mining activity and their impact on social and environmental stability, providing a theoretical foundation for future territorial planning and industrial policy implementation. In terms of empirical and practical implications, the study offers a rich exploration of overexploitation in mining. Empirically, it paints a vivid picture of how illegal mining practices can dramatically alter the socio-environmental context of local communities. Practically, these insights shed light on better land use planning in Amazonian mining sites. The research delivers tangible elements for developing sustainable mining policies, particularly on avoiding undesirable aftermaths of gold mining. By analysing the specific impacts and complex dynamics at play, the study equips policymakers and planners with the evidence-based understanding needed to navigate the challenges of post-concession mining activities, thus offering a robust foundation for planning and policy. Future research in this field should focus on exploring potential measures to prevent overexploitation post the lifespan of mining concessions. A promising avenue of investigation is to evaluate the efficacy of various zoning policies that act as mitigating strategies against rampant exploitation. Furthermore, studies examining successful interventions in other regions could provide valuable insights and potential frameworks to guide policies and practices. The findings of such research would contribute significantly to devising and implementing sustainable mining policies that prioritise not just economic gain but also social welfare and environmental protection.

This study addresses the social and environmental repercussions on Amazonian communities due to gold mining following the conclusion of official concessions. Framed within the literature on natural resource extraction, sustainability, and social impacts in developing countries, the work employs qualitative methods, including interviews with residents and field observations in the community of Yutzupino in the Ecuadorian Amazon. It reveals that post-concession mining, often informal and illegal, sharply triggers social and environmental degradation. The research emphasises the need to incorporate sustainability principles into mining concessions to prevent such effects. This analysis enhances understanding of the complex socio-ecological aftermath of mining in vulnerable environments. It proposes recommendations for mitigation, underlining the importance of dialogue between communities, governments, and mining companies.

Introduction Access to microfinance is a vital but problematic issue for persons with disabilities who wish to pursue their own businesses. In Uganda, microfinance is a strategy that is increasingly being used in the fight against poverty. Unfortunately, persons with disabilities are faced with challenges while learning about and engaging with microfinance . This is despite the existence of the Community-Based Rehabilitation Guidelines of 2010 and the United Nations Convention on the Rights of people with disabilities that advocate inclusiveness. Similarly, the good policies that exist in Uganda are not matched by good practices . Katureebe's exemplary case has been selected because it provides rich experiences of his learning and insights into many of the barriers that people with visual impairments face while learning about microfinance and the strategies to address them. Understanding the case of a person with disability's learning experiences and the challenges he faces while learning about microfinance can provide insight into the complexity of the interplay between disability and adult learning and provide a basis for improving education provision for people with visual disabilities. The case also provides a glimpse of the complex relationships between adult education, disability and microfinance. The purpose of this article is to illuminate the barriers that a person with a visual impairment encountered while learning about microfinance and the strategies that he developed to overcome them. It provides an understanding of the interplay between unfavourable physical and psychological factors, learning environment and inadequate finances. We start with the research context and then frame the study within relevant literature and theory. This is followed by an explanation of the methodology employed, a profile of Katureebe and the presentation of results focusing on adult learning practices, the barriers encountered and strategies adopted. We discuss the findings in relation to the social model of disability. We conclude with some reflections on the implications regarding adults with disabilities, learning and microfinance. --- Background --- Research context The World Report on Disability estimates that 15.3% of the world population is disabled and is likely to have lower educational and employment opportunities. WHO confirms that in Uganda, as in many developing countries, persons with disabilities have low literacy levels. While the net enrolment in primary education stands at 81.1% , only 15% of children with disabilities are able to access education, 5% through inclusive schools and 10% through special schools . This limits persons with disabilities' acquisition of what WHO calls 'foundation skills', including those required to successfully run a business. Lwanga-Ntale confirms that in Uganda many persons with disabilities are of low formal education levels and hardly have any formal employment opportunities. For those who wish to start or improve their own businesses, accessing microfinance loans requires literacy skills such as filling in loan application forms, calculating interest on loans and keeping records. Persons with disabilities' access to education may therefore enhance their access to microfinance services; conversely, lack of education may limit access. It is likely that the income situation of persons with disabilities would change if they had access to microfinance loans and appropriate adult learning opportunities . The need to provide educational opportunities for such a large and deprived group cannot be ignored. Unfortunately, in Uganda, as in many African countries, persons with disabilities hardly benefit from adult education provision . Despite the challenges, some persons with disabilities, including those who are semi-literate, do access microfinance services . However, the way they acquire the knowledge and skills to improve their livelihood is largely unknown and undocumented. The microfinance services in this study were those provided by Savings and Credit Cooperative Organisations . According to the Executive Director, Microfinance Centre, 'SACCOs are member-owned, member-managed and member-used; community based and much closer to the poor than mainstream MFIs [our addition: micro finance institutions]' . Unfortunately, the field of adult education and disability in African contexts is under-researched and especially how disability 'affects, impacts and/or constrains the adult learning context' . This is reflected in sub-Saharan countries' recommendation 28 for the International Conference in Adult Education VI that 'all adult learning and education programmes should take into consideration the special needs of disabled learners' . --- Objectives This article builds on Nuwagaba's study by engaging in more in-depth analysis to bring out the complexities of the barriers experienced by a person with visual disabilities during learning processes and the strategies employed to overcome them. --- Literature review --- Understanding the unique characteristics of adult learners with disabilities While adult learners with disabilities engage holistically in adult learning processes, like learners without disabilities , they are a minority group whose voices are often silenced . Their self-identity and how they are viewed by society play a much bigger negative role in their learning than for those without disabilities, because society often regards them as inadequate. Some of them have internalised their oppression and, as Freire argues, those who get to this stage believe their situation cannot be changed. On the other hand, there is evidence that some adult learners with disabilities have a strong motivation to learn. Rule & Modipa investigated the attitudes of adult learners with disabilities regarding education in a nongovernmental organisation setting in South Africa. They found that they had negative childhood experiences of education and suffered stigmatisation. As adults, however, they had a strong desire to learn and attempted to affirm their position in society as people with potential just like anyone else. In addition to the social barriers that exclude them from microfinance services, adult learners with disabilities may also be hindered by lack of self-esteem and self-confidence, themselves internalised consequences of social barriers . Their families' or own expectations of an entitlement to charity may reinforce this exclusion. Additionally, adult learners, especially those who have faced discrimination and inequality, have strong emotions which can either support or hinder learning . In his study on distance learners, Zembylas describes attitudes that arise out of inequality and discrimination as 'us versus them'. Adult learners with disabilities may fit this description as they face discrimination and marginalisation. For such learners, who may feel persecuted and defensive, learning with learners without disabilities can be problematic unless society takes explicit measures to accommodate them . http://www.ajod.org Open Access Adult education literature recognises the uniqueness of adult learners with disabilities . Clark identifies such learners as individuals with unique or special needs that can be addressed through provision of sign language interpretation, note-taking services, assistive technology and separate and/or extra time for exams -services that can be provided by society. Although Clark's conceptualisation relates to formal learning, it is, apart from examinations, relevant to nonformal adult learning. Relevant content and the use of facilitators, who are able to recognise the characteristics of adult learners with disabilities and employ appropriate methodologies, can also help to address their learning needs. --- Framing the study in theory: The social model of disability The social model of disability was developed as a reaction and alternative to the medical model, which defined disability in medical terms and located it as a problem of the 'patient'. According to the social model, economic, cultural, attitudinal, physical and social barriers stop people with impairments from participating fully in society, and so create disabilities . Society is viewed as the problem, not the person with impairment. The social model fits in well with the agenda of the disability movement in Uganda which advocates for the removal of barriers to the participation of persons with disabilities in all spheres of life . Uganda's National Policy on Disability understands disability as 'permanent and substantial functional limitation of daily life activities caused by physical, mental or sensory impairment and environmental barriers resulting in limited participation' . This definition focuses on the disabling environment although the impairment is not ignored. However, the social model is criticised for downplaying the role of impairment and personal experiences . The social model of disability resonates well with the critical research paradigm, which was adopted in this study, and which can be used to understand and contribute to reshaping oppressive structures and processes in society such as those experienced by persons with disabilities . --- Research method and design The study adopted a qualitative case study approach within the critical research paradigm . This paradigm was adopted as an appropriate theoretical frame because the study investigated the marginalisation of a person with visual disabilities involved in non-formal and informal adult learning and the strategies he employed to transform this situation. The transformation focused on redressing discrimination, inequalities, barriers, and social structures and systems, which according to Oliver , Truman and Ndeezi , prevent people with impairments from full social participation. In this way, the critical research paradigm and the social model of disability complement each other. A case study was adopted because, with its focus on the specific case, it can provide a rich description of a particular instance, examining the complex relations within the case and in relation to its context , as well as yield insights into the relation between the case and what it is a case of . Walter also affirms that case studies can be used to 'provide insight into educational issues and processes', in this instance, the adult learning practices of a person with visual disability. In addition, case study research can apply and develop theory such as, in this study, the social model of disability. The sampling approach used in the study combined purposive and snowball sampling . Purposive sampling was used to identify the SACCOs serving the persons with disabilities in the western Ugandan district of Bushenyi because, according to UCA , the district had vibrant SACCOs. As SACCOs do not easily release information about their clients, snowball sampling was used to identify Katureebe. A leader of persons with disabilities was contacted and she helped identify some persons with disabilities involved in SACCOs and these in turn identified others, including Katureebe. Katureebe was selected due to his long involvement in SACCOs and his role as a leader among persons with disabilities using microfinance. We do not view his experiences as representative of, or generalisable to, all persons with disabilities involved in microfinance, as we indicate in our 'Discussion' section. Nevertheless, this case provides valuable insights into the social model of disability in relation to disability, adult learning and microfinance. Data collection involved the use of loosely structured interviews and observations. Katureebe was interviewed three times between 2012 and 2013, and each time the interview lasted about one and a half hours. The interview questions focused on type and degree of impairment and their effect on learning and engagement with SACCOs, the challenges faced during learning processes and the conduciveness of the learning venues. The interviews were conducted in the local language and tape-recorded. They were then transcribed and translated into English by the http://www.ajod.org Open Access researcher and a research assistant to improve accuracy and reduce bias . The observations focused on the conduciveness of learning venues at SACCO and administrative buildings. For data analysis, the adult learning practices of Katureebe constituted the case and the unit of analysis. Open coding and axial coding were employed to generate categories and themes . The transcribed data were read many times and four key themes, namely learning, methods, barriers and strategies were identified as axial codes for analysis. Under learning, what Katureebe learnt such as knowledge and skills in savings, borrowing and attitudes were analysed. In the theme on methods we analysed how he learned, and this included touch-feel-recognise, and questioning. As for barriers, the hindrances to his learning and engagement with SACCOs were analysed and these included inaccessible teaching and communication approaches, unfavourable physical and psychological environment, and economic and mobility barriers. The analysis of strategies focused on the coping strategies and the support Katureebe received to address the barriers. The data analysis process was dialectical and involved assembling and disassembling of data to discover connections and relationships . We as authors do not have impairments but identify with persons with disabilities' struggles against marginalisation and discrimination. The first author has a sister with a disability and both authors have previously conducted participatory research on disability. Although Oliver proposes that persons with disability should conduct their own research, Barnes's counter proposal is that a researcher does not necessarily need to have an impairment in order to do it. As Katureebe was a person with visual impairment, a category considered vulnerable, particular care was taken to ensure that he was treated with respect and in a manner that was intended not to psychologically stress or humiliate him . The checklist suggested by Mcniff, Lomax and Whitehead , which includes participants' right to withdraw, researcher trustworthiness and keeping promises, was adhered to. --- Ethical considerations --- Informed consent Informed consent was sought and obtained from the research participant orally in his local language before doing the observations or in-depth interviews, but after he was informed of his rights. The UNCST guidelines accept oral consent . --- Anonymity Although respect for anonymity is a good ethical practice , Katureebe insisted we use his real name. He argued that, as he had told us the truth, there was no need to hide his identity. We agreed with him because of Nuwagaba and Rule's argument that going against his wish would signify that his views were not being respected because of his impairment. --- Profile of Mr. Katureebe Mr Katureebe desired to learn how to read and write Braille but was constrained by lack of learning opportunities and the costs involved. He has had many challenges in life. He was forced to abandon his job with a shoe company because of his impairment and his emotions are evident as he tells his story. He acknowledges that disability has made it difficult for him to realise his full potential, yet the responsibility of maintaining the family rests with him as man because he lives in a patriarchal society. The same society bestows on him control over family resources. Katureebe faced barriers such as inaccessible teaching and communication approaches, unfavourable physical and psychological environment, and lack of finances that limited his learning and engagement with microfinance. He strove to overcome these barriers, with support from fellow persons with disabilities, SACCOs, family and community members. --- Results Katureebe was found to have participated in two types of adult learning about microfinance -informal and non-formal. Rogers notes that informal learning occurs as a result of interaction between adults as they engage in activities in their everyday lives. Non-formal learning, on the other hand, is structured in terms of learning objectives, learning time or learning support and is intentional from the learner's perspective. --- What Katureebe learnt and how he learnt it Katureebe learnt a wide range of skills, knowledge and attitudes, including farming, identifying currency, getting feedback during communication, leadership roles, use of mobile phones and strategies to address barriers to participation and utilisation of microfinance services. The focus of this article is on the learning related to his engagement with microfinance. --- How Katureebe learnt The various ways through which Katureebe learnt depended on the interaction between his impairment, the environment and what he was learning. --- Touch-feel-recognise: A strategy of touch-feel-recognise was used in learning how to manage money as described by Mr Katureebe: 'I feel the sizes of the notes with my fingers after arranging them on my palm and distinguish them by size to determine their value. I know the notes are in the values of Shs 1000, 2000, 5000, 10000, 20000 and 50000 and the sizes of the notes correspond to the values of the notes.' 'The Shs 500 coin has the shortest circumference, is thickest and has an embossed picture of the head of a bird , the Shs 200 coin is somehow thin with a medium circumference and has an embossed picture of a fish, and the Shs 100 coin has the longest circumference, is thinnest and has an embossed picture of a cow.' This explanation indicates a process involving touching, followed by feeling and then recognising, which Nuwagaba coined as the 'touch-feel-recognise' method of learning. This method served Katureebe well in identifying Ugandan currency notes, which have no embossed features. It is noteworthy that while size distinguishes the notes, thickness distinguishes the coins. He acknowledged that this method could only be used when one had all the notes and the amount involved was not large. Questioning: As a learner, Katureebe used questioning as a strategy of seeking feedback while communicating with those conducting the training and fellow learners during the learning process. He mentioned that, having become blind later in life, he was aware that people often show they are following a discussion through non-verbal cues, which blind people do not pick up. His strategy was to constantly ask: Ummmhhh? Aaaahhh? Eeee? Tukwe? , Onyine? . He often did not complete the words or sentences and encouraged the listener to complete them by asking: Ummmhhh? He then used that response as feedback to gauge whether someone was following the discussion or not. Practice: Katureebe intimated that the leadership skills he exhibited as leader of their ROSCA were acquired through practising the skills acquired from the CBR training he received in 1990 saying: 'When CBR was introduced from Bushenyi, they educated us, … we made groups and from there we who got into leadership positions started practicing leadership skills'. The skills he mentioned included chairing meetings, making decisions regarding admission of members, communicating on behalf of their group, representing their group in leadership training and other meetings among others. --- Barriers to leaning and engagement with SACCO services The barriers that Katureebe faced included inaccessible teaching and communication approaches, unfavourable physical and psychological learning environment, and lack of finances which limited his participation as follows: --- Inaccessible teaching and communication approaches Katureebe could neither see facilitators' demonstrations during the learning process nor effectively participate in learning about microfinance services because the facilitators were using inaccessible teaching and communication approaches. This restricted his participation in learning. He noted: 'But for someone who is blind, when your arm is up, they will point to you and say "you", but you will not rise to contribute. Katureebe noted that barriers went beyond the teaching and learning encounter and included obstructions caused by society's practice of queuing for food at training events. He lamented: 'But it pains you when they say that you should all stand to join a line, not so? You smell the scent of the food, others have already started eating and they are swallowing and for you, you are swallowing saliva! Put yourself in that situation -by the time you get the food, the food will no longer be tasty because your appetite will have already been taken by others, ummmh?' The interconnectedness of physical, affective and social elements is evident here. Society, by using a system of lining up for food, creates a physical barrier which stops him from collecting the food himself, leading to loss of confidence, which is an affective barrier, and conditions that do not allow him to stand in the line with others create a social distance between him and the others. Each of the barriers independently, as well as the combination of the barriers, affected his preparedness to learn. --- Unfavourable physical and psychological learning environment The area where Katureebe lived was very hilly and very slippery during the rainy seasons. The buildings where microfinance training took place had accessibility and usability issues. Many had entrance steps and/or were located in steep-slanting landscapes, and inside there were steps, and cemented or tiled floors, which made use of walking sticks on them problematic. 'I will not go there', said Karureebe of learning events in inaccessible venues, 'because that place is not friendly to me'. The psychological environment was evaluated as favourable at certain times and unfavourable at other times. The psychological conditions he described as favourable included those that put him at ease with himself and with the facilitator . Katureebe experienced a sense of inferiority and fear which hindered or prevented his participation in learning. He added that some community members and development workers took people with impairments to be of low status, which limited their participation in learning and utilisation of SACCO services. He remarked, 'Persons with disabilities who think that their potential and abilities are inferior, fear to mix with others and this hinders cooperation in learning sessions'. We see here the phenomenon of persons with disabilities internalising the attitudes of the able-bodied towards them, which in turn disables them as participants. This reveals that social attitudes have affective consequences. Katureebe added that persons with disabilities were afraid of getting loans, saying: 'We fear to get the money for a loan, and then you fail to manage the project. I want to show you an example, like me, I have a pig which I all along thought was pregnant. If I could see, I would have known that it is not pregnant and taken it where? To a male for servicing … when they [chicken] were attacked by a diseasecoccidiosis -you are supposed to tell this disease by the sight of their droppings. Now if you don't have an active person at home, they will be attacked by disease and die … Because I might put money in a project and I fail to manage it, and I find myself in a loss, why should I ask for a loan? For what? … You decide to die in poverty instead of being taken to prison for failure to pay back a loan. Are you following me?' There were occasions when the physical environment influenced Katureebe's affective state. As explained above, lining up for food in a crowded room that in addition had steps, negatively affected his mood for learning. An unfavourable physical and psychological environment was therefore a hindrance to the learning process. The absence of mobility systems or support accentuated the environment's hindrances. Again here we see the creation of disabling social barriers to learning, with accompanying psychological and affective dimensions, which hinder participation. --- Financial barriers Katureebe noted that, because of limited income, he could not afford to pay membership fees of groups, transport costs to learning venues, or buy batteries for his radio all the time and so he missed SACCO-related messages. He could not http://www.ajod.org Open Access afford mobility assistive devices such as white canes or a guide and all these combined negatively affected learning about and utilisation of SACCO services. He explained that, because of their impairments and unfavourable environment, persons with disabilities spent more to access services which they could not often afford. He argued, 'As a blind person -… on top of his blindness he needs a guide. Eeh? Now life becomes double expensive'. In addition, Katureebe was aware that lack of funds denied persons with disabilities sureties when they were applying for loans because would-be guarantors were afraid that persons with disabilities lacked the resources to pay back loans. Findings suggest that, while mobility was a barrier in its own right, it was also linked to economic barriers. All these difficulties, however, did not deter Katureebe as his philosophy was that disability is not inability and that, through hard work, one can maintain oneself. --- Strategies to address the barriers The strategies that Katureebe developed to overcome barriers, such as the touch-feel-recognise method, questioning and practicing, were explained in the section on how he learnt. Other strategies, which we now turn to, included engaging in advocacy, having his daughter assist him in learning sessions and sitting close to people who knew he had visual impairment and would assist him when the need arose. He said: 'In a learning session, when I put my hand up to contribute, some community members help attract the attention of the facilitator to give me an opportunity. They pull my shirt or pinch my ribs to alert me that the facilitator wants me to make a contribution.' Katureebe mentioned that he relied on assistance from his daughter who listened in and observed demonstrations and posters during learning sessions, and later explained them to him. He added, 'She helps me put a pen on the right spot which made it possible for me to sign in an appropriate place'. Katureebe, because of his success in engaging with SACCOs, was a role model in sensitising SACCOs on how to improve access to microfinance by persons with disabilities. He was an example of how reducing discrimination against persons with disabilities can make them successful. As a result of this and efforts from disabled peoples' organisations, SACCOs had started to provide faster services to persons with disabilities and, together with family and community members, provided personal services to Katureebe to address mobility and communication barriers. To overcome financial barriers, the government had introduced disability grants, National Agricultural Advisory Services and other initiatives. It is therefore evident that Katureebe overcame some of the barriers on his own, and with others he was supported by SACCOs, family, community members and the government. He also helped other people with disabilities to overcome barriers. The principle of interdependence emerges from these strategies as important in overcoming barriers. On the whole, the data do not seem to show any difference in learning approach, barriers to learning or strategies to overcome the barriers whether Katureebe was learning informally or non-formally. --- Discussion Our discussion begins with the issue of a case study and generalisability, particularly regarding a case study of a single subject. It then follows three lines of argument: barriers to learning and microfinance existed for a person with visual disability in Uganda; the social model of disability sheds light on such barriers; and the barriers can be overcome through active engagement and interdependence. A 'limitation' of case study findings that is frequently cited is their lack of generalisability. However, case study experts have countered that statistical generalisation is not the point of case study. As Yin argues, a case study can generate 'analytical generalisations' in which generalisations are made to theoretical propositions rather than populations. In this paper, the findings regarding the social factors that constrained Katureebe's learning confirm the theoretical template of the social model of disability as a way of understanding the experiences of adult learners with disabilities regarding microfinance, as we show below. Besides testing existing theory, a case study, even the rich and detailed account of a single subject, as in this paper, can generate new insights into a phenomenon . For example, Katureebe's experiences point to the importance of psychological responses to constraining social conditions as a key factor that impacts on learning of the individual person with a disability. Applying this finding more widely could happen through a process of what Thomas calls 'abduction' and 'phronesis'. Here, the focus is on generating practical wisdom from a case study which readers can then apply to related cases and make discerning judgements about appropriateness. This paper sheds light on the experiences of a single participant with a visual impairment regarding learning and microfinance. As such, the findings yield insights, through discerning application, into the nexus of disability, microfinance and adult learning, without succumbing to the claim that Katureebe is a representative of all adults with disabilities involved in microfinance or that his experiences can be generalised to theirs. Results show that Katureebe learnt to engage with livelihood, microfinance and other activities through various methods such as touch-feel-recognise, questioning and practice. However, despite his motivation, capacities and a wealth of experience, Katureebe faced a range of barriers such as http://www.ajod.org Open Access inaccessible teaching and communication approaches, unfavourable physical and psychological environment, and limited finances. These barriers were interconnected and impacted on each other as they influenced Katureebe's mobility and learning activities. The first category of barriers that hindered his learning was identified as negative attitudes of community members who regarded persons with disabilities as inferior. This is consistent with Naami's findings in Ghana regarding society's negative attitudes towards persons with disabilities, doubts about their capacities and discrimination against them. Stone argues that some people view persons with disabilities as people who need to be pitied and yet they do not like it and prefer to be viewed as any other person. When they are pitied, it affects their motivation and consequently, their learning potential may be compromised. WHO identifies negative attitudes of families and communities as some of the most damaging barriers. It is likely that such negative attitudes may create negative feelings that may inhibit learning . The second category was the unfavourable environment in which he learnt and engaged with microfinance. These included steep landscapes and inaccessible buildings, the kinds of barriers that Stone identified as natural and artificial. The third category was financial barriers. Katureebe raised collateral with great difficulty and could not access messages about microfinance and other opportunities because, often, he could not afford dry cells for his radio. Inaccessible information about learning and microfinance opportunities constrained his participation in SACCOs thus compounding his financial barriers. Indeed economic factors limit many persons with disabilities' participation in educational and other development activities . These three categories of barriers are clearly a societal creation as explained by the social model. Viewing the barriers through the social model of disability, Oliver reveals that persons with disabilities were discriminated against by able-bodied society . The study confirms that, despite good legislation, barriers still existed in practice in Uganda. Similar results had been found earlier in Uganda and in Ghana . The study confirms Oliver's argument that economic, cultural, attitudinal, physical and social barriers disable persons with impairments. The fact that Katureebe's learning about SACCO services was possible with support from his family, SACCOs and community members is testimony that society which erects barriers is capable of removing them. This could be performed, for example, through supporting the person with impairment and providing a disability-friendly learning environment, thus enabling persons with disabilities access to services and empowering them. This strengthens the social model's explanation of disability as a social phenomenon and the holistic approach to CBR as proposed by the Convention on the Rights of people with disabilities of 2006. However, Watson criticises the social model for presenting an incomplete picture of disability. For example, it cannot explain Katureebe's personal limitations and impairment and how they affected his learning. He notes that socialisation of disability shifts the focus to commonalities, thus underplaying the complexity and diversity of each person's lived experiences The fourth category, Katureebe's negative attitudes, indicates an interplay between the social and the personal. Social barriers may have psychological consequences, including loss of confidence and withdrawal from activities. Katureebe's negative attitude towards himself and feeling of inferiority sometimes made him exclude himself from community activities including learning. A study in Ghana revealed that some barriers, such as low levels of self-confidence, negative reaction to societal attitudes and ignorance about their own potential, were personal rather than societal . Here, we argue that the social and the personal are closely related. This is because the societal barriers as well as Katureebe's personal barriers influenced each other and affected his learning. The societal and personal factors coupled with an unfavourable learning context further constrained his learning. Fear as a result of vulnerability has been identified elsewhere as an inherent barrier in the context of disability and HIV & AIDS . A combination of negative attitudes, inferiority and fear, within a sometimes excluding and discriminating social context, contributed to Katureebe's emotional disposition. Zembylas established that emotional experiences regarding injustices can sometimes inhibit learning and this can also result in the internalisation of oppression . Viewing Katureebe inherent barriers and those erected by society through the social model and critical theory indicates that these barriers combined to marginalise, oppress and discriminate against Katureebe as an adult learner. In Katureebe's case, his positive psychological disposition motivated him to learn. In this process some of the societal barriers were removed by the society that had erected them thus further enhancing his participation in learning. The study also reveals that, despite the favourable disability policies, the reality shows that persons with disabilities are still faced with barriers. http://www.ajod.org Open Access --- Limitations of the study Although we had planned to observe Katureebe's involvement in non-formal learning sessions, that was not possible as none occurred during the period of data collection. The data regarding learning processes may therefore have inadequacies as they are based on opinions about the process, although the physical layout and accessibility of training venues were observed. There could be differences between Katureebe's views on the processes and the actual learning processes. In addition, one participant and his experiences cannot be generalised to represent all persons with disabilities' experiences of microfinance in Uganda. Nevertheless, his story yields insights into some of the ways in which disability and adult learning interface with microfinance in Uganda, and as Simons notes, the case study helps 'understand the case itself rather than generalise to a whole population', as discussed above. --- Conclusions Katureebe, as a person with visual disability, successfully engaged with learning and microfinance. However, he faced barriers to learning and engagement in livelihood and SACCO activities. The barriers were actually experienced in a combined manner but were categorised to facilitate analysis. The barriers were theorised using the social model of disability. Katureebe developed coping strategies through which he changed the conception of barriers from permanent obstacles that obstructed persons with disabilities to hurdles to be overcome. He helped others and also received help from fellow persons with and those without disabilities, and this interdependence -a key feature of the social model of disability -helped reduce the barriers. Interdependence, unlike dependence, empowers, as each person has something to offer and to gain. Also, unlike the 'independence' of autonomous individuals, it shows the connectivity and relationality of persons with disabilities in an African context. This interdependence has the potential to enhance persons with disabilities' learning and engagement with microfinance. For Katureebe, therefore, many of the barriers he faced were surmountable. Although some of the barriers could be removed, the impairments remain, meaning he still remains with some challenges such as not being able to see during learning and engagement with SACCOs. Katureebe's case provides evidence to confirm that the social model of disability can be extended to encompass the psychological consequences of social barriers through a more interactional understanding of biological, psychological and social factors . --- Recommendations Although our case was exploratory and based on a single case of one participant, findings can be used to suggest that adult education programmes for persons with disabilities should aim at addressing the unique learning challenges of persons with visual and other disabilities. This is because the challenges are not homogenous to all categories of disabilities but relate to disability type. Also, the persons with disabilities, as well as the communities in which they live and work, and their agencies that provide services, should be sensitised about disability. Each side has a role in addressing the barriers faced by persons with visual and other disabilities. ---

Background: Despite Uganda's progress in promoting affirmative action for persons with disabilities and its strategy of using microfinance to fight poverty, access to microfinance services by persons with disabilities is still problematic due to barriers, characterised by discrepancies between policies and practices. Regarding education, the affirmative action in favour of learners with disabilities has not translated into actual learning opportunities due to personal and environmental barriers.The study on which this article is based investigated the non-formal and informal adult learning practices regarding microfinance that persons with disabilities engaged in. This article seeks to illuminate the barriers that a person with a visual impairment encountered while learning about and engaging with microfinance and the strategies that he developed to overcome them.This was a case study, framed within the social model of disability and critical research paradigm. Data were collected through in-depth interviews of a person with visual impairment and observations of the environment in which adult learning and engagement with Savings and Credit Cooperative Organisations (SACCOs) occurred.Findings indicate that the person with a visual disability faced barriers to learning about microfinance services. He experienced barriers in an integrated manner and developed strategies to overcome these barriers. The barriers and strategies are theorised using the social model of disability.The case of a person with visual impairment suggests that persons with disabilities face multiple barriers regarding microfinance, including social, psychological and educational. However, his own agency and attitudes were also of importance as they influenced his learning. Viewing these barriers as blockades can lead to non-participation in learning and engagement with microfinance whereas viewing them as surmountable hurdles can potentially motivate participants to succeed in learning about and engaging with microfinance.

INTRODUCTION Brazil is among the 30 countries globally with a high tuberculosis burden, according to the World Health Organization. In Brazil, approximately 10.4 million people were estimated to have TB in 2016 1 . In Brazil, around 73,000 new cases of TB are reported annually, with 4,577 deaths in 2013 . In the state of Espírito Santo, 15,225 new cases of tuberculosis were reported from 2001 to 2012, 9,356 of which occurred in the metropolitan area of Vitória 2 . The Stop TB plan recommended that, using 1990 as the baseline, prevalence and death rates should have decreased by 50% by 2015. The post-2015 End TB strategy aims to eliminate TB as a public health problem by 2050 1 . The strategy is based on increasing access to diagnosis and effective low-cost treatment and reducing TB incidence and the associated mortality rates 3 . In Brazil, TB incidence has decreased in the past decade, although not at a pace that will allow future targets to be met. The TB incidence rate in Brazil decreased from 35.3 cases per 100,000 inhabitants in 2013 to 33.8 cases per 100,000 inhabitants in 2014; the cure rate was 74% for the new cases in 2013 4 . However, the maintenance of tuberculosis indicators at the levels described above is partially associated with social determinants, despite efforts targeting their reduction. These determinants, identified through research in different countries, including Brazil, were as follows: lack of social protection, low income, lack of access to health care services, poorly ventilated residences, and a high average number of inhabitants per household [5][6][7][8] . In addition to individual care, the strategy used to identify those susceptible to or suffering from the disease requires a comprehensive approach, with the reduction of the number of determinants of TB incidence in these populations 9 . Two previous studies were conducted in this area. The first was a 4-year retrospective territory-based surveillance study of all new pulmonary TB cases conducted in Vitoria between 2002 and 2006, wherein spatial patterns of disease incidence were compared using spatial clustering statistics. A total of 651 cases of TB were reported across 78 neighborhoods, with incidence ranging from 0 to 129 cases per 100,000 population, and a strong spatial autocorrelation was observed for the incidence. Furthermore, TB incidence and socioeconomic status had a significant curvilinear relationship 10 . In the second study, 503 isolates were genotyped by IS6110 restriction fragment length polymorphism and spoligotyping. Of these, the proportion associated with recent transmission was 34.2%. The largest RFLP clusters and families showed that they co-localized in space. Distance analysis confirmed these results and indicated unique strain patterns randomly distributed in space. These results indicated that TB transmission in Vitoria is spatially determined and that recent transmission most frequently occurs among young age adults and those with a low Index of Quality of Urban Municipality 11 . Due to considerable heterogeneity in TB incidence throughout the city, and the importance of understanding disease distribution, especially in low incidence areas, in order to highlight if this area had no transmission or if the low number of cases was due to sub-notification, the aim of this study was to analyze social factors associated with spatial distribution in the under-reporting of tuberculosis incidence in the City of Vitória, Espírito Santo State , Brazil. --- METHODS --- Type of study This is an ecological study of the reported cases of tuberculosis, according to census tracts in the City of Vitória, Espírito Santo State, between 2009 and 2011. In 2010, the City of Vitória had a population of 327,801 inhabitants, distributed among 577 census tracts 12 . --- Data sources Disease-related data were obtained from the Notifiable Diseases Information System [Sistema de Informação de Agravos de Notificação ], and maps of the census tracts in Vitória. Data related to socioeconomic variables were taken from the 2010 Census, available from the Brazilian Geography and Statistics Institute Instituto Brasileiro de Geografia e Estatística ] website He outcome measure was the tuberculosis incidence for the study period, calculated as the average number of cases per year in the study period divided by the reference population per 100,000 inhabitants. We defined the following exposure variables based on reports by different authors [13][14][15][16][17][18][19][20] : % literacy; % inhabitants with income up to ½ minimum monthly wage, and % inhabitants associated with the sewerage system or with access to safe drinking water, per census tract. The variables for the fully Bayesian approach were selected according to the literature [13][14][15][16][17][18][19][20] on TB in the State of ES, according to census tracts. We collected 21 socioeconomic and demographic variables from Brazil's Atlas of Human Development and analyzed them using Pearson's correlation and a scattering matrix , in order to minimize the redundancy of data produced by the high degree of correlation between variables, ending up with 15 variables . Three of these 15 variables were selected from the 2010 Census, according to the census tracts and the scientific literature on TB. --- Data analysis Spatial statistics: spatial analysis of the tuberculosis risk per census tract was performed by smoothing the overall rate using empirical Bayes estimation , proposed by Marshal and defined as: where EB i is the estimated value; OR i, the overall rate for tract I; and LR, the local empirical Bayes rate that considers the rates of neighboring tracts. The local empirical Bayesian is allows for spatial smoothing of the rate, which reduces the instability in the measurement of the risk rate, thus, facilitatin the interpretation and correlation of the Tb event with other factors in space. The results are presented in the form of scatter plots and maps. --- Zero-inflated model In this model we used a zero-inflated process, the zeroinflated negative binomial , and as there was overdispersion of the data, the explanatory model was selected based on the Akaike Information Criterion . A way of modeling the problem is to assume that the random variable Y i can be represented by a negative binomial random variable . In this case, the expression in is written as follows: The explanatory model was based on the AIC, the statistics of which are the result of adjusting the model and the number of parameters used to calculate it 21 . The § is one of the most widely used model selection measures and is based on the difference between the values observed and those estimated by the model in question, with the model that generates the lowest AIC value deemed the best fit. Sampling zeros occur when conditions are conducive to cases, whereas structural zeros are observed when cases do not occur. Data were analyzed using SatScan software 22 TABLE 1: Indicators selected to compile municipal profiles 21 . --- Indicators --- RESULTS --- Spatial analysis A total of 588 cases of TB were reported in Vitória from 2009 to 2011, distributed among 223 census tracts, while 354 tracts showed zero cases. Figure 1A shows a significant fluctuation in the overall rate, particularly in census tracts with smaller populations. By contrast, Figure 1B) indicates a considerable decline in overall rate fluctuation for estimates generated by the local empirical Bayes estimator in tracts with smaller populations. A funnel effect can be seen in Figure 2A, which is not apparent in Figure 2B. The Figure 2 confirms the above; the map based on empirical Bayes estimates of TB incidence, Figure 2B, exhibits a well-defined spatial pattern, incidence smoothing during the period, and more evident TB risk areas in the municipality of Vitória, particularly in the Southwest, on Vitória bay, as well as in the center, and Southeast regions. --- Risk factors: model for excess zeros Table 2 shows the modeling results considering the effect of excess zeros, the adjusted models, and AIC values for each model. It is important to underscore that there were 4 census tracts in our database without information on the selected variables, in these cases, a zero value was attributed to the variables, and a 1 was attributed to the population in order to perform the analyses. In the negative binomial model, estimates for the parameters of the model in Table 2, considered the best fit, were: ( Where the mean value of p i was 0.93, that is, there is a mean probability of 0.93 that a zero observed is a false zero. From the best model adjusted according to the lowest AIC value, it can be concluded that the logarithm of the average number of cases of TB decreases linearly with the increase of the percentage of literate people. Moreover, an increase in the percentage of individuals with income exceeding ½ MMW reduced the probability of false zeros. --- DISCUSSION In the municipality of Vitoria, 588 cases of tuberculosis were recorded between 2009 and 2011, with 61.4% of census tracts exhibiting zero cases, which justifies the application of a model for excess zeros. The variables of social determinant found in this study using the better adjusted model were illiterate inhabitants and an income up to ½ MMW. Several areas with a case count of zero were observed. According to the study results, 93% of zeros were false zeros, possibly due to under-reporting. This finding may be because the occurrence of zero cases in socially deprived areas is rare in an endemic country. Consequently, in such census tracts where zero cases occurred, the likelihood of the cases being false zeros is higher. These areas have, in general, limited infrastructure for health services, including less epidemiological surveillance. Lack of reporting may lead to these figures, distorting the epidemiological scenario reported to the public officials. In spatial analysis, the distribution of tuberculosis cases in Vitória is not homogeneous over time. Some census tracts display a high risk of TB transmission while others show low risk. High risk areas should be prioritized not only for disease prevention, but for the early detection of cases and adequate treatment for those affected in order to break the disease transmission cycle. As in our study, two other studies [10][11] observed that the southwest and northwest regions of the City of Vitória presented a higher incidence and high probability of clusters. These regions are characterized by population agglomeration and low socioeconomic status. Next to these regions is the central region of the municipality, which despite not having a high probability of clusters, showed an increase in the number of census tracts with a high incidence, compared to the results in the study from 2002 to 2006 10 . This region is mainly inhabited by individuals with a higher socioeconomic status. Accordingly, we considered an average distance of 2000 meters reported in the study 11 , and, apart from the social determinants, there is a need to understand TB transmission as an increase in TB incidence has been reported in areas with a higher socioeconomic status in the over the last few years. There is also a need to include such areas for tuberculosis control and prevention, due to changes in the spatial epidemiological scenario over time To our knowledge, the use of the ZINB model is recent, and the ZINB model has not been used to analyze TB in the City of Vitória. Our findings corroborate with those reported by other research groups 7,10,23 , that is, individuals with a low socioeconomic status were at a greater risk of TB infection; however, a significant portion of this risk may be the result of limited access to health services. It is not only in Vitória that TB is associated with issues, such as poverty, social inequality, and unequal income distribution. A study performed in Ribeirão Preto 24 observed a direct association between TB, income, and education level. Two other studies in Ribeirão Preto and Spain reported an association between the disease and education level [25][26] , and TB was associated with the income of the individuals in a study in Hong Kong 27 . Priority should be given to areas with a large population of illiterate inhabitants, and those earning less than the minimum monthly wage, since these factors influence the occurrence of TB in the municipality of Vitória. The zero-inflated model, such as the ZINB, may therefore be an important tool for public health managers, as it identifies the percentage of false zeros by census tracts, generating a more realistic estimate of TB case distribution, thereby, enabling more effective action to be taken to control the disease. ---

Introduction: This study aimed to analyze social factors involved in the spatial distribution and under-reporting of tuberculosis (TB) in the city of Vitória, Espírito Santo State, Brazil. Methods: This was an ecological study of the reported cases of TB between 2009 and 2011, according to census tracts. The outcome was TB incidence for the study period and the variables of exposure were proportions of literacy, inhabitants with an income of up to half the minimum monthly wage (MMW), and inhabitants associated with sewer mains or with access to safe drinking water. We used a zero-inflated process, zero-inflated negative binomial regression (ZINB), and selected an explanatory model based on the Akaike Information Criterion (AIC). Results: A total of 588 cases of tuberculosis were reported in Vitória during the study period, distributed among 223 census tracts (38.6%), with 354 (61.4%) tracts presenting zero cases. In the ZINB model, the mean value of p i was 0.93, indicating that there is a 93% chance that an observed false zero could be due to sub-notification. Conclusions: It is important to prioritize areas exhibiting determinants that influence the occurrence of TB in the municipality of Vitória. The zero-inflated model can be useful to the public health sector since it identifies the percentage of false zeros, generating an estimate of the real epidemiological condition of TB in Vitória.

INTRODUCTION Attitudes and behaviours of nursing staff towards patients are an essential aspect of quality of care in health-settings . Treatment of elderly patients is particularly important in long-term care settings. Because of their prolonged stay and health problems elderly residents in long-term care are extremely vulnerable and find themselves in an asymmetrical relationship with the nursing staff . This is especially true for elderly residents with cognitive disorders such as dementia. Several studies have shown the importance of 2. THEORETICAL BACKGROUND Krackhardt and Hanson define communication networks as the informal networks of employees who talk about workrelated matters on a regular basis. Ties between nursing staff and relatives and acquaintances of residents cross the boundary of the organization. In line with Reagans and Zuckerman , we name these ties boundary-spanning or boundary-crossing networks because they place employees in direct contact with third parties outside the organization. Networks are often described by the density of interpersonal ties of its members, where density is seen as a measure of social cohesion . Since Seashore's classical study there have been multiple studies that link cohesion of networks to group outcomes . Yet, results remain inconclusive, partly because conceptualizations of social cohesion differ greatly . Festinger first proposed that social cohesion should be seen as the causal system that determines individuals' membership attitudes and behaviours . In this manner, conditions at the group-level can be seen as antecedents of attitudes and behaviour of groupmembers at the individual level . Over the years, several mechanisms are named through which networks influence behaviour of group-members. First, density of networks is believed to enable information exchange between actors. Granovetter first identified the strength of weak ties: low density networks of socially distant actors are more effective in information exchange and innovation than high density networks of closely knit actors . Burt argued that a network in which a person has contacts with few others who provide unique information is more productive than a network in which one has contacts with many others who provide the same information. Low density networks seem to be especially efficient for information exchange in more competitive work-settings. Tasks that depend on cooperation on the other hand seem to profit from networks with a high density . Second, cohesive networks are deemed to affect trust between actors. Buskens and Raub name two aspects through which socially embedded relations affect trust: earlier experiences with actors and possibilities to sanction untrustworthy actors . Control in a social network can be the result of direct sanctioning between actors, but can also be the result of sanctioning by third parties and may even lead to social isolation if untrustworthy behaviour is detected. Research of control has mainly focused on its positive effects. However, Flache and Macy also name a negative effect of social cohesion, or -as they name it -a weakness of strong ties. They argue that relations between two group-members evolve more rapidly than exchanges between all group-members in a group. When strong ties between two actors are established, social control is aimed at the maintenance of these interpersonal relationships instead of compliance with group obligations, which may decrease group effectiveness. Third, cohesive networks enhance social support. Close-knit networks exchange more affective and instrumental support , which in turn is related to individual wellbeing. In studies, social support has also been associated with lower levels of work stress and work strain, although overall results remain inconclusive . Fourth, networks provide a sense of social identity . According to the Social Identity Theory a person's selfimage is connected to the image of the group to which he or she belongs; individuals define themselves in terms of their group-membership and ascribe typical characteristics of the group to themselves. For social identification to occur, groupmembership has to be made salient ; especially closed and cohesive networks are deemed to facilitate social identity . Social Identity Theory forms the basis for organizational identification, which is related to feelings of attachment and loyalty to the organization . Several studies have investigated the relationship between social networks and organizational identification focusing on individual's networks . Bartels et al. found that determinants of identification with the organization as a whole differ from the determinants of employees' identification with lower organizational levels. The climate of internal communication was especially important for the identification with the lower levels of the organization. Perceived external prestige appeared more important for employees' identification with the overall organization. How are these mechanisms of social networks related to the treatment of residents with dementia in long-term care? We expect social networks to be related to behaviour of nursing staff both directly and indirectly. First, we expect that the existence of boundary-crossing ties between nursing staff and relatives/ acquaintances of residents will affect behaviour of nursing staff towards residents directly because these contacts provide information on the background and habits of residents. Information about elderly residents, that those residents cannot provide themselves due to their dementia. In addition, we argue that boundary-crossing ties will also guide the appropriate treatment of residents because they enhance trust. We will explain this reasoning through the concept of embeddedness as described by Granovetter ) and Uzzi . Uzzi noted that socially embedded ties in exchange networks are often formed through referrals by third-parties or previous personal relationships . Trust is seen as a primary feature of these embedded ties ) and described by Uzzi as: 'the belief that an exchange partner would not act in self-interest at another's expense'. When untrustworthy behaviour is detected, this not only affects further exchanges between two actors, but information about untrustworthy behaviour will also spread to others in the extended network that is shared by actors , increasing the chances of punishment . Boundary-crossing ties of nursing staff with relatives or acquaintances of residents represent the manner in which staff members and residents are embedded in the community outside the organization. If these ties exist, we expect that staff members will be less likely to act in self-interest at the expense of the resident. For instance by treating residents poorly or by rushing aspects of care to be able to spend time chatting to colleagues. Furthermore, when a boundary-crossing tie exists, untrustworthy behaviour of staff members will not only affect the relationship with the resident. It will also influence the relationship between the staff member and family/acquaintances of this resident outside the long-term care facility, giving these third parties opportunities to sanction unwanted behaviour . Notably, an important distinction from the original exchanges described by Uzzi and Granovetter ) is that there exists no equal exchange relationship between staff members and residents with dementia, making residents with dementia extremely vulnerable. For this reason, we expect that the possibilities of control by third parties become even more important in this setting. Based on these expectations we define the following general hypothesis: H1. On dementia units with more boundary-crossing networks residents are given a better treatment. Second, we expect that boundary-crossing and communication networks will indirectly influence behaviour through staff members' identification with the organization. We specify our expectations on the level of individual staff members and at unitlevel. First, we expect that boundary-crossing ties will increase identification with the organization as third parties will regard staff members as representatives of the facility, making staff's membership to the facility salient . Thus, we expect a relationship between boundary-crossing ties and organizational identification at the level of individual nursing staff. We believe that for nursing staff identification with the facility is especially important, as public opinion on quality of long-term care in the Netherlands has been mainly based on media attention to adverse events in facilities. Less attention has been paid to the quality of care of individual units or holdings to which facilities may belong. In addition, we expect that staff members' organizational identification is also influenced by the density of staff's communication networks as interpersonal relations affect a person's attitudes about the attractiveness of the group and their orientation towards group-membership . Following Bartels et al. , we expect that boundary-crossing ties are especially important for organizational identification as they are related to the reputation of staff members in the community. When no boundarycrossing tie exists, we expect that the density of internal communication networks becomes more important for organizational identification. Consequently, we hypothesize an interaction effect of boundary-crossing ties at the individual level and density of communication networks at unit-level, where density of communication networks becomes more important when no boundary-crossing ties exist. H2. Boundary-crossing ties increase staff members' identification with the facility. H3. Dense communication networks of nursing staff increase staff members' identification with the facility, particularly when no boundary-crossing ties exist. Organizational identification motivates group-members to work in the group's interest . We expect that organizational identification is positively related to work motivation which results in a better treatment of residents in dementia units. Work motivation is deemed to be especially important for nursing staff, as they often seem to choose their jobs on intrinsic values such as recognition, contacts with residents and task content over instrumental rewards such as salary . We hypothesize that this relationship between organizational identification, work motivation and behaviour exists at the level of individual staff members but will affect the treatment of all residents of the unit . H4. Organizational identification results in higher work motivation. H5. Residents are given better treatment on dementia units with more motivated nursing staff. In summary, this study investigates social networks of nursing staff and attitudes and behaviour of nursing staff at individual and group-level. It can best be described using the micro-macro scheme that was introduced by Coleman and is often used in sociology . The structure of the theoretical framework, and our hypotheses, are presented in Fig. 1. At the macro-level, we study the relationship between social networks of nursing staff and the treatment of residents. To understand this macro-relationship we investigate how social networks affect organizational identification and work motivation on the micro-level, and study how work motivation is related to the treatment of residents of the unit on macro-level. --- METHODS. --- Design and ethical considerations The study was guided by a cross-sectional design. Data were collected between October 2002 and June 2003 in 37 long-term care dementia units in the Netherlands. Each unit was visited by two researchers during three days. During these days, questionnaires were distributed among nursing staff of the units and the behaviour towards residents was systematically observed. According to Dutch regulation no approval of an ethics committee for this study was necessary, as no intervention was investigated and data were not directly collected from residents. Written informed consent from legal representatives of residents was obtained. In addition, client --- Setting In the Netherlands, long-term dementia care is provided in psychogeriatric units in nursing homes and residential homes . Residents who live in these psychogeriatric units receive multidisciplinary care and often share bedrooms. In addition, residential homes provide dementia care in psychogeriatric group projects. These group projects also provide multidisciplinary care and aim to delay or prevent admission of residents to a nursing home. Residents who attend group projects live in their own apartments in the facility, but spend most of their day in a small group setting. For this study, a convenience sample of facilities was recruited in four regions in the Netherlands; data were collected in one unit in each facility. Participating units consisted of 26 psychogeriatric units: 16 units in nursing homes and 10 units in residential homes. In addition, 11 group projects in residential homes also took part. Group projects provided care to an average of 12 residents compared to 28 residents on psychogeriatric units in nursing homes. Analyses showed that the 37 units in the study did not differ from psychogeriatric units in general in the Netherlands in terms of the psychosocial and somatic care requirements of residents . --- Social networks of nursing staff We individualized the questionnaires for each unit by presenting the names of all staff. To measure communication networks we asked the following question: 'Please report for each colleague how often you speak to him or her about your work or things that happen at work' . Frequency of contacts was presented in five categories ranging from a few times a day to less than two times a month/never . Communication networks were analyzed with the UCINET software package . First, responses of individual members of nursing staff were symmetrized , coding a tie between two members of nursing staff when at least one indicated a relation with the other. Second, the answers were dichotomized into at least once a week and rare . Third, density was computed as a measure of the general level of cohesion of the network . For boundary-crossing networks we were interested in the ties between nursing staff and relatives or acquaintances of residents in the community. We collected information on these networks with a question based upon the work of Milgram , known as the 'small world problem ' , that later became popularly known as the 'six degrees of separation experiment' . [FIGURE 1]. Individual staff members were asked if they knew residents of their units through others and how many ties existed between them and this resident. We asked the following question: 'Please think randomly of a resident of this unit, for instance by choosing a resident whose surname starts with the same capital letter as yours. How many intervening steps of people you know are necessary to arrive at this resident?' Two examples were provided to clarify the question. Example 1. 'I did not know resident Y. before she was admitted to this unit. However, I went to school with her daughter.' Example 2. 'My father knew resident X. when they were younger; they played billiards together. Resident X. visited my parents once in a while.' In both examples there is one intervening step between the resident and the member of nursing staff. For this study, the presence of boundary-crossing ties between residents and nursing staff was important, the number of intervening steps was less important. For this reason, answers were dichotomized for each member of nursing staff with a score of one representing a boundary-crossing tie and a score of zero representing no boundary-crossing ties with residents. --- Organizational identification and motivation Organizational identification was measured in two ways: identification with the dementia unit and identification with the facility. Identification with the unit was measured by an adaptation of the Dutch version of Mael and Ashforth's organizational identification scale . This scale consists of six items. Answers are scored from 1 to 5 . For this study, the name of the unit was inserted into each item. Examples of items are 'When someone criticizes <name unit>, I feel personally offended' 'I'm very interested about others' opinion of <name unit>'. For the total score, scores of all items were summed and then divided by six. The higher the score the more nursing staff identified with the unit. Cronbach's alpha of the scale in this study was 0.69. In addition to these questions for the unit, nursing staff were asked with one overall question if the answers applied in the same way for the facility the unit belonged to. Answers on this item were scored on a scale from 1 to 5 . The score of this last question was used as the main variable for identification with the organization in our analyses. Intrinsic work motivation was measured with six items derived from a scale developed by Warr et al. . Examples of items are: 'I feel a sense of personal satisfaction when I do my job well' and 'My opinion of myself decreases when I do this job badly'. Answers are scored from 1 to 5 . For the total score, scores of all items were summed and then divided by six, a higher score representing a higher work motivation. Cronbach's alpha of the scale in this study was 0.71. --- Treatment of residents by nursing staff For the observations, an observation-list of 32 items was used that focused on different aspects of care for residents. The observation-list was derived from a list that was based on the aspects of quality of care defined by Rantz et al. . Each item was scored on a five-point scale, with 5 representing the most positive score. Six items of the observation-list were related to the behaviour of nursing staff towards residents: starting a friendly conversation with residents, taking sufficient time for residents, calling residents by their name, treating residents with respect, actively caring for residents, and residents and nursing staff smiling at each other and seeming at ease with each other. The observation-list was completed at three times, one observation on each day of data-collection. Observation-times represented three important moments of care: morning , dinnertime , and the afternoon . The times of observation were not known to the units in advance. After an observation-period of twenty to thirty minutes, both researchers individually completed the list and, afterwards, discussed their findings. A total of 15 researchers carried out the observations on the 37 units. One researcher observed all the observation-moments , each time accompanied by one of the 14 other researchers. A score for each item was computed based on the average score of the two researchers over all three observation-moments. Interobserver reliability of the separate items varied between 0.65 and 0.78 , with a mean of 0.74. Cronbach's alpha of the six items was 0.84. --- DATA ANALYSIS. To test the hypotheses, data were analyzed in several steps distinguishing between analyses on macro-level and micro-level. First, the correlation between boundary-crossing networks of nursing staff and the treatment of residents at the level of units was studied . Second, we looked at the relationship between social networks of nursing staff, organizational identification and work motivation. The existence of boundary-crossing ties, organizational identification and motivation were all measured at the individual level. Density of communication networks was measured at unit-level. For this reason we carried out multilevel analyses in MLwiN in which individual and unit variables could be combined. In addition, multilevel analyses show how much variance in outcomes can be ascribed to the unit and to individual staff members. Two separate models were analyzed, each with two levels: units and nursing staff on these units . In model 1, the relationship between boundary-crossing networks, density of communication networks and organizational identification was studied . Model 2 investigated the relation between organizational identification and work motivation . In the multilevel analyses it was first investigated how organizational identification was influenced by characteristics of nursing staff and structural aspects of the units . Second, boundary-crossing and communication networks were entered into the model. Boundary-crossing networks were first entered into the analyses on the level of individual staff members; density of communication networks, measured on unit level, was then entered into the model as a crosslevel interaction, as it was expected that communication networks among nursing staff become more important when no boundarycrossing ties exist. For work motivation the analyses were repeated. In addition, organizational identification was added to the model. Finally, we studied the relationship between work motivation and the treatment of residents at unit-level . A total of 474 nursing staff completed the questionnaire of this study. This was 55% of all 861 nursing staff in the units. The majority of nursing staff consisted of women , with an average age of 38 years . Nursing staff mostly worked part-time and the vast majority held a permanent position . The question on communication networks was answered by 380 staff members. Two units were excluded for analyses due to a response rate of less than 15%. The response percentage on the remaining 35 units varied between 18% and 100% per unit with an average response rate of 53%. In psychogeriatric units in nursing homes and residential homes the average response rate was 45%. In group projects the average response rate was 71%. Response rates were negatively related to the size of the units. On units with more nursing staff, response rates on communication networks were lower . The average density of the communication networks was 0.52, varying between 0.22 and 1.0 for the participating units. Density of communication networks was also significantly related to the number of nursing staff in the unit . When we controlled for the average response on the social network questions, the relationship between the number of nursing staff and the density of communication networks of the units remained significant . The question on boundary crossing networks was answered by 391 nursing staff in the 37 units . A boundary crossing tie was mentioned by 44% of the nursing staff, varying between 0% and 100% of nursing staff on the units. On average, 35% of nursing staff in psychogeriatric units in nursing homes mentioned a boundary crossing tie. For psychogeriatric units in residential homes this was 48%; for group projects it was 53%. H1 Direct relationship between boundary-crossing networks of nursing staff and treatment of residents. Table 1 gives an overview of the correlations between boundarycrossing networks of nursing staff and the observed treatment of residents in the 37 units. In units with more boundary-crossing ties, nursing staff treated residents with more respect, and nursing staff and residents seemed more at ease with each other . Furthermore, boundary-crossing ties were related to the number of times nursing staff started a friendly conversation with residents and the amount of time they actively cared for residents . The different items to measure treatment of residents were also positively related to each other. For instance, on units where nursing staff more frequently started a friendly conversation with residents, they also took more time for residents and treated residents with more respect. The results support Hypothesis 1. H2 and H3 Relationship between social networks and organizational identification of nursing staff. Next, the relationship between boundary-crossing networks, density of communication networks and nursing staff's organizational identification was studied. Average identification with the facility was 3.0 on a scale from 1 to 5 . Table 2 presents the relationship between characteristics of nursing staff, structural aspects of the units, social networks and identification with the facility for nursing staff of 35 units. Identification with the facility varied significantly between staff members. There was also significant variance between units . Of the variance 16% could be ascribed to differences on the level of the units . Identification with the facility was not related to characteristics of the nursing staff in our sample . However, it was related to structural aspects of the units. On larger units nursing staff identified less with the facility . This relationship between size of the units and identification ceased to exist when --- RESULTS. [TABLE 1][TABLE 2][TABLE 3]. boundary-crossing networks and communication networks were entered into the model. No main effect for boundary-crossing networks was found. Yet, we did find an interaction effect of boundary-crossing networks and communication networks. When there were no boundary-crossing ties, the density of communication networks of staff in the unit was positively related to identification with the facility . The results do not support Hypothesis 2. We found no main effect for boundarycrossing networks and identification with the facility. Yet, we found a cross-level interaction effect of boundarycrossing ties and communication networks for organizational identification. The results support Hypothesis 3. H4 Relationship between organizational identification and work motivation of nursing staff. Average work motivation was 4.0 on a scale from 1 to 5 . Table 3 shows that motivation varied significantly between individual members of nursing staff. No significant variation between the units was found . For work motivation, 4% of the variance could be ascribed to differences on the level of the units . Identical to the analyses for organizational identification, it was first investigated how motivation was influenced by characteristics of nursing staff and structural aspects of the units. We found that older nursing staff was more motivated . Work motivation was not related to structural aspects of the units or the social networks of nursing staff . However, nursing staff that identified more with the facility were more motivated to provide better care . The results thus support Hypothesis 4. [TABLE 4]. H5 Relationship between work motivation and treatment of residents. Finally, scores of work motivation were aggregated to the unit-level to investigate whether motivation was related to the treatment of residents of the units. For this, the percentage of nursing staff that scored higher than average on the scale for work motivation was assessed. These percentages of nursing staff with a high work motivation varied between 25% and 100% between the units with an average of 58%. The percentage of highly motivated nursing staff related positively to the treatment of residents in the units . In units with more motivated nursing staff, nursing staff smiled at residents more often and seemed more at ease with residents , and more often started a friendly conversation with residents . The results support Hypothesis 5. --- DISCUSSION. This study is the first to examine the relationship between social networks of nursing staff and behaviour of nursing staff towards elderly residents with dementia. On units where nursing staff reported more contacts with relatives and acquaintances of residents , nursing staff treated residents more often with respect and approached residents in a friendly manner both by being at ease and by starting friendly conversations with residents. Social networks also indirectly affected the treatment of residents. Communication networks of nursing staff were positively related to staff's identification with the facility when no boundary-crossing ties existed. Organizational identification in turn was related to work motivation of nursing staff which, aggregated to unit-level, proved to be positively related to the treatment of residents of the unit. These results largely supported our hypotheses. Several characteristics of nursing staff and characteristics of the units that could influence the relationship between social networks and organizational identification and work motivation were taken into account. Only one characteristic of nursing staff was found to be related to the dependent variables. Older nursing staff was more motivated to provide good care. More nursing staff on the unit was found to be negatively related to identification with the facility. However, this relationship between size of the unit and identification ceased to exist when social networks were entered into the model. The results of this study should be interpreted with caution. First, the response rates on the social network measures were limited. The question regarding communication networks had a response rate of 53%, after we excluded two units with very poor response. We found that response rates were lower in units with more nursing staff. Evidently it is easier to answer questions for a limited group of colleagues than for a larger group. Kossinets argues that non-response in social network surveys can be partially balanced out by reciprocal nominations of actors. If A does not fill in the network questionnaire but B and C of the same network describe their interactions with A, information about the social network of A is still available. In the analyses data were symmetrized, coding a tie between members of nursing staff when at least one staff member indicated a tie with this colleague. Through this, information was gained on the communication networks of those who did not complete the questionnaire. Furthermore, when low response rate leads to smaller numbers, the Empirical Bayes Estimation used in the multilevel analyses shrinks the estimates to the general mean, which results in a conservative approach. The question on boundary-crossing networks was answered by 44% of nursing staff. It is not known whether the remaining nursing staff had no boundary-crossing tie , or if they did not understand the question due to how it was constructed. The question used to obtain boundary-crossing information was relatively complex, not only asking after the presence of a boundary-crossing tie but also asking after the number of intervening steps. Perhaps response rates would be higher if the latter part of the question was omitted, as it would make the question easier to understand. Dementia care in the Netherlands is provided by an educationally diverse nursing staff and, due to the growing number of older people that need extensive care, often staff with a low education level is employed. As this is the first study to address networks between nursing staff and family and acquaintances of residents in longterm care, it is impossible to compare our findings or response rates to other studies. To address our response problem, we performed additional analyses in which all missing values were recoded into value 0 . The findings of these analyses did not differ from the results that are presented in this article. Nevertheless, the limited response on both social network questions is an important limitation of this study. Further studies should focus on methods to obtain more complete social network data of nursing staff. Second, the study was guided by a cross-sectional design in which several outcomes were used. Overall, reliability of the scales used for organizational identification, intrinsic work motivation and behaviour towards residents with dementia was sufficient. Yet, several limitations can be identified. Organizational identification was measured in two ways: identification with the dementia unit and identification with the facility. The score of this last item -that measured deviations from the identification with the unit -was used as the main variable for identification with the organization in our analyses. This measure has to our knowledge not been used before. Further research is needed to see if similar results may be obtained in other settings. Cronbach's alpha for intrinsic work motivation was 0.71. Although not very high, this is comparable to other studies in the Netherlands in which the scale was used. For instance, Janssen et al. reported a Cronbach's alpha of 0.70 in their study of nurses in a general hospital. The behaviour of nursing staff towards residents with dementia was observed during three days on each unit by two researchers. Although the observations show sufficient interrater reliability, there were differences in how the researchers interpreted the interaction between nursing staff and residents. In addition, with the results of this study, it is impossible to determine whether treatment of residents differed over time in the units and whether nursing staff reacted to the presence of the researchers. However, precautions were taken to optimize the reliability of the findings. One researcher observed all 37 units on all occasions. The observations were carried out at three different moments which were not known to the nursing staff in advance and researchers were asked to report possible reactivity effects of nursing staff if they became aware of them. Overall, reactivity of nursing staff to the researchers was found to be limited, which is consistent with earlier research by Schnelle et al. , who found no effects of reactivity of nursing staff when using observations to assess quality of care. Third, although we corrected for several characteristics at staffand unit-level, we expect that the relationship between social networks and identity may also be contingent on other characteristics that were not part of this study. Furthermore, the relationship may also be mediated by other mechanisms which we discussed in the theoretical background but were not part of this study, such as social support. The power of our multilevel analyses was restricted to 35 units at the highest level of analyses and only a limited amount of unit variables could be taken into account. Consequently, our analyses are not extensive and it is important that future research identifies which other aspects and mechanisms mediate the relationship between networks, identification, work motivation and behaviour of staff in long-term care. An important characteristic which we would like to mention separately is the experienced workload of nursing staff as it may be expected that especially workload is related to the time nursing staff spend interacting with residents. For the 35 units, the average workload was not extremely high . Although we found a weak correlation between workload and the density of communication networks , we found no significant correlation between workload and organizational identification or motivation. Workload was significantly correlated to nursing staff taking sufficient time for residents and the number of times nursing staff called residents by their name . Interestingly, those two aspects of the treatment of residents were not significantly correlated to either the existence of boundarycrossing ties or to the work motivation of nursing staff. These results show that workload is important when studying the treatment of residents in long-term care, but seems to affect the treatment of residents through different mechanisms and on different aspects. In this study, we focused on the relationship between social networks of nursing staff and the treatment of residents with dementia at the macro-level by studying the attitudes and behaviour of staff at the micro-level. For this, we followed the micromacro scheme that is often used in sociological studies . Raub et al. state that: "micro-macro models aim at explanations of macro-outcomes and at incorporating macroconditions in the explanation rather than at explaining individual behaviour as such". In the next paragraphs, we will discuss our findings in view of this micro-macro explanation. Boundary-crossing ties of nursing staff with relatives/ acquaintances of residents were investigated using a question based on the small-world problem. Although the accuracy of small world chains by respondents is questioned and the response in our study was limited, the results indicate that this type of question is suited to gain insight in indirect ties of nursing staff with residents who are extremely vulnerable. Our definition of boundary-crossing ties was closely linked to the concept of embeddedness as described by Granovetter ), and Uzzi . We proposed two mechanisms through which boundary-crossing ties affect treatment of residents on the macro-level: contacts provide information and boundary-crossing ties enhance trust and provide opportunities for control. In this study a positive relationship was found between the existence of boundary-crossing ties and the treatment of residents in dementia units. However, due to our study design we cannot unravel if this result is due to information exchange or to the trust/control mechanism. Yet, the findings of this study indicate that when a boundary-crossing tie exists a staff member is more likely to treat all residents of the unit better, not only the resident with whom the boundary-crossing tie exists. This may be ascribed to the fact that the boundary-crossing ties in our study indeed can be seen as a measure of social embeddedness of staff and residents in the community, which decreases the inclination of staff to act in self-interest at the cost of residents. For this mechanism, we focused on the behaviour of nursing staff and not on the behaviour of residents as they, due to their dementia, are the most vulnerable party in the exchange relationship and are not able to maintain their social networks themselves. Although we found a positive relationship between boundary-crossing ties and the treatment of residents by nursing staff, our findings must be seen as a first attempt to unravel how embedded ties may influence quality of care in healthcare settings. For instance, in our study no attention was paid to the fact that information about untrustworthy behaviour of relatives and acquaintances of residents may also find its way to the dementia unit and may affect the behaviour of nursing staff towards particular residents. Furthermore, we have no information of values and norms that are shared between staff members, residents, and third parties outside the organization. Baker and Faulkner name this cultural embeddedness, and they use the term 'double embeddedness' to include both structural and cultural embeddedness. Our research is also closely linked to the concept of job embeddedness as constructed by Mitchell et al. to explain employee turnover. Job embeddedness not only incorporates connections to colleagues and organizations, but also includes connections of employees with the community and people in the community . All in all, the findings implicate that it may be beneficial for long-term care facilities to employ nursing staff who have ties with relatives and acquaintances of residents outside the organization, as this positively affects the treatment of residents. This may be achieved by recruiting staff from the community where residents originate from. On the micro-level, we found a relationship between networks, organizational identification and work motivation. The results show that the communication network between nursing staff of a unit is important for organizational identification, especially when few or no boundary-crossing ties exist. No main effect for boundarycrossing networks at the individual-level was found. We hypothesized that relatives and acquaintances of residents would regard nursing staff as representatives of the facility, which would make their group-membership to the facility salient. Yet, our results indicate that organizational identification is not so much the product of the salience of individual group-membership, but is shaped by closely-knit communication ties with other staff members at unit-level in combination with the existence of boundary-crossing networks at the individual-level. This finding does not correspond with earlier findings of Bartels et al. who found that internal communication patterns were especially important for identification with the lower levels of the organization and external prestige was important for identification with the organization as a whole. Perhaps our findings are a result of our view on group-membership. Implicitly, we assumed that nursing staff would regard residents as members of the facility. Yet, when nursing staff do not regard residents as members of the same group, contacts with residents will make staff's membership to the organization salient all the time and contacts with outsiders will become less important. This may explain why no main effect for boundary-crossing ties on organizational identification was found. It may also explain why especially communication ties with staff members seem to be important for identification with the facility, as only staff members are seen as the fellow members of the group. Two more aspects of our study need to be discussed. First, we investigated the existence of boundary-crossing and communication ties of nursing staff and not the strength of these ties. It may be expected that very strong ties may hinder the treatment of residents. For instance, in our observations, we incidentally noted that strong ties may also result in nursing staff talking to each other during care, instead of interacting with residents. When ties with relatives are strong, this may lead to less criticism and an unwillingness of relatives to impose sanctions. This is the weakness of strong ties that Flache and Macy addressed in their study. Although, we found no indication for a negative relationship between the density of communication ties and the treatment of residents, such a negative relationship may exist if the ties are particularly strong. It is important that further research focuses on this possible adverse effect of strong ties. Second, we based our study on the assumption that a good treatment of residents is an overall aim of the facility. Thus, we expected that resident-oriented behaviour of staff coincides with formal group-norms. Moments of observation, especially morning care and dinner-time, were specifically chosen because some interaction with residents was part of the job. In this regard, noncompliance with organizational norms was not a subject of this investigation. Yet, it would be interesting to study how behaviour of nursing staff towards residents is influenced by group-norms and under which conditions nursing staff will turn against organizational rules. Implicitly, our results emphasize an important point: to be able to provide good care to residents with dementia in longterm care it is important that organizational norms and protocols focus on the interaction with residents. The results show that social networks of nursing staff play an important role in care processes in long-term dementia care. The findings indicate that care may be improved by facilitating contacts between nursing staff and relatives of residents with dementia in the community. Although we did not look at the actual presence of relatives in the unit, our results tie in with other studies that underline the importance of contacts with relatives of residents in long-term care . Furthermore, care may be improved by facilitating informal communication among staff members, especially when no or few contacts between nursing staff and relatives of residents exist. Recent studies have demonstrated that higher staffing levels are related to better quality of care in nursing homes. Although it is difficult for long-term care facilities to increase manpower because of costs, results of this study indicate that care may also be improved by changing extra-and intra-organizational communication patterns. Further research is needed to study how social networks of nursing staff affect other aspects of care.

This study investigated social networks of nursing staff and staff's behaviour towards residents with dementia. We focused on two types of networks: communication networks among staff, and networks between nursing staff and relatives/acquaintances of residents. Data was collected in 37 long-term care units in nursing-and residential homes in the Netherlands. In units with more networks between nursing staff and relatives of residents, staff treated residents with more respect and were more at ease with residents. Social networks were also positively related to staff's organizational identification which, in turn, related to their work motivation and their behaviour towards residents.

Steadman Jones, therefore, suggested not to "translate archival silence into historical passivity" i.e., the cultural passivity of the lower classes, as too many scholars have done. Though more than a quarter century has passed since Steadman Jones made these observations, still, only a handful of historians have addressed private, creative and domestic modes of leisure in general, and hobbies more specifically, as widespread popular phenomena. This lack of attention to the home as the legitimate domain of an entire culture of creative leisure is only one symptom of the fundamental bias of historiography, which takes nearly all popular leisure to be passive and non-productive. Chris Waters pointed to the deep roots of this tendency when he showed how John Stuart Mill, in his On Liberty , identified all forms of lower-class leisure activity with a passive, conformist, and absolutely non-creative popular culture. 4 In this context, even revisionist historians, like Peter Bailey and Hugh Cunningham, did not steer clear of the received notion that yokes popular leisure to activities experienced mostly in the public sphere. While they did recognize the emancipatory potential of numerous kinds of leisure activities, they failed to grasp the importance of domestic types of creative leisure, in particularly, hobbies. 5 Cunningham's revisionism, for instance, prompted an examination of the rich inventory of leisure types in the second half of the nineteenth century, yet the majority of which involved group-or community-oriented activities that took place in the public sites like parks, public libraries, museums, or public baths, and in commercial leisure sites like beaches, race tracks, fairs, music halls, the penny gaffs, and circuses as popular leisure sites. In that respect, Bailey and Cunningham did recognize the cultural agency among members of the working classes similar to the way Richard Hoggart described the mass leisure culture of the first half of the 20 th century: Hoggart …was equally alive to the powers of agency and creativity in working-class communities. People in Leeds and elsewhere fought continual battles, not for the most part in favour of abstract ideologies but in order to 'make ends meet', to achieve pride, self-respect and, if possible, the 'little comforts of life'. These were not struggles which merit high priority in the globally transformative schemes of hegemonic intellectuals, but they were a matter of necessary and urgent priority to those on the ground. 6 And yet, one can plainly see that lacking from this rich inventory of leisure activities, are individual, domestic modes of leisure, the core of which involves a wide variety of handicraft hobbies. No doubt the very definition of leisure activity as something that took place mainly in the public arena got in the way of addressing Victorian domestic leisure and impeded the understanding of this phenomenon as an important instrument in the subject's social toolbox. 7 And so, these forms of leisure, defined by the participants themselves as occurring during their 'leisure time', are almost entirely absent from the historiographical discussion. Cunningham even stated, in relation to the notion of leisure time, that until mid-century no unified concept existed to describe the full panoply of leisure activities, so that the everyday use of the word 'leisure', at least until the last decades of the century, was restricted to designations of those serving in the role of the commentators. The meaning of the word leisure was, accordingly, 'abstract'. People talked in terms of concrete activities like going to the pub or to the races, but not, he argued, about leisure proper. 8 As distinct from this notion of 'leisure', this article argues, that for many members of the working classes, amongst others, artisans of all kinds, cabinet-makers, factory and agricultural workers, house servants, workmen's housewives, seamstresses, grocers, and policemen, who spent many hours engaged in the intense, productive labour of a hobby, the word 'leisure' was associated with a concrete experience and carried emancipatory significance, referring to a stretch of time unfettered by the employer's authority and the strains of the work place. It is in this sense that the notion of leisure was not necessarily applicable only to the higher class, as Thorstein Veblen argued: it was more than just the prodigal, conspicuous and non-productive use of free time through which the privileged liked to distinguish themselves or their kind. 9 This class bias regarding the notion of leisure did not leave the discussion of hobbies untouched either: at least two historians -Ross McKibbin and Steven Gelber -have looked at Victorian leisure from the point of view of the domestic hobby. 10 Both scholars, however, mistakenly assumed that the domestic hobby became a popular practice only in the last two decades of the nineteenth century. Gelber based his periodization on an imprecise linguistic analysis that focused on the unfavourable connotation that accompanied the word hobby, contending that before about 1880 a hobby was a dangerous obsession. only after that it became a productive use of free time. 11 He took the absence of the word 'hobby' from mundane language as conclusive evidence that hobbies were not common until the last decades of the century. This is substantiated, according to him, by the dramatic 'linguistic mutation' the word 'hobby' had undergone by the end of the century, a transformation he illustrates through two articles published, twenty-five years apart, in Charles Dickens' magazine All the Year Around. 12 In an 1865 article entitled 'Hobby Horses', hobbies were presented as a pastime that, while perhaps not actively harmful, was esoteric, bizarre and mainly elitist. Activities listed included "re-creating historic battles with toy soldiers; fishing; fox hunting; collecting art, china… gardening… moral philosophy… self-pity; homeopathy; social reform… and giving parties." 13 A quarter of a century later, an article in the same publication, entitled "About Hobbies", displayed none of this irony and mockery towards the hobbyists. 14 In this latter article, described by Gelber as the "de facto manifesto of the new home leisure", the hobby was no longer presented as something eccentric and obsessive but rather as an "antidote to ennui". 15 McKibbin's contribution to the study of hobbies as creative leisure is crucial insofar as it questions the chronic dichotomy between leisure and work and suggests, instead, a complementary and more fertile approach, according to which "[…] for skilled craftsmen the hobby was often simply an extension of ordinary work routine with the crucial modification that routine was replaced by autonomy and choice." 16 Yet his historical examination of the notion of the hobby, like Gelber's, is inadequate, as McKibbin misinterprets the publication of the popular magazine Hobbies, beginning in 1895, as evidence that hobby activities became widespread among labourers only towards the end of the nineteenth century. However, number of contemporaneous documents and treatises dealing with modes of creative leisure establish conclusively that domestic hobbies were already widespread among workmen in mid-century and the word itself was explicitly and positively applied. One such document, among others, is the tractate The Artisan, his Recreations & Hobbies, written in 1870 by William Fretton of Coventry. This text is notable not merely for its use of the word 'hobby' but because of the detailed way in which its author links hobbies to leisure practices that were common in the family lives of many workmen. It suggests a domestic leisure pursuit for artisans and workers of both genders, involving mostly labour-intensive hobbies based on handiwork or systematic collecting, for artisans and workers of both genders. By no means does this pamphlet intend to preach or moralize. The text reflects, rather, an actuality, a certain way of life as well as an attempt to remove the traditionally sceptical tone of the word 'hobby': Hutton says, "Every man has his hobby horse, and it is no disgrace prudently to ride him. He is a prudent man who can introduce cheap pleasure without impeding business." 17 By combining recreation and work, Fretton effectively imported the realm of work into the domestic domain-or, as he himself put it poetically, "Here again is a kind of rest in doing labour of love." 18 Between a Historiography and a Sociology of Leisure Why is it, then, that forms of domestic leisure, and above all, hobby-work, escaped the attention of the historiography of lower classes' leisure practices? I propose that historiography has failed to grasp the notions of creative leisure and hobby mainly because it avoided dynamic, and comparative sociological models almost entirely, relying instead on three intuitive assumptions about the nature of leisure activity. The first of these was that leisure occurs where there is no work, and vice versa. Second, it was assumed that leisure activity, being voluntary, demands no regularity and is obviously beyond the purview of work discipline. The third assumption was that leisure must be pleasurable or at least relaxing and restorative. To these was added a belief that if the working classes did subscribe to some form of consistent creative leisure activity, it must clearly have been 'rational recreation', a form of activity imposed from above by social missionaries or political reformers. Hence this activity should be seen as an extension of the social control that sought, by means of the hegemonic capitalist ethos, to instil praxes of self-improvement. These assumptions, however, are misleading if we wish to assess the full meaning invested in these creative and private leisure activities among the Victorian lower classes. In this case sociological theory comes to our aid by casting doubt upon the limited notion of 'rational recreation', while also offering alternative considerations: first, that just as being enjoyable does not turn work into leisure, so being arduous, skilful and disciplined does not thereby turn an activity carried out in leisure time into work; and second, that leisure, taking place under relative freedom, at a self-directed pace and with self-selected contents, plays a key role in enabling self-expression and a sense of self-worth. 19 The sociology of leisure successfully explains how people can be deeply involved in leisure activity that requires work skills and self-discipline because it takes account of sentiments like freedom, self-esteem, pride, satisfaction, and a sense of achievementall of which may equally result from leisure as from work. the sense of achievement is high when the core activity is endowed with such intense appeal that the line between work and leisure is virtually erased. In this context, the notion of serious leisure as opposed to casual leisure, developed in the early nineteen-eighties by the Canadian sociologist Robert Stebbins, may come in handy. 20 Serious leisure is defined by Stebbins as: [the] systematic pursuit of an amateur, hobbyist or volunteer activity that participants find so substantial and interesting that, in the typical case, they launch themselves on a career centred on acquiring and expressing its special skills, knowledge and experience. 21 Casual leisure, by contrast, can be defined as an immediately and intrinsically rewarding, relatively short-lived pleasurable activity requiring little or no special training. 22 It typically involves play, relaxation, passive or active entertainment, and occasionally such deviant activities as drinking and moderate gambling. Serious leisure, then, is a productive activity, systematic and on-going, which relieslike the world of work -upon accumulated skill and knowledge that can be seen and appreciated by other members of the community. The serious leisure player is invested in a lengthy process of learning and of honing his or her skills until, frequently, the hobby becomes a substantial career -a leisure career that affords no less of a sense of self than would derive from success in the domain of work. It is, writes Stebbins, the kind of self-worth and social respect that Cicero must have had in mind when he coined his famous dictum: Otium cum dignitate. 23 Moreover, in contrast with those approaches that regard payment or its equivalents as a clear mark of distinction between work and leisure, subjects of a serious leisure career may eventually gain partial or even full livelihood from their hobby. 24 All this is the antithesis of the organizing principle of the historiography of leisure, which, as described above, mistakenly assumes that the industrial revolution cut off the traditional and popular practices of creative leisure, and replaced them with a multitude of casual leisure tactics. Instead of creative leisure, the historiography preferred to deal with recreation, pastime, or amusement. Unlike the various forms of casual leisure, which are overwhelmingly discussed at the macro level , serious leisure is mainly the business of the lone player and can only be fully appreciated through close observation of a particular leisure work. This individualization of leisure work is reflected in the personal narratives, brimming with a sense of achievement that subjects recount to themselves or their surroundings. Thus, the study of serious leisure requires the use of micro-historical strategies: it obliges us to learn about the broad phenomenon via specific reports, personal stories, or marginal events. These, while insignificant in themselves, might emerge as synecdoches -details that, as Hayden White argued, are representative of the whole. 25 --- James Anderton as a Serious Leisure Actor If, as Giovanni Levy put it, doing micro-history is, to some extent, to prefer an individual portrait -over a group portrait, then the story of James Anderton, born in 1825, provides the study of serious leisure with a particularly detailed and illuminating individual portrait of a serious leisure devoted player. 26 The case of this Lincolnshire agricultural worker is the ultimate exemplar of a serious leisure career, a prime instance of a 'culture of commitment', to quote the sociologist Alan Tomlinson. 27 Anderton devoted an entire decade of his life to the construction of a model of Lincoln cathedral out of one million and eight hundred used corks, ten years of dedicated leisure work that culminated in Anderton's participation in the South Kensington International Exhibition of 1862. Like other independent exhibiters, Anderton received little, partial and casual mention in the official publications covering the event, as well as in other texts that accompanied the exhibition. In a collection of letters submitted to the Durham Chronicle in the autumn of 1862, the journalist Francis Mewburn noted the corks model, but seemed to look right through its creator, not even mentioning him by name. Anderon was an "invisible man", as Axel Honneth would say in portraying social invisibility. 28 The official catalogue of the exhibition makes two separate references to Anderton; the first entry appears under the name James Anderton and carries the title 'Lincoln Cathedral', omitting any reference to the fact that it was made out of a vast number of corks; in the second entry, under the title 'The English cathedrals in corks', Anderton is mentioned briefly alongside the 'ingenious product' of the professional architect J. Norbury. 29 Anderton also received the following summary mention in the comprehensive commercial catalogue that came out in the same year: "The cork model of Lincoln Cathedral is a curious specimen of patient labour somewhat ill employed"not the most flattering comment, particularly when compared with the "great model of the new Bourse at Berlin [which] is the most interesting in this class of objects." 30 It was George Rowdon Burnell, well-known author of practical and theoretical books on construction, bridges, civil engineering and metal work, who was charged with editing the catalogue's section on architecture. The encounter between Anderton the hobbyist and Burnell's professionalism was doomed from the start. Indeed, Burnell would have preferred that Anderton's work be classified as a curiosity rather than architectural artefact, while Anderton, for his part, never meant to be part of the professional architectural scene, with its long tradition of well-made models marked by precision, subtlety and close adherence to the rules of perspective. One has the impression that Anderton's cork model did not in the least resemble that genre. Descriptions of his model are more reminiscent of Gombrich's wooden horse, of which Gombrich writes: "It is usually content with its place in the corner of the nursery and it has no aesthetic ambition… it is satisfied with its broomstick body and its crudely head...." 31 If the architectural model aims to tell us something about an existing building or to illustrate a building yet to be constructed, Anderton's model purported to convey more about its maker than about Lincoln Cathedral. Its maker's pride had more to do with the Herculean feat of collecting one million and eight hundred corks than with architectural accuracy. The exhibition organizers' choice to include the corks cathedral in the architecture section was one of default, reflecting, at best, a taxonomic perplexity, and more likely a fundamental failure to grasp the meaning and motives of this dedicated hobbyist. Two further unofficial sources, published a decade after the exhibition, provide us with more information about Anderton and the evolution of his hobby. One is an 1871 pamphlet likely published on Anderton's own initiative, and the other is a picturesque magazine reportage that appeared in 1870 in the highbrow Gentleman's Magazine. These two documents offer invaluable biographical information and teach us, in particular, that following the 1862 exhibition, Anderton developed a highly profitable career involving the display of his cathedral as part of a travelling sideshow in peripheral towns. The pamphlet in fact makes substantial and deliberate use of the earlier reportage, and in addition includes autobiographical sketches, an engraving immortalizing the cork master and his wife , and a selection of press-cuttings from the local popular journals showering the corks cathedral and its builder with It is a stupendous piece of workmanship to be built with such materials, and very ably shows what may be done by patience and perseverance. 32 Ill.1. James Anderton and his wife flanking a church cork's model 34 The picture symbolically juxtaposes proudly the tools of the agricultural worker and the product of his leisure time, which sit side by side in natural harmony. The Life of the Ingenious Agricultural Labourer, James Anderton, Builder and Founder of the Model of Lincoln Cathedral as Shown in the Exhibition, London, 1862, Made from One Million Eight Hundred Old Bottle Corks. Newcastle-upon-Tyne, 1871, p. 16 . 23 Hargreaves' article must be read as a double-layered story. In the first layer, the author brings Anderton's story as 'the cathedral builder' himself tells it, while in the second he introduces his own impressions upon meeting Anderton and his cathedral. A screen of irony -but also a considerable measure of respect and even admiration -separates the protagonist's narrative from Hargreaves' own observations and interpretations. Hargreaves uses two modes of representation: one is direct speech, i.e., a simple and literal rendering, sometimes through quotation, of what Anderton said, and the second is a report, cast in Hargreaves' own ironic language, of the event as perceived from the external point of view of the onlooker. Thus, as the author combines his own trenchant voice with Anderton's naïve articulation and rustic language, a complex expression emerges, forming a kind of counterpoint duet. The fusion of these two modes of expression -subtle mockery laced with admiration and amazement, on the one hand, and an earnest innocence on the other -produces a tension that tells us something about the patronizing attitude of Gentleman's Magazine readership towards popular forms of creative leisure in general and especially handicraft hobbies. Hargreaves' irony is manifest from the article's very first paragraph, an exposition in which he describes how he first came to learn of the subject of his current writing assignment: Not long ago I had the honour of seeing the modern "wonder of the World". No one will be surprised to learn that I felt greatly excited by the spectacle […] Not until a few weeks ago did I learn that the great marvel of the age was in England, was in the good old city of D-; was in a structure temporarily erected in the Market Place for its reception; and that it was open to all visitors who could command copper coinage to the extent of three pence sterling. 35 And yet, Hargreaves' admiration for the impressive model seems to have triumphed over his mockery. His subsequent description of the corks cathedral reveals his ambivalent and complex attitude towards the model and its maker. It seems that the very human encounter between the writer and the hobbyist impedes the former's efforts to render the latter invisible: the writer's sarcasm undermined by the hobbyist's story and by his speech-act. Anderton did exactly what Honneth's invisible man as social subject attempts to do: "to counter his own invisibility through an active 'striking out' that is aimed at prompting others into cognizing him." 36 'Striking out' is a metaphor designed to capture the core of the various practical efforts through which subjects attempt to make themselves noticed. And indeed, in the case of Hargreaves' account of his meeting with Anderton, out of disrespect emerges recognition. His description becomes detailed, accurate and rich, as though Hargreaves wanted to impress the structure's actual splendour upon his readers: "Before me rose up like a fairy fabric -say, rather, like a dream in Cork." 37 One alteration, nevertheless, had been made to the model since it was first displayed in South Kensington. Above one of the gates at the front of the cathedral, Hargreaves noticed a small metal plate attached close to a penny-sized slot. The slot took coins, which caused the miniature church bells to ring for the pleasure of the spectators and to satisfy their fascination with automata of various kinds. A legend, inscribed on the metal plate, declares « in plain and homely English », as Hargreaves took care to note, the following: At the International Exhibition, 1862, Thousands came there this model for to view; And thousands yet do come to hear This peal of bells above you there. The peal of bells, you all must know; Put a penny in, and off they go! 38 The inflected irony regarding Anderton's financial gains from his hobby becomes more explicit when Hargreaves states that Anderton « turned his cork into gold ». This sarcasm leaves no doubt as to Hargreaves' status as a faithful representative of the Liberal-Whiggish mind-set that regards obsessive hobby-horse as an extravagance reserved for gentlemen with time on their hands. On this view, a hobby has the right to exist only in the sphere of symbolic properties and never where there is a real need to earn a livelihood. Wherever amateurism and professionalism, or hobby and livelihood, became entangled, contempt set in. 39 Corks and a Cathedral in South Kensington: a Case study of Victorian Serious ... --- Revue d'histoire culturelle, 3 | 2021 The Encounter: The Hobbyist's Pride as a Biographical Spectacle Hargreaves describes the encounter with Anderton as a theatrical event: Anderton's assistant announces the impending entry of the 'ingenious man', and the protagonist enters the display area, with its expectant crowd, like a venerated actor. But his appearance is a complete anti-climax; Anderton is a small man dressed in his traditional agricultural labourer's smock which, as we shall see later, was destined to play a significant role in his biography: In a few moments an individual, small in stature, plain in aspect, provincial in his dialect, deficient in his 'aitches' and dressed in a white jacket or smock , made his appearance; and I soon discovered that I was in the presence of the inventor, designer, architect, builder, joiner, glazier, plumber, painter, carver, moulder, and proprietor in fee simple of the majestic pile before me. 40 In complete contrast with Hargreaves' cordial sarcasm, the biographical narrative in the second source, the 1871 pamphlet, sketches the illiterate Anderton, son of a hardworking unlettered family of saddle and bridle makers, with pride and self-esteem. The pamphlet tells the reader that young James showed extraordinary skill at traditional carving from a very early age: "His leisure moments he devoted to making ingenious windmills, out of hemlock, ornaments in rushes, fly cages, puzzle chains, &c." And it was these pursuits -despite his lack of education or his crude dialect--that "made his name so famous throughout England 41 ." What we see here, then, is a self-improvement biography that revolves around traditional hobby-making, rather than intellectual enhancement, rendering its subject, Anderton, the archetypal serious leisure actor. His leisure career evolved slowly and persistently: starting from small models, he moved on to large ones made of wood, and these foreshadowed his great future. Thus, we should read the biography of Anderton the consistent hobbyist as evidence of the existence of forms of traditional leisure, as well as of the popularity of types of self-improvement that involved devotion to the world of domestic handicraft hobbies. And this devotion doesn't come without difficulties. Ample empirical evidence shows that those who engage in serious leisure tend to describe themselves as living in a world of absolute commitment and undergoing considerable hardship for the sake of their hobby. Serious leisure activity is not a way of relaxing or an escape from daily routine. On the contrary, the intensities associated with serious leisure, sometimes bordering on madness, maintain an ambivalent relationship with daily life, of which the leisure practitioners are well aware. 42 Indeed, Anderton proudly tells his audience stories that glorify his hardships, such as the anecdote about an acquaintance who, upon first hearing about the cathedral model, suggested that Anderton "apply for a berth at a neighbouring asylum". 43 These accounts of hardship, therefore, can be considered a type of speech act through which Anderton, the invisible man, renders himself visible. Difficulties, obstacles, and their surmounting are integral ingredient of the experience, the rhetoric and the biography of the serious leisure actor as a someone seeking recognition. Hargreaves describes Anderton's life story as a central part of his narrative: Our journey round the cathedral was in a great measure biographical […] How he came to conceive the idea of constructing a minster in cork […] He himself could […] he spoke quite solemnly on the point, and I concluded from his manner that he regarded the conception as a kind of visitation from some supernatural source, and looked upon himself as a man with a mission, compelled to execute some inscrutable decree of fate. 44 Asked to explain what had driven him to such a demanding activity, and failing to find reasons in the actual world, Anderton came up with a kind of metaphysical explanation -as though some extraneous, occult power had told him to build the corks cathedral. It is the kind of rhetoric that reflects what Tomlinson refers to as a 'culture of commitment', without which serious leisure loses its unique substance. In this spirit of commitment, the hobbyist must create his own timetable and set himself challenges binding by hardships. Exacting difficulties are central to enhancing the significance of the hobby activity, and Anderton indeed imposed upon himself a number of such testing complications. For instance, he chose to erect his cathedral strictly from individual used corks, rather than employing bought pieces of cork or any other material, such as wood for a frame and base or paint for a finishing touch. One further self-imposed constraint was Anderton's commitment to do all this only in his "hours of leisure", that is to say, at night. All day long he must toil at his ordinary tasks, and then when evening came, must slave at his cathedral, instead of dozing at his own fireside, or lounging at the alehouse with his pipe in his mouth and his tankard at his elbow. 45 It is significant to note that Anderton describes the time devoted to work on his hobby with the term 'leisure', and not with any of the purportedly common phrases, such as 'recreation time', 'pastime', or simply 'free time'. 'Leisure time' is qualitatively different. It is a state of mind, a feeling, a mood: a sense of absolute liberty, including the liberty to imbue free time with meaning rather than leaving it an empty technical notion that refers to the unoccupied hours that remain after work and other everyday duties. Thus, Anderton effectively illustrates that, as early as the mid-nineteenth century, leisure time -as an actual and quotidian notion -was perceived among serious leisure devotees not as an abstract idea but as a praxis dominated by the typical features of a work discipline, such as necessity, skill, persistence, hardship, difficulty and an exhausting routine. To demonstrate his own exhausting routine, Anderton told his spectators that, living three miles away from the city of Lincoln, he could only see the cathedral from considerable distance and was forced to walk back and forth many hundreds of times to take in all the details: "One small detail … cost him no less than eighteen miles walking". 46 Collecting the corks was, of course, itself very toilsome. A professional cork cutter estimated that the cost of the cork used in the model would have added up to £62, so buying the raw material was out of the question. Anderton began by collecting used corks himself, but as his story reached more and more people, members of the community started supplying him with an ongoing stream of corks. 47 In this respect, Anderton compromised his vow to abjure outside help, proving that he too, like other serious leisure participants, needed at least the recognition of his community: He picked up all the corks he could find in the streets of Lincoln, or glean from the river Witham; the older they were the better for his purpose, as they would impart a mellowed air of antiquity to his cathedral; other people, as he humorously observed, might have the liquor if they liked, but give him the corks, and thus he should have the best of the bargain -a sentiment which I fancied was but faintly endorsed by the audience [...] 48 This kind of relationship between the hobbyist and his community implies the dialectical nature of the serious leisure praxis: individuation on the one hand, and the necessity of the community on the other. 49 Commenting on the link between individuation and recognition, Honneth argues that […] human individuation is a process in which the individual can unfold a practical identity to the extent that he is capable of reassuring himself of recognition by a growing circle of partners to communication. Subjects capable of language and action are constituted as individuals solely by learning, from the perspective of others who offer approval, to relate to themselves as beings who possess certain positive qualities and abilities. 50 The granting of recognition depends, consequently, largely upon appreciation of the subject's achievements and his ʽpositive qualities', taking into account his hardships and the extent of his investment . According to Honneth, the subject's self-esteem depends largely on that which his social surroundings consider valuable and significant. Since not everything human beings do is regarded as equally valuable, a persistent struggle is conducted by groups and individuals who experience a lack of recognition and respect. The societal significance of serious leisure activity, then, is not a matter of a solitary ego appraising itself so much as an intersubjective process aimed at gaining respectability and recognition. Often, however, the difficulties of the dedicated serious leisure actor also spill over into his family life. Anderton's description, as articulated by Hargreaves, of his relationship with his wife, who did not take kindly to the cathedral project, sheds interesting light on the domestic aspect of handicraft hobby and the tensions that could arise in the narrow and suffocating confines of working-class homes: I regret to state that the patient architect was not blessed with an equally patient wife. The good lady, finding corks on the table, corks on the floor, corks in the kitchen, corks in the chamber, corks in every quarter, frequently lost her temper, and « banged » them at the head of her husband. 51 Mrs Anderton's diffident attitude towards her husband's hobby is presented with humour and jolly exaggeration, yielding a domestic melodrama that reproduces representational conventions regarding the home, with a central role reserved for the ever-prudent woman. Still, Mrs Anderton's disapproval reflects faithfully the objective difficulties posed by a corks cathedral in excess of one and a half meters high, three meters in length, and a little over two meters wide to a family living in a cottage the size of a living room. The essence, or moral, of this family farce is obvious: the harder the conditions under which the hobbyist works, the closer his serious leisure toiling approaches a calling. --- The Exhibition: A Worker's Smock in South Kensington Work on the corks model went on for ten and a half years, consuming almost all of Anderton's free time. After sunset, he would dedicate himself to his hobby, toiling until midnight on Saturdays and until two a.m. on weeknights. It is likely that the work continued into Sundays as well, occupying at least part of the day of rest and including walks back and forth to Lincoln Cathedral -otherwise it is hard to explain a ten-year time span for such an enormous undertaking. What went on in the Anderton household during these years did not stay unknown: as his fame spread, Anderton's home became a kind of pilgrimage site, and what had hitherto been his private affairs came to be, to an extent, a matter of public interest. 52 When the model was complete, according to the pamphlet, Anderton took it, "on the advice of friends, to the 1862 International Exhibition". 53 Anderton's journey with his model to London was, like the rest of his life, obstacleridden. As the result of an accident, the model was seriously damaged, and this "put Anderton's patience and persistence to a grave test". But there was more to come. London posed tough social challenges. Hargreaves chose to describe Anderton's strangeness and alienation in the metropolis through an encounter between Anderton and a well-to-do London relative -a meeting whose unforeseen consequences were to change the course of Anderton's life. Anderton's strangeness is highlighted through the linguistic jumble generated by the combination of dialect with Hargreaves' ironical observations: It would seem, however, from a confidential communication with which the Ingenious Man favoured us that his opulent relative "axed" about his health, and his family, and his prospects in life and London. The gentleman also "axed" about his model, declaring with the freedom which wealth confers, that his nephew must be a "rum fellow" to dream of making a cathedral in cork. Far more important still, as it then appeared, he "axed" his visitor about his clothes; and on learning the low state of his wardrobe, this remarkable and very exceptional relative, instead of abandoning the poor artisan on the spot, took him to a tailor's, and had him promptly arrayed in habiliments which would bear the scrutiny of the metropolitan eye. 54 And so, Anderton, now dressed for the occasion, stood beside his cathedral, ready to regale the audience with his explanations and stories but also to receive and enjoy their generosity. But, alas, his Sunday best did not serve its purpose: his entire receipts for many days did not exceed one shilling! How account for this mournful fact? Possibly, thought he, he did not look stupid enough for the post […] An acquaintance happening to enquire into his receipts solved the mystery. « Why James », said he, « you have got far too fine a coat on your back! How can you expect people to give to a gentleman in broad cloth? Try your own old smock! » Next day the Patient Man took his stand by the cork chapter-house in his labouring attire; and what does the reader think was the result? Why; in the course of a few hours, he pocketed £44 in good solid cash! From that time, money poured in; and when the Exhibition closed, the Lincolnshire husbandman had realised the magnificent sum of £800 without selling a single cork in his cathedral. 55 The apparent respectability bestowed by Anderton's new suit -functioning like a costume -did him a disservice, for in the gentleman's system of values, no money should be paid for leisure activity. Thus it was only once Anderton changed back into his traditional agricultural worker's garb -that is to say, from the moment he replaced the costume with a uniform -that the money started flowing. From the point of view of the audience, which consisted, in the first weeks of the exhibition, of the upper classes, Anderton's good old smock acted as a familiar code. 56 It allowed him to transform himself into folksy show case as his workman's smock -functioning as a uniformrelocated him and his model in the domain of toil and labour. This meant that the smock fitted the dominant Whiggish ideology, which regarded leisure and work as wholly separate categories. Key to the turning of Anderton's luck, this incident concerning his dress was to have a powerful effect on his view of himself. The conversion of the meaning attached to his traditional work clothes came to be a landmark in the story of his life, as Hargreaves renders it somewhat sarcastically: Upon the builder of the minster himself the incident made a profound impression. His gratitude to the garment which had effected such a change in his fortunes was so great, that he resolved to wear a white smock to the day of his death. No more fashionable coats for him […] Indeed I am strongly disposed to believe that if her Majesty were to command his presence at court to receive the honour of knighthood, he would make his appearance in the famous white smock which had turned his cork into gold. 57 While, originally, the linkage between the work smock and the corks cathedral -as a product of leisure -was rather loose, once Anderton donned his smock as a uniform, the smock came to serve as the platform for his serious leisure career and a token of his emerging respectability. Consequently, the smock completely lost its functional link to the work domain and was re-charged with symbolic meaning. In the decade following the International Exhibition, Anderton converted his hobby into a successful career. Over the course of his life he produced only two more models: a pair of corks churches, inside one of which he reproduced the scene of his own wedding. With his three models and his white smock, Anderton attained what McKibbin calls "ideal work" -in terms both of his material prosperity and of the construction of his identity and selfhood. The agricultural worker clearly became an affluent man, with the display of the cathedral at the 1862 International Exhibition yielding an initial sum of £800, and a further regular income provided by the travelling sideshow at provincial towns. A few days at a small town could earn him £50. All in all, from the first day it went on public show, the corks cathedral brought in about £3000. Yet these financial gains, however important, did not overshadow the mental and moral gains, the sense of potency, self-worth and recognition his hobby had provided him, as Hargreaves compelled to admit: For of all good properties in this world, one of the grandest is the power of saying to difficulties -"Out of my way! Don't dream of daunting me"; […] For here was a man who had sacrificed all the leisure of more than ten years […] Perhaps, however, the fact which impressed me most of all about the Son of Genius was the sense of victory achieved. "I am the man as did it all", exclaimed he, with an air of triumph […] He had struggled-had fought-had vanquished. […] I could not but admit that it was a grand thing to be a conqueror, even if it be only in cork. The Patient Man was now the Triumphant Man. 58 The story of this self-sufficient 'Triumphant Man' thus aptly illustrates Geoffrey Crossick's argument that "The will to seek [this] independence, and the moral qualities needed to achieve it, were proof of respectability". 59 Yet Anderton 'rose in the world' in another, more profound sense: he shifted his workethics -industriousness, skilfulness, hardship, patience -to the domain of leisure activity, turning by this the former into a symbol of autonomy rather than a sign of subjection. The devotion and commitment transformed his hobby-toil into a kind of secular pilgrimage whose end laid the prospect of self-fulfilment and self-realization as a respectable human being as well as a legitimate citizen. In other words, the marquee and everything that occurred within -i.e., the cork spectacle -turned into 'representation of a worth', an expression of the on-going --- ABSTRACTS The article points to the culture of productive and creative leisure among the mid-Victorian English working classes from the standpoint of domestic hobby-making, largely ignored by the historiography of leisure. Relying on previously unpublished primary sources, it analyzes a test case centered on a Lincolnshire agricultural worker whose model-building hobby became a lucrative career and a platform for self-improvement. Though his tale is fairly eccentric, it nevertheless demonstrates the broad range of popular leisure practices, mainly handicrafts hobbies, among working men and women. These leisure habits, the article argues, challenge the historiographic conventional dichotomy between work and leisure. To address this historiographical lacuna, the article proposes using sociological models such as 'serious leisure' hitherto excluded from the historical research, which explain the involvement of workmen in labour-intensive hobbies as a measure of their sense of self-worth and autonomy. It concludes that a devoted hobby career was not just an effective instrument of self-improvement, but also an expression of the legitimate demand of the working classes for recognition and acceptance into the civil body.

As long ago as 1975, Gareth Steadman Jones noted that historiography on Victorian leisure has largely ignored the concrete ways in which workmen, artisans, shopkeepers, and other members of the working classes, organized their private and domestic leisure activities. As a result, he argued, the "cumulative picture conveyed by research into popular recreation and leisure is out of perspective." 2 Its «sharply outlined foreground» is occupied by evangelical improvers of the public mores, Methodist activists, aristocratic patrons, utilitarian employers (who offered leisure activities subject to their calculations of increased output), well-intentioned reformers, goodhearted philanthropists and skilful leisure entrepreneurs. Behind these figures, hardly visible, are the blurred features of the urban masses. Occasionally, their vague profiles are illuminated by incidents of class conflict and some forms of resistance, but typically, workmen's leisure is associated by the historiography with uninhibited drinking, gambling, absenteeism, or popular and ragged entertainment. It is, Jones argued "as if the only records of the bourgeoisie came from the bankruptcy courts, the only evidence of marriage from divorce petitions." 3 Corks and a Cathedral in South Kensington: a Case study of Victorian Serious ...

Introduction Industry 4.0 will allow new forms of interaction between humans, machines and software systems. Such phenomenon are known as the industrial Internet of Things, Services and People , where interconnecting things, services and people via the Internet will improve data analysis, optimise operations, boost productivity and flexibility, enhance reliability, save energy and costs, and generate innovative e-services for smart factory environments [1]. Smart devices and smart wearables, such as data goggles or tablets, will increasingly make it possible for humans to interact with so-called "social machines", and powerful social software systems will guide operators in increasingly complex cyber-physical systems , including smart machines and supply chains, as temporarily equal partners at the shop-floor [2]. Moreover, with the emergence of the Social Internet of Industrial Things , manifested as smart machines with social properties , namely "social assets", such will share their status information and cooperate via enterprise social networks to achieve a common goal, an optimal smart factory production system [3]. This paper explores the role of the Social Operator 4.0 in the context of smart and social factory environments, where humans, machines and software systems will cooperate in real-time to support manufacturing and services operations. Furthermore, a high-level Social Factory Architecture based on an 'adaptive, collaborative and intelligent multi-agent system' will be introduced in this paper as a proposal to enable such cooperation, as well as, some production scenarios envisioning how social operators, social machines and social software systems will communicate and cooperate with each other via enterprise social networking services to accomplish production goals in the Social Internet of Things, Services and People. --- The Social Operator 4.0 and its Social Companions An Operator 4.0 is defined as "a smart and skilled operator who performs not only 'cooperative work' with robots, but also 'work aided' by machines as and if needed, by means of human cyber-physical systems, advanced human-machine interaction technologies and adaptive automation towards 'human-automation symbiosis work systems' " [4]. Moreover, a Social Operator 4.0 is a type of Operator 4.0 [4] that uses smart wearable solutions together with advanced human-machine interaction technologies to cooperate with other 'social operators', 'social machines' and 'social software systems' in order to communicate and exchange information for mutual benefit and align/alter activities as well as share resources so that more efficient results can be achieved at the smart and social factory of Industry 4.0. With the emergence of smarter factory environments and the Social Operator 4.0, smart wearable solutions [5], HMI technologies [6], and adaptive automation strategies [7] will play a significant role when combining different interaction mechanisms and sharing and trading control strategies between social operators, social machines and social software systems towards a 'social factory' [8]. A Social Factory is a live enterprise social network with powerful middleware and analytics backend to improve the connection between social operators, social machines and social software systems working together in a smart production environment, and the data created within the networking process [8] towards a sustainable 'learning factory' [9] [10]. According to [8], a social factory should be able to provide the right information and the right time and place to the right person, machine and/ or software, support humans under any working conditions, engage humans to contribute to new knowledge creation, treat humans, machines and software as equal partners, and learn from all this socialization of knowledge by explicitising it. In this context, the faithful social companions of the Social Operator 4.0 will be other social operators, social machines and social software systems. The Social Operator will be able to interact with these other social entities, communicate and exchange information, align or alter activities, share resources, and work together on joint tasks. --- Social Factory Architecture: Components & Technologies The Next Generation Balanced Automated Production Systems [11] [12] consist of 'hardware' , 'software' and 'humanware' components coexisting with mechanical and human autonomy as well as with human-machine collaboration capabilities where autonomy and synergies between human, machines and systems create a social sustainable and competitive factory. The next subsections will detail selected areas of relevance. --- Hardware: Smart Wearable Solutions and the Internet of Things Several smart wearable solutions, part of the IoTSP paradigm, have been designed for a variety of purposes as well as for wear on a variety of parts of the body, such as head, eyes, wrist, waist, hands, fingers, legs, or embedded into different elements of attire [5] in order to tech-augment operators physical, sensorial and cognitive capabilities [12]. Similarly, a diversity of 'things' has been embedded with electronics, software, sensors, actuators and network connectivity in order to augment their capabilities. Such is the case of smart machines, now capable of operating autonomously , avoid and correct processing errors , learn and anticipate future events , and interact with other machines and systems [13]. --- Software: Actively Adaptive Agents for Human-Automation Symbiosis The essence of Agent Technology is to mediate interaction between human beings and technological artefacts. Hence, AT has been considered an important approach for developing socially sustainable factories, where human agents can cooperate with other human agents and artificial agents as hybrid agents and emerging agents to keep their agenthood [12], and therefore optimally leverage human skills and automation capabilities at the shop-floor in order to provide human inclusiveness and harness the strengths of human beings and machines to achieve new levels of efficiency and productivity that neither can achieve alone [14] and that not compromise production objectives [12]. Agents' Agenthood is defined by Wooldridge & Ciancarini [15], "as a system with the following properties: autonomy, reactivity, pro-activeness and social ability". According to Yamasaki [16] in Xu et al. [17], an Active Interface is "a type of human-machine interface that does not only wait for users' explicit input but also tries to get information from users' implicit input, and external environment. Based on the gathered information, it acts spontaneously and keeps the system in advantageous conditions for its users", with users being human agents or artificial agents in this case. Furthermore, an Interface Agent "can learn by continuously 'looking over the shoulder' of the user as he/she/it performs actions against other artefacts, and provide the users with 'adaptive aiding' as well as of alternating the activities instead of human" [18]. In this sense, a human or machine in the physical world will coexist with its associate human or artificial agent in a cyber-physical environment, so that as an intelligent agent can evolve by itself as a human or machine user's proficient level improves [18]. For humans, such learning/ evolution could be tracked by means of Advanced Trained Classifiers [19] [20], while for machines the use of different Machine Learning Techniques [21] might be considered. The use of intelligent and actively adaptive collaborative multi-agent system to coordinate the support of manufacturing and services operations at the shop-floor is proposed to achieve human-automation symbiosis [11] [12] at the social factory and its smart production environment. In such a set-up, active interfaces within the social IoTSP of the factory, as interface agents, will allow to gather information from the social operators, social machines and social software systems agenthood status and send a request for cooperation to other human or artificial agents in order to keep their agenthood, and therefore production running. In this sense, the social factory should be considered as a 'collaborative environment of intelligent multi-agents' [22], where humans and machines 'twin agents' use interface agents to facilitate communication between them and the cyber and physical worlds, and other agents such as broker agents support tasks allocation and control sharing & trading [23] in the cyber-physical production environment. Fig. 1 presents a high-level Social Factory Architecture based on an Adaptive, Collaborative and Intelligent Multi-Agent System . Fig. 1. High-level Social Factory Architecture based on an ACI-MAS Such intelligent MAS architecture will aim to facilitate communication between the social operators, social machines and social software systems, assist them to distribute tasks and share & trade control in collaborative tasks, maintain as much as possible human inclusiveness without compromising production objectives, and record and track humans and machines evolution as their proficient levels improve through learning and practice. The following agents will operate in the social factory fulfilling different roles:  Human agents -represent the humans and their capabilities in the system and are a duo consisting of human + interface agent, which allows a human to interface with the rest of the system.  Artificial agents -represent the machines and their capabilities in the system and are a duo consisting of machine + interface agent, which allows a machine to interface with the rest of a system.  Interface agents -represent a set of interaction rules and conditions for supporting humans and machines interfacing with the rest of a system; their 'active' feature allows the interface agent to constantly learn and evolve its rules by being trained by observation, imitation, feedback and/ or programming in order to be able to personalise the assistance to its user agent) [24] and such assistance be provided in an adaptive and dynamic manner, and only when required, to help the human or machine in difficulty to main his/her/its 'agenthood' at the tasks at hand by different automation or mechanisation invocation strategies [11] [12] .  Broker agents -represent the levels of automation [25] [26] available in the system and the rules for sharing and trading control in human-machine cooperation in order to efficiently allocate labour and distribute tasks between the automated part and the humans at the workstations of an adaptive production system [11] [12] [27]. --- Humanware: The Human Factor in Adaptive Automation Systems Humanware is defined as "a function of 'leadership', 'followership' and the reciprocal interaction between the two, where leadership is a leader's willingness to fulfil both task accomplishment and group maintenance and followership is followers' voluntary desire to follow their leader and to achieve their tasks" [28]. In the social factory, the Social Operator 4.0 will be empowered with technology and thus encourage collaboration with other social operators, social machines and social software systems. At the same time, the Social Operator 4.0 will be monitored with the help of ATCs [19] [20] and other detecting and preventing error approaches like "digital poka-yokes" [4] [29] for 'poor humanware' in order to avoid human error and provide a virtual safety net. In this context, the main goal of adaptive automation, based on active interface agents and brokerage agents, is to prevent errors and to reduce out-of-the-loop performance of the humanware by preserving an adequate level of situation awareness and mental workload [30], while providing a crucial perception of empowerment materialised into an appropriate level of freedom [31] for the social operator [4] [12]. --- Enterprise Social Networking Services & Production Scenarios Enterprise Social Networking Services focus on "the use of mobile and social collaborative and interface methods to connect the smart operators at the shop-floor with the smart factory resources, including other social operators, social machines and social software system. Such connections include 'social relations' among the workforce and between social operators and smart things and services to interact, share and create information for decision-making support and/or alignment or altering of activities and their related resources to achieve a compatible or common goal" [Extended from 4]. In this case, the social operator is considered the main focus and the following scenarios are always centred on the Social Operator 4.0. While there are many other scenarios possible and worthwhile to be analysed, this is not the focus of this research work. --- Social Operator Networking Scenarios One of the possible collaboration scenarios is a Social Operator interacting with other social operators. In such, a Social Operator to Social Operator scenario, the use of adapted social network services like a B2B Facebook or Twitter that are capable to facilitate, e.g., one-to-many communication, incorporate location based services and real-time sharing of media or allow for facilitating a dynamic community based capability matrix. Such E-SNS, supported by an intelligent and actively adaptive collaborative MAS, can enable opportunities and real-time multimedia communication capabilities between social operators using smart wearables that can empower the workforce to communicate and contribute with their expertise to different problem-solving scenarios at the shop-floor by bringing together the right people with the right information and the right time to address a situation without certain limitations . --- Social Machine Networking Scenarios Enhancing the 'senses' of the Social Operator 4.0 through, e.g. smart wearable tech, enables her/him/it to engage in social interaction and communication with social machines within the E-SNS. SIoIT can connect, through 'interactive machine learning', smart operators with smart things in social networks for sharing information and exchanging messages about their location, condition, operation status and availability for improving at machine level the asset reliability and at production line level the material flows and resources productivity towards social problems-solving and optimisation of the production system. --- Social Software Systems Networking Scenarios Similarly to the Social Operator 4.0 interacting with social machines , being 'always-on' and connected enables the social operator to naturally engage in communication with social software systems. This can be envisioned as a 'virtual assistant' with an Artificial Intelligence backend, like IBM Watson, where the social operator can either actively ask questions that the system will answer based on available information/data or, passively, the social software system might monitor the environment and behaviour and provide pro-active information and/or decision making support through voice, video or holographic communication channels. This paper is suggesting a Social Operator 4.0 concept in the context of smart and social factory environments. Furthermore, a high-level Social Factory Architecture based on an adaptive, collaborative and intelligent multi-agent system was introduced taking advantage of a 'multi-agent approach' for interconnecting and interoperating multiple agents across an enterprise social network to provide solutions by means of temporary collaborations in situations where expertise and capabilities are spatially distributed. Finally, some production scenarios envisioning how the Social Operator 4.0 will communicate and interact with other social operators, social machines and social software systems have been presented.

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers. L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction Gold mining has a long history in Indonesia , because gold has long been a key commodity globally . In some instances the extraction of gold and related activities has gained support from the various levels of the Indonesian government and locally affected communities. In Banyuwangi regency, religious teaching and development phraseology have been combined in support of mining activities and as a way to obtain consent from the affected communities. This support has been led by a religious organization, called Nahdlatul Ulama . Such action from the nu could help to ensure the success of the gold-mining operation, including by oppressing the anti-gold-mining movement, as shown in the case of the Tumpang Pitu Hills' gold-mining conflict.1 Medeiros argues that the role of religious organizations in civil society creates a political hegemony for the dominant and subaltern classes through ideology, culture, and consensus. Studies have shown that gold-mining activities cause many negative effects on the affected communities, including environmental degradation, air and water pollution, and socio-ecological damage.2 Furthermore, in Banyuwangi, gold-mining conflicts have often occurred due to competition for employment, environmental damage, and water pollution, and social jealousies between pro-and anti-mining groups.3 These problems have prevented local peasants from accessing land in the hills, the source of their livelihoods , which has led to resistance from the affected communities in Sumberagung village where the gold mining takes place. Bijdragen tot de taal-, land-en volkenkunde 179 5-37 As a consequence, various social groups, including farmers, fishermen, and young people, have opposed all mining activities since 19974 and have established social movements to this end in Banyuwangi. In both 2015 and 2017, there were clashes between the anti-gold-mining movement, the mining corporation, and the local police, which included the involvement of religious organizations. Since then, the anti-mining movement has been plagued by internal divisions, as well as experiencing external pressure from religious and social nationalist organizations in Banyuwangi that aim to 'safeguard the state' and 'safeguard' the interests of the extractive industry in the Tumpang Pitu Hills operated by pt. Bumi Sukses Indo .5 The ongoing situation is described as being a 'battleground' , and has led to various forms of exclusion or oppression . Although objections to gold mining have been strongly voiced by Banyuwangi's anti-mining movement, the central and local governments have remained silent due to the 'golden share' of 10% that is donated by pt. Merdeka Copper Gold Tbk to the Banyuwangi government. In 2016, the Kementerian Energi dan Mineral of the central government identified the gold-mining operation as a vital national strategic asset in Decision no. 631 k/30/mem/2016,6 and it was highlighted as a source 4 Permadi and Dewantara 2018; Ike Ningtyas, 'Pasca rusuh, Yenny Wahid mundur dari Merdeka Copper and Gold ' , Tempo, 30-11-2015. https://nasional.tempo.co/read/723504/pasca-rusuh -yenny-wahid-mundur-dari-merdeka-copper-and-gold . 5 The corporation pt. bsi is a subsidiary of pt. Merdeka Copper Gold Tbk. It is a national corporation with its headquarters in Jakarta. The corporation engaged in the gold-mining business in the Banyuwangi regency after securing gold-mining licence No. 188/547/kep/429.011/ 2012 from the local government of Banyuwangi . 6 See Ismail et al. 2018 and www.bumisuksesindo.com. Gold mining began in 2016 and by March 2017, the corporation had extracted 25,063 ounces of gold and 6,420 ounces of silver; in 2018, 167,506 ounces of gold and 140,738 ounces of silver were extracted. See F.U. Ulfah, 'Sepanjang 2019, produksi emas mdka tumbuh 33.15 persen' , Bisnis, February 2020. https://market.bisnis .com/read/20200224/192/1204973/sepanjang-2019-produksi-emas-mdka-tumbuh-3315 -persen . By 2019, this had increased to 223,042 ounces of gold and 409,492 ounce of silver, before a reduction in annual quantities in 2020 to 157,175 ounces of gold and 549,440 ounces of silver. By December 2020, the mineral resources of pt. Merdeka Copper Gold Tbk were estimated at around 32.8 million ounces of gold and 85.3 million ounces of silver . Based on these figures, the central government obtained a tax income of idr 45,860,000,000 in 2016, increasing to idr 54,760,000,000 in 2017. In 2018, the tax paid increased significantly due to the phase of extraction, with the central government receiving idr 514,024,000,000; in 2019, idr 688,717,000,000 was paid in tax. Furthermore, the corporation shared royalties with the local government of Banyuwangi of idr 66,850,000,000 in 2017, idr 125,078,000,000 in 2018, and idr 165,258,000,000 Downloaded from Brill.com 02/23/2024 04:54:32PM via Open Access. This is an open access article distributed under the terms of the CC BY 4.0 license. https://creativecommons.org/licenses/by/4.0/ alkatiri and kiwang Bijdragen tot de taal-, land-en volkenkunde 179 5-37 of income for the economic development of the territory . Empirical debates and studies of social movements have not represented all types of mining conflicts . This is because most of the literature on mining conflicts and social movements has focused more on Western societies, where attention is mostly paid to the political dimensions and less to the social and cultural perspectives . Having said this, a growing number of studies exist on social movements in developing countries , including ones dealing with the role of religious and social organizations and the socio-political context. Some scholars have underlined and emphasized the decline of social movements as an important theme , but such a theme is unpopular with other social movement scholars . Moreover, it is simply not described in the strategic and tactical methods mentioned in some of the literature . Therefore, Gamson has encouraged scholars to construct better theoretical arguments concerning the movement's decline . In Indonesia, research around the role of religious organizations in goldmining conflicts is still limited. The existing literature dealing with conflicts around mining in Indonesia has not touched on the role of religious-nationalist organizations in specific local, social, and political contexts. There are very limited studies on the involvement of religious-nationalist organizations in gold-mining conflicts. For example, Arti shows that the establishment of a sustainable ecological movement by Catholics and Indigenous religions in Manggarai has been able to stop mining activities in the regency. Arti argues that the establishment of the local anti-mining movement was driven by religious forces and shaped by the interactions between Catholic and Indigenous religions for centuries, and was successful in pushing the district government to issue a moratorium on mining by pt. Aditya Bumi Pertambangan. However, other studies of gold-mining operations on the Tumpang Pitu site have found that religious organizations take the opposite approach. Furthermore, there have been two other findings related to the role of the nu in the gold-mining sector. First, Alfian has demonstrated that the nu, as a religious organization, has engaged a global capitalist entity that influences the nu's position and thinking concerning the mining project in the Tumpang Pitu hills. Alfian's article highlights the internal dynamics among the in 2019. See K.A. Rido, 'Menambang emas tanpa melupakan tanggung jawab sosial' , Berita Jatim, December 2020. https://beritajatim.com/politik-pemerintahan/menambang-emas -tanpa-melupakan-tanggung-jawab-sosial/ . Bijdragen tot de taal-, land-en volkenkunde 179 5-37 nu's prominent leaders, which indicate that while several leaders of the nu have rejected the mining operation in Banyuwangi, others have supported and benefitted from it. Second, the research outcomes of Wardhani and Cahyati demonstrate that the anti-mining movement in Banyuwangi has used different methods and formations, framing and shaping the impacts of mining on the community in a way that ensures wide support from its members. The interesting point is that pt. bsi has established relational ties with both political actors and religious organizations, including the nu's members, in order to support the issuing of the licence for the corporation. Those previous studies have limited their discussions to the resistance of religious organizations, along with the affected communities, to mining companies; the internal dynamics of the religious organizations; and how the religious organizations maintain their relationships with the company. However, these studies have rarely addressed the local, social, and political conditions, such as the involvement of the religious organization in protecting the interests of the gold-mining company. This article addresses an important issue: the decline of the anti-gold-mining movement in Banyuwangi due to the involvement of religious-nationalist organizations in the 'pro-mining' counter-movement. It is essential to understand that the religious organization, the nu, has played a significant role in obtaining consent from the local community both through adding mining investment slogans into religious teaching and by coercion, which has resulted in the weakening of the anti-mining movement in Banyuwangi regency. This article analyses three important elements that have contributed to the decline of anti-gold-mining discussions in Banyuwangi. First, it identifies the subgroups within the anti-mining movement and analyses the divergence of agendas within it. This divergence has weakened the anti-mining movement internally. Second, the Gramscian hegemony perspective is deployed to analyse the involvement of the nu's elites in accepting mining investment and linking investment slogans with religious teachings about the use of natural resources in order to persuade the common people to think as they do. Third, the article underlines the roles of religious-nationalist groups in safeguarding the community and state from communist ideology, and assesses the use of political-ideological rhetoric to diminish any anti-mining movement, which thereby exposes the religious-nationalist groups as a 'pro-mining' lobby with strong ties to economic and business interests within the extractive industry. --- 2 The Decline of the Movement, Hegemony, and the Role of Social Organization: An Analytical Framework Social protest regarding mining activities has often been analysed by scholars in both developing and developed countries to establish the causes of social conflict in this sector . Scholars have found several causes of conflict related to the demand for, and securing of, the mining resources . Social conflicts in the mining sector have been connected to the unequal relationship between corporations and developing countries; conflicts between the management of corporations and labour ; the environmental impacts on local communities; the repressive regimes working in the mining industry and human rights ; and Indigenous rights and livelihoods in rural areas . In a social context, Andrews et al. declare that the dynamic social relationships and conflicts between a corporation and an affected community have often been underlined in social research studies. Studies show that to challenge a corporation, the affected community establishes a social movement supported by activist groups to voice their disapproval of the project, either during the initial phase or during ongoing mining operations. However, while some social movements have developed and succeeded, many have failed to achieve their main aim due to 'negotiation' ; the co-optation of leaders by opponents of the movement; repression by the authorities and other forms of social control ; and the dissemination of false information by various actors, including the corporation, the government, security institutions, and social groups that take an opposing stance . Another well-known mechanism of controlling a social movement is through hegemony. According to Antonio Gramsci, hegemony is connected with power and domination concerning life values, norms, and the culture of dominant social groups over other weaker or subordinate groups , using consent as the main method , with coercion or domination as other possible means . Funfgeld underlines the consent aspect as being a convincing way for dominant groups to impose certain ideas on weaker groups. Consent can be derived from education and local values, where the hegemony is not challenged because the education system does not teach its students to think critically; on the contrary, education is considered the essential pathway to gaining consent to continue the hegemony Bijdragen tot de taal-, land-en volkenkunde 179 5-37 . This approach is promoted by the intellectuals or civil society within the society who work for the dominant groups . The intellectuals are members of social institutions such as schools, churches, political parties, the mass media, and others, who implement and maintain the dominant group's preferred ideology and values to subdue society's thoughts and desires . In Funfgeld's view , each intellectual group develops its own model of organizing consent. In Indonesia, social conflicts between pro-investment stakeholders and the anti-mining movement can be analysed using Gramsci's concept of hegemony , particularly in terms of the decline of a movement. Such a decline is the result of both the use of enforced consent methods and the political approaches taken by intellectual elites. Politically, such a decline can therefore be seen as a consequence of the Indonesian political-economic power structure and its pursuit of neoliberal policies. The oligarchic relationships inherent to this political-economic structure have ensured the establishment of alliances that benefit these businesses with both central and local government, and not only with government officials and private actors, but also with thugs and paramilitary groups that pressurize, threaten, and use violence against social movements or local protest groups . This has led to predatory domination and coalitions forming over public resources . As the dominant group, a corporation is politically powerful in mining projects. Persson writes that dominant groups can extract consent from subordinate groups through the use of development slogans that indicate that the project investment is considered legal, legitimate, and bringing prosperity to all stakeholders. The corporate slogans about prosperity have been used to establish hegemony over communities, in particular through implementing social assistance in the form of a csr programme . While such programmes have been seen as a way to control a movement by offering social and economic assistance to affected communities , taking this approach actually maintains and secures the company's interests . Besides these social and political strategies, religious and cultural values could also be used as complementary ways to limit the impact of a social movement. The decline of the social movement in Banyuwangi regency has been shown to be the result of a combination of techniques. Religious and nationalist organizations have taken roles that directly and indirectly support corporate and local government policy regarding the gold-mining project. The religious leaders have strong ties with the majority of the followers of these religious Bijdragen tot de taal-, land-en volkenkunde 179 5-37 organizations, including the nu and its members. The majority of the nu's members are grass-roots followers who respect the religious leaders for their religious teaching and cultural values. Zulkifli has stated that the relationships engendered by the importance placed on the religious doctrines and cultural values of the nu by the organization's followers are carefully utilized by the kyai. For most scholars and followers, it is still prohibited to reject or disobey any command or instruction of the kyai or gus, in what Fox and Dirjosanjoto describe as a patronage relationship . This combination of social, political, and cultural approaches is used by religious-national organizations to reduce the impact of the social movement, weakening it, and thereby assisting the corporation in gaining consent from local communities and maintaining its strong position vis-à-vis the mining operation project, as well as putting pressure on the anti-gold-mining movement. --- Methodology According to Tarrow, research into social movements should be carried out when an event has reached its peak and the decline of social movements should be studied in the context of its development, particularly with regard to the influence of the local political context. A lack of political support may lead to powerlessness . This study took a qualitative approach based on the observation of several protests, particularly in 2019 and 2020, and of the livelihoods of farmers and fishing communities in the villages of Sumberagung and Pesanggaran as the main locations of our field research. These two locations were chosen for two reasons. First, the village of Sumberagung is affected directly by mining operations; therefore, it has become the centre of the anti-mining movement. Second, the village of Pesanggaran is located near the mining operation and is the place where two key social groups have originated: one consisting of farmers and members of the fishing community, which is considered to be the first anti-mining movement group, and a second, composed of former illegal miners and groups of youths. The villages were visited three times-from October to November 2018, in July 2019, and from January to February 2020-to study the lives of farmers and fishermen as the main opponents of the mine, as well as looking at the anti-gold-mining movement's progress and the pro-mining movements' responses. Interviews were conducted with four prominent figures in the antimining movement and two in the pro-mining movement, and subsequently with others, using the snowball technique to make contact. These individuals Bijdragen tot de taal-, land-en volkenkunde 179 5-37 included religious leaders in the nu, the five heads of the villages, two martial arts leaders, and several members of the anti-mining movement from the farming and fishing communities. In addition, information was also gathered from three other villages through focus group discussions, particularly with those in the fishing and farming communities. Moreover, additional information was also gathered from officials of the sub-district and district of Banyuwangi. Structured interviews were also conducted with the top managers of the corporations. The collected data were useful for analysing and mapping the actions of both movements and their affiliations and interests in order to fully understand the movements. The combination of the snowball and deliberate methods was used to ensure that relevant information was obtained from the informants and that the researchers established the entire picture. Alongside field research, supporting data were gathered through secondary sources such as books, newspapers, and other related documents, particularly those which discussed and analysed the socio-cultural and historical backgrounds of the local and affected communities, the social groups' differences, the influence of the religious groups, and the conflict's escalations and patterns from 2009 to early 2018. --- 4 The Socio-political Context of the Mining Conflict: Institutional Support and Policy Inconsistencies Scholars have pointed out that the socio-political environment in which goldmining activities take place is impacted by issues such as the environment, community resistance, the inconsistency of regulations and policies, and weak government institutions . In the case of the gold-mining activities in Banyuwangi, three socio-political aspects have been analysed: institutional support for the mining company leading to the inconsistency of forestry policy implementation, environmental risks, and societal opposition. According to Ismail et al. , the issue of forestry policy in the goldmining area of Banyuwangi has become polemic since 2000, when the Hakman Group corporation submitted a mining licence application to the local government. The proposed mining area covered 409,136 ha, including several natural conservation areas, such as the Taman Nasional Meru Betiri , which was not only conserved for its benefits for the natural environment and biodiversity but also because it supplied water and food for the local community. On consideration of the risks to the park, the local Bijdragen tot de taal-, land-en volkenkunde 179 5-37 regent of Banyuwangi, Ratna Ani Lestari, rejected the application. However, Triatmojo et al. have explained that the regency did issue a mineral survey licence to pt. Indo Multi Niaga in 2006, followed by an exploration permit for 2007-2015, covering 11,621.45 ha of the Tumpang Pitu hills as part of Sumberagung village. Ismail et al. have noted that imn also requested permission from the provincial government to mine the forested area of south Banyuwangi and requested permission for exploration activities from the Ministry of Forestry; both requests have been granted. However, the Ministry of Forestry has only granted access to 1,987.80 ha of the protected forest area. In October 2007, the provincial assembly of East Java issued a letter of recommendation to the district and provincial governments, as well as to the Kementerian Kehutanan , to upgrade the exploration permit to an exploitation one; this was followed by the granting of an exploration licence by the governor of East Java to pt. imn. Ismail et al. have shown that those recommendations were considered unprocedural by the provincial assembly and not in line with the zoning regulation for the Tumpang Pitu area, which had been declared protected forest set aside for the local community in Pesanggaran.7 In 2012, pt. imn sent a letter to the regent of Banyuwangi, Abdulah Azwar Anas, asking for the transfer of the mining business permit to pt. bsi; the permission was granted until 2014.8 In 2012, the regent of Banyuwangi proposed a change of status for 9,743.28 ha forest, from that of protected forest to productive forest . The minister of forestry, Zulkifli Hasan, only accepted such a change for 1,942 ha. This decision was seen as the path to realizing gold-mining activities smoothly. In 2014, the local government of Banyuwangi announced that the government had gained a 10% golden share in pt. Merdeka Copper Gold . However, the reality of this share has been questioned publicly because of the lack of detail provided about it. Several heads of villages, local politicians in the Banyuwangi assembly, and social and political activists have noted that they have insufficient information about the golden-share issue. In an interview, a politician in the local assembly stated that knowledge of this golden share is not well known publicly due to the political culture of Banyuwangi, 7 Ike Ningtyas, 'Pasca rusuh, Yenny Wahid mundur dari Merdeka Copper and Gold ' , Tempo, 30-11-2015. https://nasional.tempo.co/read/723504/pasca-rusuh-yenny-wahid-mundur-dari -merdeka-copper-and-gold . 8 Putri Akmal, 'Kata Bupati Anas soal kronologi izin tambang emas Tumpang Pitu Banyuwangi' , Detiknews, 26-3-2016. https://news.detik.com/berita/d-3173240/kata-bupati-anas-soal -kronologi-izin-tambang-emas-tumpang-pitu-banyuwangi . Bijdragen tot de taal-, land-en volkenkunde 179 5-37 whereby the elites make the political decisions and ensure that these are in keeping with their own interests. The offer of a golden share to the local government and the people of Banyuwangi has been insufficient to stop the local community from protesting the presence of pt. bsi, because they are aware that the benefits of the golden share may not cover several of the environmental issues that have occurred in gold-mining projects around Indonesia. The anti-gold-mining movement's coordinator from Pancer was taken to Sumbawa to visit the location of the Newmont Case in Teluk Buyat, thereby increasing their knowledge of the risks of gold mining. According to the anti-mining coordinator in Pancer hamlet and Sumbermulyo village, the change of forestry status and the use of mercury and cyanide could damage the soil and the sea. The presence of these chemical substances could affect fishermen's and farmers' livelihoods and have socio-economic consequences for the affected community, as occurred in 2016 when mud flows due to heavy rain and water overflow caused pollution in the Katak river and on Pulau Merah beach, affecting the fishing and tourism industries. The local community is also worried about blasting activities that could lead to air pollution in the Pulau Merah area. Furthermore, the deforestation of, and extraction on top of, the Tumpang Pitu hills have caused concern in the local community. They fear that the hills may be lost as a natural breakwater for tsunamis, as they acted in 1994.9 A report by Kristanto mentioned that the gold-mining activities in Banyuwangi may cause the loss of some part of the hills considered the natural breakwater for southern Banyuwangi, which is susceptible to tsunamis.10 Environmental and livelihood issues have been the main points raised by the local community in its struggle to stop the gold-mining activities in Sumberagung village. However, the protests over those risks have been minimized by pressure from powerful religious-nationalist organizations. Bijdragen tot de taal-, land-en volkenkunde 179 5-37 --- The Anti-mining Movement: The Internal Challenges Raised by the Variety of Groups and Motives The conflict between the corporation and the anti-mining movement is concentrated in Sumberagung village. To some extent, rejection of the mining activities has also spread to two other villages, Kandangan and Sarongan, in the sub-district of Pesanggaran, where it involves other social groups and interests, and where an anti-mining movement led by the farming and fishing communities has also been established. From our interview with the heads of the two villages, it became clear that this rejection of the mining activities within the two villages is due to concerns over seawater pollution and the potential expansion of the production area, which may affect control of the land and springs around the villages and the national park. In contrast, in Sumbermulyo and Pesanggaran villages there is less anti-mining sentiment. The head of Sumbermulyo village stated that the population of his village consists of people from a variety of professional backgrounds, such as farmers, government employees, traders, and home workers. In contrast, the majority of the people of Pesanggaran village used to be illegal miners in the Tumpang Pitu hills before the current gold-mining operations began. The profits obtained from this illegal activity were used to buy land and property and in their development. Therefore, most of the people in this village seem to be wealthier than the majority of the people in the other three villages. Furthermore, Sumbermulyo and Pesanggaran villages are a bit further away from the mining site. Although the anti-mining groups are not well-represented in the village, small representative groups used to voice their rejection of the mining operations, with protests and demonstrations taking place in Sumberagung village. Based on our findings, we have divided the anti-mining movement into three front-line groups and described their roles within the dynamics of the mining conflict. The first front-line anti-mining group consists of those who have been directly affected by the mining operations and have taken a strong, principled stance against the mining activities. They are particularly concerned about their livelihoods and about the negative outcomes of mining, such as environmental and water pollution. They also emphasize the cultural meaning and value of the hills. This group consists mainly of residents of Sumberagung village who work in the agriculture, fishing, and tourism sectors. The majority of the members of the fishing and farming communities are concerned about the possible natural changes in the Tumpang Pitu hills that would affect their lives. The hills are seen as the natural breakwater for the sea, as it protects the local community from tsunamis. This was evidenced in June 1994, when almost all the coastal zones of the regency were damaged Bijdragen tot de taal-, land-en volkenkunde 179 5-37 by a tsunami, while the people of Pancer hamlet in Sumberagung village who lived behind the Tumpang Pitu hills were less affected. The hills are seen as a natural protector that may save lives in the case of future tsunamis. The fishing community is also worried that seawater may be polluted by the mining activities, affecting the fishermen's income and family life. In 2008, the fishing community established the Forum Peduli Masyarakat Nelayan Banyuwangi to voice their views concerning mining exploration. Alongside the agriculture and fishing sectors, some young people from Pancer hamlet involved in the Kelompok Sadar Wisata consider tourism a new promising sector for the area. They have tried to find opportunities in this sector to develop the village and create a better life there, while avoiding the uncertainties of agriculture and fishing. The majority of those involved in the tourism sector are between fifteen and forty years old, and these include a few fishermen who work in the sector during the off-season for fishing, between September and February. Members of this younger group have no qualifications to work in the mining industry and therefore the tourism sector is their only hope for the future. As a consequence, some of them have become anti-gold-mining activists, rejecting the mining project because they believe that tourism and mining cannot be developed in the same location side by side, as is occurring in Sumberagung. For them, agriculture, fishing, and tourism are enough to sustain their livelihoods. The second group of anti-gold-mining activists is seen as an opportunistic group, whose members are indifferent towards pt. bsi. On the whole they have not been directly affected by the mining and live in other villages within the same sub-district; despite this, they play important roles in the survival of the movement, often taking advantage of it. They can be divided into several groups: the heads of the villages; the unemployed, who were formerly employed by pt. imn; former illegal miners of the Tumpang Pitu hills, who mined before the exploration phase had taken place; and former contract workers of pt. bsi. The first sub-group of the second group includes the heads of the villages within the sub-district. Generally speaking, in the sub-district of Pesanggaran, the majority of the heads of the villages have positioned themselves as antimining, albeit indirectly. Although they form a part of the local government and therefore are supposed to support the government's policies, they still support the anti-mining movement through 'silent tactics' . Their positions with the local authority has not stopped them from rejecting the mining operations. Four of the heads of the villages have demonstrated their anti-mining positions, while one village head tends to take a more moderate line. Bijdragen tot de taal-, land-en volkenkunde 179 5-37 The second sub-group of the second group is made up of former employees of the previous mining company, pt. imn, service-sector workers, and former illegal artisan workers in the Tumpang Pitu hills. These individuals are usually between the ages of twenty-five and forty years old and are enthusiastic about the mining sector. They have high expectations that their interests can be accommodated through the sector, at least if they have worked in the sector for a long period; this is particularly true of the former illegal miners, who have experienced the numerous effects of the mining sector. However, these former employees are not really fighting for the community-their focus is mainly on their own interests as jobseekers. There are two basic issues regarding employment in the context of Banyuwangi's mining operation. First, pt. bsi promised to recruit the former employees of pt. imn after this company dismissed them. However, according to the anti-mining movement, pt. bsi has not recruited all the former employees of pt. imn. The second issue is the employment criteria, as not all of the local people are qualified to work in the industry. Kapesa, Mwitwa, and Chikumbi explain that the topic of employment has become a matter of contention in the extractive industries because specific skills are required. From our observation, this second group is the one that maintains the dynamics of resistance; however, members of this group may leave the movement when they see attractive opportunities or offers from any party, particularly from pt. bsi. In the context of the anti-miming movement in Banyuwangi, this opportunistic attitude could potentially influence the strength or weakness of the resistance. One of the anti-mining movement coordinators in Pulau Merah and a prominent member of the Asosiasi Perhutanan Sosial Banyuwangi admitted that there were opportunistic individuals within the anti-mining movement that could be bribed or satisfied by offers during political campaigns by particular political candidates or with regard to projects from pt. bsi. Consequently, the anti-mining movement is easily weakened and reduced. Bebbington et al. ) believe that such internal dynamics could lead to the failure of a social movement. The third main group in the movement consists of environmental activists and student associations, who normally advocate for the community affected by the mining activities. These activists support the anti-mining movement in Banyuwangi through advocacy and protests and by providing comparative data for the affected communities. The environmental activist groups are Wahana Lingkungan Hidup Indonesia and Jaringan Advokasi Tambang , and Banyuwangi's Forum for Environmental Learning . There has been involvement from several student organizations from the local universities, including the Gerakan Mahasiswa National Indonesia Bijdragen tot de taal-, land-en volkenkunde 179 5-37 of Banyuwangi; Islamic student associations; the nu's youth environmental organization, called Front Nahdliyin Untuk Kedaulatan Sumber Daya Alam ; the Banyuwangi Forum for Environmental Learning; the Pusat Studi Hak Asasi Manusia Universitas Airlangga Centre for the Study of Human Rights of Airlangga University; Jaringan Advokasi Tambang ; and the Forum Konservasi Indonesia Jawa Timur . The student movement and youth organizations in the capital of Jakarta have assisted the affected community in its struggle. These groups mainly appeared on the scene in 2008 with environmental protection and local livelihoods as their main agendas. For several years, rejection of the mining operations was voiced sporadically by these organizations, until a more cohesive social movement was established in 2012. In 2018, as mentioned above, several organizations, including the student and community alliances and the Forum for the Care of Banyuwangi's Fishing Community, took the initiative to establish a new anti-mining organization, the Banyuwangi Movement Forum , later the Banyuwangi People's Forum, which embraced all elements of anti-mining activities. The bmf was supported by the fnksda and Banyuwangi Solidarity Forum separately. However, the bmf has provided little financial support while the fnksda is not fully supported by the nu as its parent organization. However, the new movement has not been as unified as expected. In our interview with a prominent leader of social-forestry activism in Banyuwangi, it was noted that all the groups within the anti-mining movement have different backgrounds and interests, and the bmf has not been seen as a source of power or a strategic alliance but rather as a temporary coming together. The movement's lack of focus is due to its members chasing personal interests and setting differing agendas. As a result, the movement has not remained strong, with many individuals and groups disappearing after achieving progress for their interests, or surrendering, or taking up other causes. The leader of the fishing community of Sumberagung village also noted that the anti-mining movement also consists of other groups associated with political parties, local bosses, and prominent individuals, which has created distrust among the antimining movement internally due to the various hidden agendas of these political figures. As a consequence, the anti-mining movement has appeared to be in a steady decline over the last few years. --- The Internal Challenges of the Anti-mining Movement of Banyuwangi The internal causes of the decline of the anti-mining movement in Banyuwangi can be linked to the behaviour and personal interests of the heads of the villages who have supposedly played important roles in the survival of the movement, often taking advantage of it. These individuals want to maintain at least their current social status and ensure their future political careers by winning votes. In the case of Banyuwangi, they have established social and political contracts to secure possible votes, even though this breaches their duty as public servants. In one particular case, one of the heads of a village, who was elected for the period 2017-2022, committed to continue the policies of the previous village head, who had been a supporter of the anti-mining movement. At the time of writing, the head of the village was trying to maintain support for his social and political positions for the 2022 village elections. Similarly, another village head declared that as he had been elected mainly by anti-mining movement members, and could see the possibility of using these votes as a stepping stone to election to the local parliament, he has had to accommodate the antimining movement's interests in his platform. Giugni and Passy have highlighted that if members of the elite did not respond to minority demands, they would risk not being elected in the future. Strong opposition to the mining operation has also been demonstrated by another village head, as his proposed corporate social responsibility programmes have been ignored by the company since 2015. According to the company's management officials, the village programmes would be considered by the csr team of pt. bsi. However, the restructuring of the internal management of the company has led to changes to social-programme priorities. The disappointment felt by the head of the village has led to his opposition to the presence and future possible projects of the mining company in his administrative territory. Through our conversation it became clear that the head of the village has not stopped any villagers from joining anti-mining movement protests in Sumberagung village. It was confirmed by one of the anti-mining coordinators in Pulau Merah that protesters from the villages of Kandangan and Sarongan have participated in protests due to their having a similar perception of the situation and to show solidarity. However, the majority of the heads of the villages and some of the former employees of the previous mining company have admitted that they have in some instances taken advantage of the conflict. The heads of the villages have used the issue of gold mining to gain political support and votes in the village Downloaded from Brill.com 02/23/2024 04:54:32PM via Open Access. This is an open access article distributed under the terms of the CC BY 4.0 license. https://creativecommons.org/licenses/by/4.0/ Bijdragen tot de taal-, land-en volkenkunde 179 5-37 elections by voicing anti-mining demands during their leadership of the village. In one instance, the head of a village signed a 'political contract' with the anti-mining group. For these village heads, the most important thing was electoral success. However, their anti-mining agendas have not been easily realized post-election because of the need for the village heads to follow the local government's instructions. Meanwhile, former employees have taken advantage through participation in projects and csr programmes with the company. Our findings show that the company has approached former employees through its csr programmes as a substitute for earlier promises to recruit them as permanent employees when pt. bsi replaced pt. imn. Initially, this approach was welcomed by the former employees; however, this goodwill did not last, due to the termination of contracts and changes in the company's priorities. The majority of the former employees became disappointed and got involved in conflicts with the company. In response to this, the company accepted project proposals and offered csr programmes to the former employees and the affected community generally. This conflict cycle has existed since pt. bsi took on the mining operation in the Tumpang Pitu hills. In other words, the economic benefits and personal gain of the former employees have been prioritized over voicing rejection of the gold-mining project. Castells has observed that the failure of a social movement can also be linked to opportunistic approaches from certain individuals or groups that see the social movement solely as a political arena. It is well-known that the bmf has representatives from various sub-groups and with various concerns. This has contributed to a seriously weakened social movement. According to the head of Pesanggaran village, the anti-mining movement has gained support from former contractors of pt. bsi who worked under limited contracts for the company towards the end of the construction phase, from 2013 to 2015. These include small, local enterprises, food suppliers, welding service providers, and other service sectors. According to the human relations department of pt. bsi, the termination of such contracts has led to disappointment and resentment; conflict is therefore inevitable as the terminated contractors can no longer see any benefits to be derived from the presence of the company. --- The Corporate Response: Building Consent with the Local Community In the mining sector, environmental damage, the prosperity and livelihoods of the local community, and employment levels are sensitive issues that need an Bijdragen tot de taal-, land-en volkenkunde 179 5-37 adequate response from the corporation in question because they are sources of social conflict in this sector . These issues, in our view, have become the central focus of pt. bsi's efforts to obtain consent from the local community. In this regard, the company has emphasized that its mining investment brings fewer risks in comparison with other mining activities elsewhere in Indonesia and that it will bring prosperity for all stakeholders, including the affected community in Sumberagung village and the communities in Pesanggaran sub-district more generally. Regarding the environmental issues, pt. bsi has responded by sharing information related to the technology used during the production phase through the media, seminars, and dialogues with the local community. According to one of the general managers of pt. bsi, the corporation has declared that the method used in the mining project is environmentally friendly. The heap leach method, as it is called, does not generate mine tailings as waste. The ores are intercepted, recycled, and reused. At the end of the project, the ores will be rinsed to remove any waste before replanting.11 However, the anti-mining movement is still distrustful of the company due to the mud flood that occurred in 2016 and the information regarding environmental damage provided by environmental activist groups such as walhi and jatam. In terms of employee composition, the total number of employees working for pt. bsi in December 2020 was 2,735. Of these, 2,708 employees are from the local community in Banyuwangi regency and just 27 are foreign employees . According to the pt. bsi's head of hr, the workforce has mostly been recruited from among Banyuwangi residents, with particular attention paid to the Pesanggaran sub-district. However, the company acknowledges that the majority of the locally recruited staff are unable to work at higher levels in the business due to their limited education and capabilities. The coordinator of the anti-mining movement in Pancer told us that many local youths have been employed by pt. bsi, but that their employment has gradually ended due to contractual agreements, which, he believes, means that the number of local employees has significantly decreased. Bijdragen tot de taal-, land-en volkenkunde 179 5-37 Furthermore, pt. bsi annually announces via its csr programme that the company's presence has benefitted the local people.12 From our observations, bsi's financial support for various local home-based industries has assisted the growth in businesses, particularly among local housewife groups in Sumbermulyo and Pesanggaran villages. This is also true in Sarongan and Kandangan, but to a lesser extent due to their geographical locations and dependent on the individual proposals and the villages' resources. However, the company is more concerned with Sumberagung village because this is the location of the mining site and is where the strongest resistance to the operations can be found. The company has tried to develop basic infrastructure and homestay opportunities as part of the development of the area as a tourist destination, particularly in Pancer, where Pulau Merah and Mustika beaches are located. In an interview, one of the top anti-mining movement leaders, who is also the leader of the women's anti-mining group, admitted that the company has supported the local community in Pancer through csr programmes by building roads; providing a school bus for local children; building tourism infrastructure, parks, and lighting; and carrying out other social charitable actions. According to her, these actions are an attempt by the company to obtain consent for the mining from the local people in Pancer as they aim to show that gold-mining investment brings economic and social benefits. She confessed that this has led to a reduction in the strength of the anti-mining movement because the majority of its members have begun to accept this support and have changed their attitude towards the company. Therefore, she is worried that the next generation may be seduced by this support and not continue to fight the mining operations. She realizes that the anti-mining movement has been in decline for the 12 pt. bsi has divided its social responsibility into five priority areas since 2016: economic empowerment, education, religion and culture, health services, and infrastructure; see Bumi Suksesindo, 'Sekilas perusahaan' , 2020. https://bumisuksesindo.com/sekilas -perusahaan and Bumi Suksesindo, 'Tentang csr' , 2020. https://bumi suksesindo.com/tentang-csr . In 2020, the corporation increased its social budget for four of the five sectors, namely economic empowerment, education, health, and infrastructure . The total amount allocated to the infrastructure sector was idr 15,000,000,000 for 122km of roads in five villages, irrigation, disaster prevention, and the provision of other public facilities. Moreover, the budget for education was idr 25,000,000,000 for learning centres, scholarships, libraries, school buses, and educational infrastructure. Meanwhile, the corporation has offered idr 26,900,000,000 for the development and empowerment of more than 45,000 local people in five villages through economic and health programmes between 2014 to 2019. See A. Amenan, 'bsi siapkan dana program csr ppm Rp. 26.9 miliar' , Berita Satu, 2020. https://www.beritasatu.com/ekonomi/613819/bsi-siapkan-dana-program-csr-ppm-rp-269 -miliar . Bijdragen tot de taal-, land-en volkenkunde 179 5-37 last few years, although she believes that there is still a group of anti-mining activists who stand up for their cause. Our findings show that the corporation's attempt to win the public's consent for their mining operations has not entirely been accepted by some members of the local community, particularly the first group outlined above. The negative track record of mining activities in other places is front and centre in the minds of the affected community in Sumberagung village. As a result, the corporation has had to seek support from other entities, such as social organizations. --- Relationships between the Corporation and Religious Organizations: Establishing Organic Intellectual Arrangements and Seeking Consent from Local Communities In the earlier stage of exploration in the Tumpang Pitu hills, a group of ulama from nu in Banyuwangi had shown their discontent with the presence of pt. imn in the regency. In 2009, 200 ulama and leaders of Islamic boarding schools , expressed their objection to the mining exploration plans.13 At a meeting, they recommended rejecting all types of mining activities due to the industry's monopolistic management, environmental unfriendliness, and the destruction of the way of life of affected communities. Nevertheless, some local ulama expressed a different view, stating that the nu's judgement towards the company should be based on scientific evidence and that the company should therefore have the opportunity to explain their operational plans.14 The opportunity to give an explanation was seen as a way for pt. bsi to seek consent from a religious organization, in this case the nu. For pt. bsi, the mining project in the Tumpang Pitu hills is an investment that will bring prosperity to all stakeholders without harming the environment. Alfian has described the nu's point of view as being based on Islamic thought, in that mining activity in Banyuwangi is allowed if it meets several important criteria. These include answering questions about the reasons for the exploration; who exploits the area and benefits from the exploitation; the business ethics 13 'Ulama Banyuwangi rekomendasikan tolak tambang emas' , Koran Tempo, 16-3-2009. https: //koran.tempo.co/read/berita-utama-jatim/159638/ulama-banyuwangirekomendasikan-tolak-tambang-emas . 14 'Tolak monopoli tambang emas, Batsul Masail ulama nu' , Surya, 16-3-2009. https://suraba ya.tribunnews.com/2009/03/16/tolak-monopoli-tambang-emas-batsul-masail-ulama-nu . Bijdragen tot de taal-, land-en volkenkunde 179 5-37 involved; the management of the mining activity for the common good; and hazard avoidance. As a result of the meeting at which pt. bsi's plans were laid out, the scholars of the nu split into two groups, for and the against the mining project. The pro-mining group sees that mining activity in Banyuwangi could bring income and prosperity to the local government and local communities. In contrast, the anti-mining group argues that the environmental damage caused by mining would have negative consequences for the communities, as has occurred in other mining locations. These differing views remain a stumbling block for mining operations in Banyuwangi. These contradicting opinions are still expressed today. According to a kyai in the city of Banyuwangi, these divergent opinions are considered normal within the organization because of the range of interests related to political support, access to economic resources, and the need for funds for their educational institutions. Therefore, a kyai may accept personal financial support from certain corporations or entities, in exchange for endorsing these corporations' investment objectives and gaining consent for these corporations' activities from their followers through their religious teachings. Alfian has stated that this type of beneficial personal support for mining activities in Banyuwangi is due to the existence of multiple interpretations of mining activities dating back to a Lajnah Bahsul Masail15 meeting in 2009. Moreover, these divergences of opinion make the nu seem a pragmatic and flexible organization . In our view, this type of personal agreement with a kyai or local official of the nu can be seen as an organic intellectual arrangement that benefits the corporation as described in the concept of hegemony. It can be used to establish and produce consent with most nu scholars and followers for mining investment due to the focus on the positive aspects of mining. This raises questions about the religious organization's role in the mining project in Banyuwangi. In our interview with the coordinator of the anti-mining movement in Sumbermulyo, it became clear that the majority of local grass-roots nu members have met strong opposition from several local officials and kyai of the nu who have seemed to support the mining activities of pt. bsi. The local grass-roots members of the nu have come together through prayer or pengajian and have participated in environmental activities 15 Lajnah Bahsul Masail is an internal committee of the nu which consists of certain figures . This internal committee deals with decision-making concerning religious, social, and economic issues. One of the issues discussed at a 2009 committee meeting was the gold-mining project in Banyuwangi regency. Bijdragen tot de taal-, land-en volkenkunde 179 5-37 led by the fnksda. However, they have avoided direct contact with the corporation and the nu's local elites. From our observations, however, the local grass-roots membership of the nu in Sumberagung and the fnksda are not strong enough to directly challenge the nu's local elites or kyai. This change of attitude has been seen through a shift in support for the mining corporation in Banyuwangi. Several of the nu's top members from the national to the local levels have close connections with the corporation, supporting it through rhetoric on its social and economic benefits and in exchange accepting important positions in the corporation. Nahdlatul Ulama was chosen because of its members' historical support of, and relations with, the company but also because it has the largest number of Muslim community members in the country . Members of this religious group have taken on key roles high up in the company. A similar situation can be seen in the history of the previous mining company in the area, the imn, which was directed by the daughter of the former Indonesian president, Abdurrahman Wahid, widely regarded as one of the most influential leaders in the nu. Wahid's daughter was invited by other commissioners of pt. Merdeka Copper Gold, with whom she was friends, to become the company's director. However, she resigned from the company in 2015, before conflict broke out between the corporation and the affected community of Sumberagung,16 and was replaced by another member of the family The appointment of members of the former Indonesian president's family is believed to have been a way of gaining support from the religious group's members and society in Banyuwangi . At present, another influence can be seen through the connection between pt. bsi and the presence of the religious group's most prominent figures in management positions at the company: the Ketua Majlis Wakil Cabang Pesanggaran has been appointed to fill an important position in the community relations department of the company. Moreover, Media Indonesia has reported that the central leadership of the nu has also shown its preference for supporting the company: the chief of the nu in Jakarta flatly refused to listen to several anti-mining group members when they approached him.17 -dari-merdeka-copper-and-gold . 17 'Terkait tambang Banyuwangi, pbnu memihak manfaat bagi rakyat' , Media Indonesia, 30-8-2018. https://mediaindonesia.com/read/detail/176303-terkait-tambang-banyuwangi -pbnu-memihak-manfaat-bagi-rakyat . Bijdragen tot de taal-, land-en volkenkunde 179 5-37 It seems that this religious organization and its affiliates are increasingly important, not only as a means of networking but also in terms of political support and in their role as future conflict mediators. However, this reciprocity could be potentially used to certain persons' or groups' advantages. --- 9 Coercion Dynamics and the Decline of the Anti-mining Movement: The Role of the Religious-Nationalist Organization Efforts to put pressure on anti-mining activities have been in place since the rejection of the corporation's exploration phase. The divergences of opinions among the kyai and the strong resistance shown by the first anti-mining group illustrate that the message regarding the investment from the corporation as a result of mining and the organic intellectual arrangements with several of the nu's elites have not been accepted by some of the nu's grass-roots and local communities and consent has not been achieved. As a result, the rejection of mining activities has taken the form of violent resistance. In our interview, the head of the anti-mining movement in Sumbermulyo village mentioned the huge demonstration against pt. bsi that took place on 4 April 2017 on the main road in Pancer, part of Sumberagung village. The movement and the local community marched towards the company headquarters with several banners. The protesters gathered at the company's headquarters and some chanted their demands, while others held the banners aloft. However, many of the participants in the march were surprised to discover that one of the banners depicted communist symbols; it appears that the banner had been donated by an unknown person as the march was in progress. The coordinator said that this suggested that the unknown person was a 'trained' individual, with the appearance of a member of a security service, and therefore the coordinator suspected that the banner had been donated in order to label the protestors as a subversive movement. The coordinator noted that all the other banners had been produced in the movement's leader's house, and their production witnessed by members of the local police and other members of the local community. If there had been communist banners produced in the house, then the anti-mining leader would have been immediately arrested. As a consequence of the inclusion of these communist symbols, the antimining movement of Banyuwangi has been accused of being sympathetic to communist ideology; therefore, legal measures have been taken not only by the formal security services but also by religious-nationalist organizations. In January 2018, anti-communist groups responded by establishing the Massa Gerakan Anti Kebangkitan Komunis under Bijdragen tot de taal-, land-en volkenkunde 179 5-37 the command of a religious leader, led by the nu and its affiliates such as the Barisan Ansor Serba Guna or Banser . Several martial arts groups and nationalist youth organizations, including the Pemuda Pancasila , the National Defence Brigade and the Forum Suara Blambangan , among others, have joined this movement.18 The head of forsuba accused the anti-mining movement of being a provocateur and an illegal movement that does not reflect the interests of the affected communities. forsuba asked the security services to investigate the situation and take appropriate action.19 As a result, the local police has arrested several of the coordinators of the demonstration and processed them not only as ordinary criminals but also as rebels that might be a threat to national security.20 It is well known in Indonesia that propagating communist ideology, including its symbols and activities, is strictly prohibited . The majority of citizens are aware that the following of communism has been banned since 1966 under the Soeharto regime;21 therefore, any person who is associated with such ideology is considered a rebel, a label which can then at any point in the future be used for political purposes . Historically, the nu had a long battle politically with the communist political institutions in Indonesia. This began when the nu was a political party during the transition from the Sukarno to the Soeharto regime in the 1960s. At that time, the nu was an independent political party and a competitor to the Partai Komunis Indonesia . This led to several clashes between the Forum Petani Indonesia , a group affiliated to the pki, and Banser, a semi-autonomous paramilitary brigade affiliated to nu . These clashes then continued between the pki and another of the nu's 1948and 1965. Thus, a breach of this ideological prohibition was placed squarely at the feet of the anti-mining leader and his collaborators. This was seen as an appropriate moment to implement coercive measures against the anti-mining movement. By accusing the anti-mining movement of being communist, opportunities arose for the security services and religious-nationalist organizations to act legally to prevent and control the anti-mining movement's activities. However, according to the coordinators of the anti-mining movement in Sumbermmulyo and Sumberagung villages, the accusation of being a communist organization and the arrest of the movement's leader Budi Pego in 2017 were used to discredit the movement and prevent it from recruiting new members, spreading its ideas, and receiving public support. To some extent, the anti-mining coordinators in Pancer acknowledge that some ordinary people did lose sympathy for the anti-mining movement at this point and would no longer join it. Since then, social control of the anti-mining movement has been enforced. Religious-nationalist groups have established an anti-communist awakening movement, building informal security posts, arranging convoys in certain places in Banyuwangi to counter the anti-mining movement, and conveying messages about the dangers of communist ideology. As a result, the anti-mining movement's activities have been reduced significantly since the arrest in 2017 of Budi Pego because of the pressures applied and control taken by the religious-nationalist organization. We have observed that anti-mining activities were limited during 2019 and 2020, having been reduced to small demonstrations or protests that avoided clashing with the corporation and security services, and that the anti-mining movement was based in Pancer hamlet. The movement believes that its activities are being monitored by the security services and religious-nationalist organizations and that its members could be arrested at any time. As a consequence of being accused of having an affiliation with communist ideology and the arrest of the anti-mining leader and his fellow protestors, there is no consistency and no firm figurehead for the movement. Every possible method has been used to legitimize the religious-nationalist organization's presence and give credence to the idea of communism as a dangerous alkatiri and kiwang Bijdragen tot de taal-, land-en volkenkunde 179 5-37 ideology in Indonesia. To some extent, the reasoning given by the religiousnationalist organization has been accepted by many people in the Pesanggaran sub-district, who believe the anti-mining movement to be associated with communist ideology. However, the involvement of officials of the nu who were working at pt. bsi and its affiliated groups to put pressure on the anti-mining group is still being questioned by those who understand the situation, and this includes those in the first group of the anti-mining movement and the nu's grass-roots followers. These individuals have questioned whether the nu's elites were truly acting against the communist ideology and defending the Pancasila as the national ideology of Indonesia, or whether this 'exposure' of the movement as communist has been a business-relations exercise with a hidden agenda within this mining conflict. As pointed out by a kyai interviewed in Banyuwangi, economics and business relations may be the main reasons for taking action against the anti-mining group. In the view of Giugni and Passy, the pro-mining movement has used the opportunity to raise public awareness of the danger of any issue which may threaten the gold-mining project or provoke conflicts between the corporation and the affected community, speaking as though it represents the public at large . The more support it obtains, the more legitimate its counter-movement becomes. Because of the pressure that has been applied, the movement has changed strategies, moving from an anarchist approach to a gentler tone, with the aim of entering into a dialogue with the local government of Banyuwangi to find better solutions, while still rejecting the presence of pt. bsi. However, the coordinator of the movement from Pancer hamlet has said that persuasive approaches to the local government have not as yet been successful. Therefore, resistance has had to continue through the use of a mixed approach, including violence, blockades, intimidation, and talks at the grass-roots level, as well as symbolic protests such as group prayer, street banners, and hunger strikes, as occurred throughout 2019 and early 2020. However, all in all, the number of protestors involved seems to be declining. --- Conclusion In summary, Banyuwangi's mining conflicts have seriously affected communities and social groups in the mining-operation area, particularly in Sumberagung village. The communities affected by the mining activities in the Tumpang Pitu hills of Banyuwangi are worried about the risks of mining, as is often the case in other mining locations. As a result, social movements have Bijdragen tot de taal-, land-en volkenkunde 179 5-37 been established over time by these communities to voice their opposition to the mining operations. The divergence of opinions among socio-religious elites, such as the kyai of the nu, has created the opportunity for pt. bsi, the mining company, to approach members of the nu individually. As a result, several pro-mining elites of the nu have come to organic intellectual arrangements with the company, mixing religious teaching with slogans about the socio-economic benefit of mining investment in order to persuade their grassroots followers and local communities and gain their consent for the operations. Tensions between pt. bsi and the affected communities have been recorded due to their differing views of the mining activities. pt. bsi has declared that the technology used is environmentally friendly; the affected communities are doubtful of this and have demanded that the corporation withdraw from the Tumpang Pitu hills. As a consequence, tension, distrust, and conflict have occurred continuously, with clashes breaking out in 2015 and 2017, resulting in the arrest of prominent leaders of the anti-mining movement. Internally, the anti-mining movement in Banyuwangi has faced significant weaknesses, such as opportunistic behaviour in terms of local village heads who want to meet certain political agendas or members and jobseekers who aim to benefit personally. Externally, the anti-mining movement has faced pressures from religious-nationalist groups led by the nu, which have acted to safeguard the state from communist ideology and have framed the anti-mining movement as a communist-affiliated group. As a result, coercive measures have been taken against the anti-mining movement. The use of anti-communist rhetoric by the pro-mining lobby has successfully destroyed the agenda of the anti-mining cohort. At the same time, pro-mining elements have gained significant support from the wider community to apply pressure and take control of the anti-mining movement. Consequently, the anti-mining movement's activities have been weakened and its membership has declined. However, this decline does not mean that the anti-mining movement in Banyuwangi has failed. It continues to voice its disapproval and rejection of the mining operations at the grass-roots level in Banyuwangi regency, albeit in more subtle tones.

Although the Banyuwangi anti-mining movement clearly has the capacity to grow, this article argues that the movement's manoeuvres against pt. bsi seem to have become weaker since 2017. The article seeks to explain how the interests of the internal groups within this local social movement have weakened its position and how religiousnationalist organizations, that is, the nu and its affiliates, have manoeuvred to defend the state and the corporation indirectly. The data have been qualitatively collected through in-depth interviews, focus group discussions (fgd s), and relevant documentary sources. By using the Gramscian concept of hegemony, this article shows that the decline of the anti-mining movement is related to the agenda-setting of individuals and subgroups in the movement, as well as the ability of religious-nationalist pro-mining groups, such as the nu and its affiliates, to use their influence, legitimacy, and ideological rhetoric to this end, combined with some social and political characteristics of East Javanese society.

Introduction/Background: On March 11, 2020, the "World Health Organization declares COVID-19 a pandemic" and within 96 hours, the entire United States of America was thrown into a whirlwind shutting down borders, schools, and organizations to contain the transmission of the infectious disease known as the Coronavirus . In the first quarter of 2020, Americans clung to their television screens as the number of Covid-19 cases crept across the globe. As more cases developed, organizations had to reassess the human capital cost in light of dwindling revenue. The decision by U.S organizations to furlough and/or lay off workers lead to an unprecedented 14.7 percent unemployment rate. "This is the highest rate and the largest over-the-month increase in the history of the data . The number of unemployed persons rose by 15.9 million to 23.1 million in April." The United States drew a clear line in the sand, nonessential employees had to cease working in physical buildings or be able to work remotely. In addition, the economy slowed which forced companies to "decide who they can still afford to pay" . --- Research Question: For years, the idea of work/life balance has been a topic of discussion among human resource professionals and this topic could be instrumentational in understanding the paradigm shift that has occurred in the mindset of workers post pandemic. Over the last year, the data has demonstrated there are more jobs open then available individuals to work and there appears to be a gap. To investigate why there is a delta of five million between job openings and unemployed individuals, this research looked at what obstacles workers encountered that prohibited them from re-engaging in the job market after the pandemic within the framework of Maslow Hierarchy of Needs Theory? In the third quarter of 2020, the CDC released guidelines and tools to reopen the United States schools and corporations. As the post-pandemic fog cleared, organizations found themselves in an unexpected and unprecedented crisis. Henny states, "The U.S. economy is poised to take off in coming months as it rebounds from the coronavirus pandemic, but the recovery faces a new challenge in an apparent labor market shortage. Employers are reporting difficulty in onboarding new workers, even though the nation's unemployment rate is at 6% and some 9.7 million Americans say they are actively looking for a job, according to Labor Department data. "Henney goes on to emphasize people who had either been terminated, furloughed, or voluntarily left the job market are slow to return for fear of catching COVID-19 or walking away from unemployment benefits that provide greater stability than working a forty-hour week. Many legislators and media hosts suggested individuals are not returning to the job market due to the increased stimulus checks, extended unemployment benefits and eviction bans being in place. The financial windfall of money was one potential reason for individuals not participating in closing the labor shortage, however, we suspect this could be an attributing factor but not the root cause. The purpose of this research is to explore what obstacles have prohibited workers from returning to the job market after the pandemic. Their lack of labor participation has led to a deficiency of economic pollination throughout the United States causing shortages, delays, and stock outs. --- Literature review Maslow discusses the basic needs that every individual faces as they progress through life. According to McLeod , Maslow hierarchy of needs states there are five tiers of human needs that can be further broken down into three categorical needs listed lowest to highest: base needs , psychological needs and lastly self-actualization . Maslow goes on to state individual must fulfil or satisfy the lower-level need prior to transitioning to the next level and thus we set out to demonstrate this has been observed over the last two years with respect to the Covid-19 pandemic and the slow return to the workforce. During the government shutdown individuals were able to fulfil the basic needs through the accumulating savings from minimal commute, lack of vacation spending and/or federal stimulus package which provided $300 a week, child tax credits and instated eviction bans. In addition, individuals were able to develop meaningful relationships with immediate family as the distractions of commutes, activities and social meetings were halted. Once the restrictions were lifted connections with extended family and close friends became more heartfelt and cherished. Individuals were able to reflect on work-life balance and their own self-worth which leads to the top of the pyramid, doing something that is fulfilling and not just a job but the thing we were created to achieve. According to Maslow , the five levels of Maslow's hierarchy are as followed: 1) Physiological needs are at the base of the pyramid as these are biological needs such as food, water, warmth, and shelter 2) Safety needs are centered around safety, security, and order 3) Belongingness and love needs are where individuals seek personal connections through meaningful relationships with others 4) Esteem needs hinge on establishing respect and achievement for oneself and in the eyes of others and lastly 5) Self-Actualization needs are described by Maslow as "self-fulfillment…the desire to become more and more what one is, to become everything that one is capable of becoming". --- Conceptual model and propositions This study utilizes an inductive qualitative methodology to understand what elements are being considered while re-engaging in the labor force by workers. Corporate America has been thriving for years whereas workers have been struggling to manage the stress of making ends meet with through the current living wage. According to Maurer ; Richter and Rosenberg, E. , the Job Opening and Labor Turnover reported that approximately 4.5 million Americans quit their job in November of 2021 and some noted attributing factors were pay, flexibility, commute, family safety and improved working conditions. According to Richter , the pandemic created a space for individuals to reconsider "their work and their priorities and what they want to do". The pandemic changed everyone's perspective on working conditions, salaries, standards, and overall work/life balance. In addition to the perspective shift, K through 12 educations morphed into virtual learning from homes. Dining room tables and kitchen islands became the new classroom and parents became pseudo teachers. The measures listed above were put in place as a strategy to reduce the spread of Covid-19. Nevertheless, the closures of daycares/schools, buildings and the implementation of healthcare screens made returning to work more challenging. Over time, social distancing and immunization strategies were implemented which slowed the spread of COVID-19 and therefore, corporations were able to resume supplying goods and services. However, corporations found themselves without individuals to conduct tasks which would produce saleable goods and services. Workers seemed to have found a way to embrace life without work. At the same time, there seemed to be a shift in how workers viewed the meaning of work. Could the dismissal of their services have triggered an awakening in their sense of self-worth? As Corporate America struggles to entice workers to trade in quality family time for eight hours days on a production line, there appears to be resistance. The call for workers is being made on social media, television, billboards, and radio stations. Nonetheless, there is still a labor shortage. The way of work is on the brink of collapse and understanding the mindset of workers could be the key to entice individuals back to the job market. To identify what is unfolding, we have performed a document analysis to set the framework. --- Propositions: P1: The pandemic changed the workers sense of self-worth/self-actualization as individuals leave jobs in pursuit of more fulfilling purpose. P2: The time away from work during the pandemic has led to individuals value fulfilling belongingness and love needs above having a job. P3: The labor shortage provided an environment that allowed workers to negotiate compensation packages as esteem needs were met. --- Research method The research methodology was structured to identify what obstacles have prohibited workers from returning to the job market after the pandemic. According to the BLS, there are approximately 11 million job openings and six million unemployed individuals. In other words, if every person was placed in a job vacancy there would still have a deficit of five million individuals. In addition, the labor force participation rate is down two percent hovering around 61.5%. The LFPR "shows the number of people seeking work or working, expressed as a percentage of the total population." and is calculated by taking "the total labor force and divide it by the total civilian noninstitutionalized population." Baker states the LFPR aides in understanding the landscape of the labor market as it indicates the number of individuals who are unable or unwilling to work at the current wage. To understand the phenomenon that is unfolding, a document analysis was conducted to identify various document sources that provided a firsthand account of the job market landscape and the working individuals perspective. Bowen and Morgan state the use of document analysis as an unobtrusive and non-reactive methodology which allows for avoidance of social desirability bias, is representative across spans of time and the method is more efficient in cost and time when compared to other qualitative research methods. According to Cardno , the approach and management of the content is straightforward and rarely requires Internal Review Board approval to analyze the data. This research study and the methodology was vetted through the Temple Internal Review Board and determined to be exempt. In the words of Mitch Kapor "getting information off the internet is like taking a drink from a fire hydrant" and therefore, it was crucial to select the most appropriate sources that both represented the labor market and the individual being sought after for employment. To ensure a holistic viewpoint was presented, 76 documents across three types were analyzed to investigate the paradigm shift occurring in workers across the United States. --- Data Collection In selecting where to obtain data, we searched the internet from April through June of 2022 using the key phrase of "why people aren't going back to work, why are people not returning to work, the great resignation, and the great reshuffling". The title and opening paragraph of each article was read prior to importing the article into the Qualitative Analysis System . A total of 45 articles were identified and imported into a data file within Nvivo using NCapture. To effectively observe the tone, sentiment and voice of the worker, the Reddit social media platform was selected. Thus, the "r/antiwork "subreddit community was selected to observe content that "is curated and promoted by site members through voting" . To obtain a more representative sample from the working individual, 31 "r/antiwork" subreddit posts were analyzed over a month. The subreddit "r/antiwork" is a community "for those who want to end work, are curious about ending work, want to get the most out of a work-free life, want more information on anti-work ideas and want personal help with their own jobs/workrelated struggles." The Reddit posts were unfiltered and first-hand accounts from individuals who were or had worked. The posts contained emotional language, imagery and stories that opened the door into their life and shared actual situations pertaining to work and why they were or had left the job market. The Reddit platform was selected as it provides a forum for the people to share content from their point of view and in through their own voice. According to the Reddit site, "Reddit is a growing family of millions of diverse people sharing the things they are care about most" and with over 100,000 active communities and 13 billion post and comments this platform is a representative sample of individuals at the center of this research . --- Data Analysis All documents were compiled through the search criteria listed above. In accordance with Proferes et. al. the documents were obtained and imported into the Nvivo system, the records were screened and any duplicates or unretrievable full text articles were removed. The remaining documents were either stored in a data file labelled Website or Reddit. Each document was systematically coded in NVivo, a computer assisted qualitative data analysis software. Two rounds of document analysis were performed. The first round contained and coded 60 documents, however, to ensure data saturation was achieved an additional 15 documents were coded as a robustness check. As specified by Miles , the articles, and posts were processed through first and second cycle coding by assigning descriptive labels/meanings and then consolidated into code clusters which in turn condense into themes. The first level coding was utilized to "reduce the qualitative data to allow a more manageable focus". The second level coding process was used to consolidate the first level codes into more generalizable terms that narrows the focus. Level 3 coding was employed to further refine the content focus and move towards "critical density" better known as themes . --- Data analysis and results/discussion This study set out to explore what obstacles have prohibited workers from re-engaging in the job market after the pandemic within the framework of Maslow Hierarchy of Need Theory. The document analysis yielded fortyseven first cycle codes which were consolidated into nine second cycles codes and five themes. The five main emerging themes were identified as salary, stumbling block, steward of care, sense of worth, and stress . --- Results The codes listed above were systematically categorized into themes with the total number of times the code was linked to a file and/or references. The data indicates that sense of worth was the highest referenced with denoting 498 references, followed by salary at 301, stress at 90, steward of care at 74 and stumbling block at 29. The data suggest that during the pandemic, individuals that were released from their employment experienced a paradigm shift within where a sense of self-worth emerged. According to Krugman , the pandemic "gave employees more time to think about their careers: The pandemic gave American employees time and opportunities to reassess their situations and priorities". We would claim that surrounding factors caused by the pandemic allowed for the four lower levels known as the deficiency needs to be met thus given rise for individuals to engage in the growth needs. According to McLeod , "growth needs continue to be felt and may even become stronger once they have been engaged" and hence this sense of self-worth to upskill and take one's time finding the right job that brings about happiness. This newfound realization has led millions to redefine what requirements need to be in place for them to accept an offer. Workers are leveraging unions and strikes to demand better conditions in return for their services. Workers are demanding "a living wage, wages are not the only factor in job quality, with the pandemic likely propelling people to reevaluate what they value and want in a job. Workers also place a high value on-and now have the leverage to demand-benefits such as paid family and medical leave and health insurance; a workplace safe from harassment, illness, and physical injuries; flexible scheduling; a better work-life balance; and a career path with clear upward mobility". . The days of saying you are valued and are "essential" to the organization are over if the companies support and actions are not mirroring the sentiment. "Essential workers are tired of being thanked one day and then treated as expendable the next day, …The headline isn't that there's a shortage of people willing to return to work. Instead, it's a scarcity story. We have a shortage of safe, good-paying, sustainable jobs." Therefore, the results support P1: The pandemic changed the workers sense of self-worth/self-actualization as individuals leave jobs in pursuit of more fulfilling purpose and P2: The time away from work during the pandemic has led to individuals valuing fulfilling belongingness and love needs above having a job. As the study progress the initial code of work-life balance moved into focused coding as work conditions and finally into axial/thematic coding of Sense of Worth. Thus, leading to the workers awakening of their sense of self-worth after the pandemic. The changing dynamic has led to a power shift that has given workers a negotiation platform that did not exist pre-pandemic. In this current environment, individuals are negotiating for a sustainable salary, flexibility, better working conditions which will lead to less stress. For example, one reddit post referred to the current salary at a specific job as "Poverty Wages" and made a declaration to "reclaim your life." This one post focuses on the obstacles created by working for low wages and highlighted that it deprives individuals of their times with hobbies, friends, and family. If the salary cannot sustain the lowest level of need such as water, food and shelter why should one allow it to strip away the benefits obtained in the next three levels . Ergo, workers are leveraging the labor shortage to demand an improved working experience inclusive of salary, stress reduced conditions and acknowledgement of the workers sense of worth/esteem value. Hence, supporting proposition P3: The labor shortage provided an environment that allowed workers to negotiate compensation packages as esteem needs were met. Furthermore, the pandemic has created an environment that has demonstrated that remote working can be equally as effective. During the pandemic, several organizations quickly reconfigured operations to enable employees to work from home . After more than 365 days with productive results, individuals are associating hybrid work environments as normal. One survey demonstrating that 68% of workers prefer the option to work from home. In the same article, "The Prudential Survey showed that 1 in 3 Americans would not want to work for an employer that doesn't offer at least partial remote working." . The hybrid working arrangement plays another key role in whether worker can and/or are willing to return to work. Many working individuals are stewards of care for children or elderly relatives that has caused them not to be able to return to work. According to the Biden Administration, "Between February 2020 and March 2021, 520,000 mothers and 170,000 fathers between ages 20 and 54 left the labor force and have not returned. Many needs or want to work but cannot because of childcare disruptions." Moreover, individuals have been able to engage in loving meaning relationship with family that has fulfilled the sense of connection that has been traded for years of work. The last two themes that emerged were stumbling block and stress. Many individuals had to contemplate whether they could or should return to work due to obstacles that existed. Individuals were faced with wanting to accept an offer, but the following had to be considered: cost of childcare versus salary, school scheduling, vaccination policies and jobs availability/location. The stumbling blocks that could impact one's ability to return without interruption has led to declining and delaying acceptance of offers. In line with, Hossain et. al., , the global pandemic has had an impact on the mental and physical wellbeing of individuals. Parks et.al., states, "Previous studies suggest that depression, anxiety disorders, substance abuse, increased suicidal tendencies, and PTSD commonly follow major economic crises or natural disasters" and this crisis is no different. Stress has seeped into everyday life as individuals continued to navigate through school closures, unintentionally contracting disease and/or infecting others, financial instability, food insecurity, disruption to routine and having to be everything to everyone in one space. These stressors, in combination with the "trauma of job loss…might be keeping some workers from returning to the workforce. This trauma can erode confidence and self-esteem, which surfaces doubt in skills and abilities." The power of stress could be hampering one's esteem needs and ultimately surpassing the desire or ability for individuals to return. Employers need to convince their employees that they are taking measures to alleviate stress inducing factors from the workplace. Based on this study organizations need to develop a comprehensive package that acknowledges and appeals to the five levels of Maslow's hierarchy need theory. Individuals have had time to assess and meet levels of need within their life. As these individuals have satisfied the lower need levels, they are moving up the Maslow Hierarchy pyramid and thus requiring more than the pre-pandemic workplace baseline. --- Discussion As the job market is changing and the expectation of an acceptable employment offer is being redefined, there are various elements the tangential that should be considered. What happens if most workers never return to work and/or continue to shuffle between companies? Will this labor shortage and the response to the potential and existing workers become a lynch pin to the success of organization culture and retention and if it goes unaddressed how will the economy respond? Dotsey et.al, mentions the absence of the workers will be felt in "government programs such as Social Security and Medicare, or through family assistance… As a result, a society with a lower participation rate is also burdened with higher tax rates because the government has a narrower tax base from which to draw revenue." In other words, the economy could reach a breaking point that will be felt by all-in-one way or another. --- Research Contribution The purpose of this study was to explore: What obstacles have workers encountered that has prohibited them from re-engaging in the job market after the pandemic within the framework of Maslow Hierarchy of Need Theory. During the height of the global pandemic, educational institutions, restaurants, hotels, and various corporations closed their doors in alignment with government mandates and this led to millions of individuals being laid off or furloughed. Nonetheless, once corporations were ready to return to normal productions level, the workers did not answer the call. Organizations quickly found themselves in a precarious business state where the demand had returned but inventory and/or services could not be met as staffing shortages were felt across the country. This labor shortage quickly became known as "The Great Resignation" where individuals were and are continuously saying no to job offers entirely. Based on the document analysis, five emerging themes were identified. These emerging themes salary, stumbling block, steward of care, sense of worth and stress. Workers appeared to have an awakening in which the pre-pandemic work conditions and salaries are no longer acceptable. The practical implications of this information could help organizations understand the worker in this current work environment. Organization can no longer just think about filling a seat as there are just too many to fill at this time. The current five millionperson gap between unemployed individuals and job openings means organizations are left in a perilous state. If the labor shortage continues, the economy will continue to experience supply shortages, delays to schedules and climbing inflation. The findings from this study suggest workers are facing five obstacles that are prohibiting them from returning to the job market. Hiring managers and human resource representatives should be aware of these obstacles or consider asking question in the interview process to understand 1) what the biggest obstacles are and 2) are there ways to mitigate them in a way that both parties can be move towards agreement. There is a potential for these findings to be incorporated into Human Resources strategies to engage, attract, and maintain workplace loyalty and commitment in a time when workers have the negotiating power. --- Limitation In accordance with Bowen, this study has unveiled several discussion points, however, there are limitations that require acknowledgement. The research was conducted on 76 documents and posts which is not an extensive data set. In addition, document analysis is primarily generated for a purpose outside of research and therefore may not obtain insufficient details, obtain biased selectivity which can skew the format or tone of document and content can have low retrievability as some documentation can be blocked or deleted. Boslaugh mentioned, secondary data was not collected with this specific research question in mind. The literature also suggests document analysis should be triangulated to add validity. Lastly, Reddit is one social media forum with a specific subset of individuals which may not represent the larger population.

The objective of this study is to understand the paradigm shift that unfolded during the "Great Resignation\Reshuffling" (2020-2022) within the minds of workers with respect to not re-engaging in the job market after the pandemic. In early 2022, according to the U.S. Bureau of Labor Statistics (BLS), there were approximately 11 million job openings and 6 million unemployed individuals. The convergence of these two data points indicates five million jobs with vacant seats. Therefore, we aim to answer this research question: What obstacles have workers encountered that have prohibited them from re-engaging in the job market after the pandemic within the framework of Maslow Hierarchy of Needs Theory? To investigate this question and the associated unprecedented phenomenon, an inductive qualitative research analysis was conducted to review and code archival data from three sources: Reddit posts, the U.S. government (BLS, White House, Federal Reserve) documents, and press articles. The content from more than 1,000 pages (31 posts and 45 articles) was systematically analysed through first and second cycle coding to extract themes that identify the factors being considered by individuals who have chosen to remain on the job market side lines. This article attempts to magnify the American worker's voice in an environment where it could feel like "nobody is listening" (Shaw, 2000) The findings indicate that salary, stumbling blocks, steward of care, sense of worth and stress are the leading factors that may prohibit individuals from returning to work. To triangulate these findings, additional press articles, government documents and Reddit posts will be coded to increase the data set (second study). The research limitations include a review of only three document sources, a focus on one country alone (the United States) and only one social media platform. Therefore, it cannot be stated that this list is exhaustive. More research is needed to include other platforms and sources. Nonetheless, the findings could help organizations understand this paradigm shift and formulate recruitment and retention programs that address the factors and needs of employees in a post -pandemic work environment that remains full of uncertainty and disruptions.

Introduction The economic, environmental, social and cultural importance of family farming was recognized by the Food and Agriculture Organization of the United Nations and reflected in the implementation, in 2014, of the International Year of Family Farming. This recognition aimed to put "...family farming at the center of agricultural, environmental and social policies in the national agendas..." ) and, later on, by proclaiming the United Nations Decade of Family Farming , as an opportunity to address family farming from a holistic perspective and to contribute to achieve the 2030 Agenda for Sustainable Development . This recognition reinforces the role of family agriculture in fighting hunger and poverty, in preserving natural resources and the landscape, in improving the quality of life of local and rural communities, and in food security . Family farming is a concept used to identify agricultural production units that are managed at the family level and relies predominantly on family labor, with a strong relationship between land, labor, and family . The family is simultaneously a production and consumption unit: work is organized by and for the family. Family farming is the most predominant type of agriculture worldwide: it was estimated in 2014 to occupy about 70-80% of the world's agricultural land, account for about 90% of agricultural production in 93 countries, and be the source of 80% of the food consumed that guarantees food for 40% of the world's households . In Europe, in 2016, about 96% of agricultural land is dedicated to family farming, where about 90% of the farming population works . In this context, the role that women play in this sector of agriculture also has been the focus of attention of various international bodies. Women represent, on average, almost half of the agricultural labor force, playing a central role in family farming, not only through their work, but also because of their ancestral knowledge, sustainable management of natural resources, production and conservation of agricultural products, as well as caretakers of children and/or the elderly . In 2011, in "The State of Food and Agriculture 2010-2011" report, with the subtitle "Women in Agriculture. Closing the gender gap for development, " the role of women in the development of rural areas and the economy, particularly in developing countries , was recognized . In the same report, FAO recognized the inequalities and difficulties that women farmers face compared to men farmers in various areas such as access to land, education, markets and services, among others. In 2016, the European Institute for Gender Equality listed this type of gender inequalities in the agriculture sector, at European level, namely related with women's participation and representation in rural development and in decision-making positions in agriculture . In fact, in the same year, in the European Union only 3 out of 10 agricultural leaders were women . The invisibility of women farmers and their work in agriculture , as well as the preponderance of male at the center of the discourse in family farming , originates a knowledge gap about women roles and importance in family farming. This is specially relevant in countries, such as Portugal, were family farming still represents 94% of the farms, with more than 30% being managed by women . Furthermore, at the national level, there is no updated and in-depth information about Portuguese women farmers and their contributions at the social, economic and environmental levels. This article aims to give voice to women farmers and provide insight to help other researchers to produce knowledge about women's agricultural work in Portugal, which will contribute to the development of better public policies that respond to the real problems of family farmers and especially women farmers. Thus, we intend to answer the following research questions: How do women farmers perceive their activity in three rural areas of Portugal? What are the role and difficulties that women farmers experience in agriculture? Is there a gender division of labor in family farming? --- Women and family farming in Portugal Although major transformations have occurred, both in agricultural activity and in rural territories and their communities, over the last decades, the most recent data from Portugal, suggest the importance that family farming maintains in the country . In 2019, in Portugal about 68% of the agricultural work volume is carried out by the family farming population occupying the 14th place in the European Union . Only 13.1% of farmers live exclusively from agriculture and ∼2/3 occupy <50% of their working time on the farm. Most farms are managed by individual producers , although the number of companies has increased in the last decade . The representativeness of women leading farms is 33.3% , but 47.9% of the farm labor force is provided by women . The strong feminisation denoted by quantitative data in family farming is not a recent phenomenon in Portugal. The presence of women in agriculture is observed in Portuguese statistics since the second half of the 20th century . The statistical information available in the censuses, despite some weaknesses and limitations, suggested a growing female labor force in comparison to the male labor force, in agricultural activity . This increase is noted both as individual farmers and unpaid family workers. This process of feminisation of the agricultural sector dialogued with broader social processes, namely industrialization, and the consequent rural exoduses . In the case of industrialization, this process caused the displacement of male labor to other areas of activity and made agricultural activity less prestigious and rewarding . The rural exoduses are intrinsically linked to the greater opportunity for work abroad and in other professions offered to men . In short, these macro-social transformations, allied to micro dynamics within the family, placed the woman as the center of work within family agriculture, in countries such as Portugal . Thus, despite the reduction in agricultural assets in both genders " the regular presence of women in agricultural work is almost always contrasted with an irregular and more or less important male presence..." . In fact, over the last 30 years old, it has been women who have remained in agriculture the most. National data reveals this trend: while in 1989 there were 501,978 men and 91,870 women leading agricultural holdings , 30 years old later 183,916 men and 90,332 women remained as managers of their farms . This variation stands for a less 63.4% for men and less 1.7% for women. Despite the fact that there are more women remaining in the agricultural activity and that women assuming leadership of their farms have increased, formal leadership positions continue to be mainly "male territory." In fact, in Portugal, in 2019, around 69% of farm managers were men; women hold only 31% of leading positions, while in 1989, 83.7% of farm managers were men and only 16.3% were women . However, this feminization of the agricultural labor force and leading roles has not been sufficient to eliminate gender inequalities in this sector . Although this feminization is evident, nationally and internationally, there are few studies that portray agricultural activity from the point of view of women , remaining almost always around male-dominated places of discourse. It is thus important to better understand the issue of gender equality in It is important to note that the feminization of agriculture is not a linear process. Di erent geo-spatial contexts explain di erent paths for the feminisation of agriculture, coupled with di erent broad social transformations. Some authors, as Cernea ( ) and Lastarria-Cornhiel refer di erent factors leading to the feminisation of agricultural assets, in contexts outside the Portuguese case. this specific social context, and to identify factors of inequalities between men and women farmers. --- Gender roles in family farming With regard to European research on gender roles in agriculture, Sarah Whatmore outlined some conceptual changes, namely to stop looking at men and women as fixed categories, but rather taking into account the meanings and practices that define and characterize them. The use of gender role theory gave way to gender identity theory, more specifically the representations in daily life of what it means to be a man or a woman farmer, thus giving greater prominence to the roles and tasks performed by them . Discourse is one of the most used units of analysis in the literature to understand existing gender inequalities. The results of studies carried out within this scope point to an ever-present patriarchal logic . Brandth , carried out a study on gender identity in European family farming, and identified that the positions of male and female farmers portrayed in the literature were linked to 3 types of discourses: "the discourse of the family farm, " "masculinisation, " and "detraditionalization and diversity." In the first discourse, the male farmer is portrayed as the "public figure" of the family, and the woman is almost in a secondary position, not participating in events outside the family circle. Land ownership is seen as something that should pass from father to son, while women see their access limited and it is only possible to obtain the title of land owner through widowhood or marriage, i.e., the title of land owner never comes from the woman's choice, but from marriage. This type of discourse highlights the patriarchal character as one of the primary characteristics of family farming. The second discourse focuses on the process of masculinisation of agriculture, i.e., the transformation of agriculture into a markedly male area of work. Family farming has a strong masculine connotation, as it is the man who controls and manages the family business, so when one thinks of a farmer there is a tendency to imagine a physically strong male individual . The process of industrialization of agriculture was a period where women lost part of the central role they had. A good example of this is the mechanization of milk production: "Milking used to be an important task for women, but in the mid 1900s when the milking machine was introduced, it became just as much an area of work for men, and thus women were forced into a secondary position, or into a position of housewife" . Agriculture followed the global process of industrialization and, with it, an increase demand for more skills from farmers overcome, with men being the first one to acquire them, leaving women in a secondary role . The third and last type of discourse portrays a shift toward the empowerment of women farmers. Research on women farmers in Europe reveals the occupation of new positions such as " farmer, housekeeper, business secretary, farm assistant, agricultural worker, off-farm income earner " . The positions that women farmers occupy nowadays are changing: according to Haugen and Brandth , younger women farmers choose agriculture as a profession and, calling themselves professional women farmers, seek to acquire skills that give them autonomy in farm management, such as driving agricultural machinery . Gomes et al. made a more recent analysis of the scientific production on women in rural contexts and concludes that the current thematic focus can be grouped into two subthemes, namely the "... gender relations and rural spaces that encompass discussions focused on: class relations; gender relations; care and health; right to access to water; body and sexuality and gender and new ruralities that involve studies on: rural development; political protagonism" . The proposal for analysis that places the relationship between gender and class in the spotlight continues to be a usual conceptual path in the research of this theme; however, currently science has favored a poststructuralist perspective, transcending the classic Marxist vision: in addition to the economic sphere, the importance of gender relations is also recognized under an intersectional approach, which takes into account the individuality of these women, as well as their agricultural and community work and the analysis of the discourses of the subjects of various social spheres . With regard to studies on gender relations in the Portuguese rural space, Carmo sought to understand how the sociospatial divisions and social practices have changed according to gender, in the last 30 years, taking into account factors such as the modernization and urbanization of daily life in the rural community. The conclusions of this study show some reconfigurations in relation to the traditional model of division of roles, namely: the widening and intensification of social contact with the urban environment for both men and women; and the management of the domestic economy ceased to be exclusively the domain of women, with men taking on some of the burdens related to financial matters and domestic consumption . On the other hand, the continuities of the patriarchal model of inequality still appear persistent and in large numbers. The author found that sociability relations in public contexts are still more practiced by men, as they live more regularly in urban and leisure spaces such as bars, discos, restaurants and cafés. The appropriation of public spaces is also carried out differently according to gender differentiation, since it is the man who identifies and presents himself with a more public image, also accompanied by a greater intensity of regular social relationships . Added to this inequality of social capital, there are also differences in the way men and women occupy the public space during socialization: women talk more at the door of the house and in the markets while men use the café for this purpose, which reveals a continuity of the figure of the woman associated to the domestic space. The café, which used to be called "tavern, " continues to be a place described by women as awkward and where they do not feel "welcome, " because it is dominated by the opposite gender. These customs, by allocating female power to the private and male power to the public , reproduce an asymmetry of representations and meanings attributed to these gender identities, in various dimensions of society ), of which agricultural work is no exception. These customs, imaginaries, representations and meanings when incorporated in different spheres throughout life, define the sexual division of labor and the appropriation of certain spaces . Based on the findings from an exploratory qualitative study carried out in two regions of the inner Portuguese territories, we intend to explore the meanings and perceptions of women farmers on different dimensions of their professional activity. It is intended to contribute to the construction of knowledge about family farming, with special focus on its gendered dimension and the need and relevance of including women's point of view in this field of studies. Likewise, to denote the importance and need to undertake efforts to combat gender inequalities in this sector of activity, as well as to value women roles, which is so pressing in food systems worldwide. With this work, and similarly to other international theoretical approaches, we intend to unveil and understand the discourses of Portuguese women farmers, something that has not yet been presented. Our main research questions are: What are the perceptions of female family farmers toward the agricultural activity and their work? What types of discourses are dominant in the Portuguese agricultural scenario? --- Methodological approach and data collection This work results from the project "MAIs -Women farmers in inner territories" which aims to increase the civic and associative participation of women farmers in inner Portuguese regions, through their empowerment, the promotion of the visibility of their social role and gender equality. The focus of the project is family farming, through a pilot experience in two municipalities: São Pedro do Sul and Sabugal, where the family farming population plays a relevant role. In 2019, the proportion of the family farming population was 20% in São Pedro do Sul and 30.7% in Sabugal . The proportion of women in the family farming population was 49.5% in São Pedro do Sul, and, 47.4% in Sabugal, that is, almost half of the family farming population. The percentage of women farmers aged 65+ was 39% in São Pedro do Sul and 44.8% in Sabugal. The methodological approach used in this study is qualitative, by seeking the meaning and the rational adjacent to the action , which will allow us to explore the imaginaries and symbolic universes, taking as unit of analysis the voice and discourses of the participants . The qualitative approach allows the researcher to see inside the reality at study , as a construction of the participants and not of the status quo around them . There are several qualitative techniques, all with different functions . Within the scope of the broader project, of which this study is part, the focus groups were carried out in an exploratory phase of research and aimed to better understand the women farmers of the municipalities in study, as well as generate and evaluate ideas collected a priori through theoretical analysis on the subject. They also allowed the team to facilitate access to individuals or groups normally reluctant to communicate. Its potential is to create threads of discourse, life stories and experiences that are shared during the sessions. Focus groups are a qualitative research technique for gathering information in which a number of people are brought together as a group to discuss a particular topic of interest, with the facilitation of a moderator who poses questions and encourages a diversity of opinions . This type of group interviews is a qualitative research technique which allows for a deeper understanding and analysis of the perspective of a group of selected participants about specific themes/issues . Once the type of focus group to be conducted had been defined, the script was developed. The script was constructed with few items , in order to allow flexibility in the conduct of the focus group . The items considered were: . how agriculture entered the lives of these women; . understand agriculture and rural life in these regions; . identify perceptions about the gender division of labor; . understand the social/political involvement; . identify the main problems and needs. Participants, identified among family farmers in both regions, were selected based on their professional activity , gender and familiarity with the issues under analysis with the aim of fostering a comfortable environment where all participants could share experiences on the topics addressed. Fourteen women farmers participated in the two focus groups . These participants were chosen by the officers of the Municipal Councils, and their selection, among women family farmers, was based on the availability to participate in the group interviews. Thus, this is a non-random sample by convenience. Given the characteristics of the selection method of the participants, the sample of this study is not representative of the women family farmers of the two regions, nor of the Portuguese women family farmers, therefore the results presented here are limited to this study and sample. The participants have an average age of 50.5 years old, the youngest being 28 years old and the oldest 66 years old. Half have completed secondary education and the other half has a lower level of education ; most are married or in a situation of cohabitation , as shown in Table 1. The two focus groups took place in May 2021, in spaces provided by the municipalities, where the conditions for the collective interviews where assured. The interviews were conducted by a member of the research project, with two people present in the room to collect information and to provide logistical support if necessary. The focus groups had ∼2 h, and the interviews were recorded in video to facilitate the material transcription and the identification of the speakers in moments of overlapping speeches . The records of the participants' speeches in the focus groups were subsequently transcribed. This analysis was focused on the excerpts of discourse considered most relevant for the objectives defined in the project. For the treatment of the qualitative data collected, a categorical content analysis approach was used. Such categorization allowed reducing the complexity of the material, identifying the main issues addressed and allowing its treatment , The categories were defined based on the themes contained in the guide, as well as on the strengths of the theoretical material gathered during the literature review, and on the themes that emerged during the analysis of the material. The findings of this analysis will be presented in the next section through excerpts of the interviewees' speeches, systematized and divided according to the dimensions of analysis and corresponding categories . These are: perceptions of agriculture ; gender division of labor in farming; perceptions about their role and difficulties as women farmers . --- Analysis and discussion of findings --- Perceptions of agriculture --- Changes in agriculture The discourses of the focus group participants highlight four major changes in agriculture: corporatisation/entrepreneurship, mechanization, market competitiveness prices and community dynamics/agricultural popular economy logics. Professionalization and the increase of companies , together with the greater entrepreneurship in the sector, was one of the transformations identified by the participants. These transformations are associated with the bureaucratisation of agricultural activity and the aggressiveness of the market, when compared to the agriculture reality of previous generations: "Today's agriculture does not compare with the old days. it was subsistence farming, today it's business. It's a business and there's a lot of bureaucracy along the way. It requires too much documentation and paperwork "We are not farmers anymore; we are a company. We have accounting, we have to do invoicing, we work like a normal company." With regard to mechanization, the discourses highlight the ease and time savings in the performance of certain tasks, which previously would have taken days. Improvements in the quality of life were also mentioned, as the use of machines reduced the amount of tasks with high levels of physical demand, as well as tasks that were performed with rudimentary work tools or the use of animals: "It completely changed . came with tractors, machines, which in the old days was with the plow, the cows plowing the land. There are machines for everything today, pretty much." "In the old days, it took almost 3 days to plow, with the help of the cows . It was done in stages" "We loaded the pitchfork again for the cow cart. With the cow cart, we put soil in mounds . Now, on my farm, everything is done with a tractor. The tractor has some hooks, they take the manure and spread it and plow " " [the use of machines] has brought us some life quality!" Price competitiveness, as a transformation in the sector, was mentioned. One participant highlighted the difficulty of selling on some products, especially due the lower prices on other selling platforms/markets. In other words, the monetary devaluation of certain products makes it difficult for farmers: "In my parents' time, if my father produced potatoes, he always sold them. If he produced rye the price was always assured Today, if we wanted to produce potatoes, there is no one who looks for a potato, a kilo of corn. --- " There are also several references to the changes felt in terms of community dynamics and local economy. These discourses mention the progressive abandonment of agriculture and rural territories, as well as the disappearance of community activities and forms of conviviality that are lost or replaced by other social dynamics: " in the old days, it was family farming, it was uncles, neighbors who helped each other. Today we can't even hire a friend or relative, because if there's a problem on the farm, all we earn on our farm, is not enough to pay [the costs of an accident, disaster, etc]." "It was, it was... a joy, it was a joy that we had there. We never did that again! [about a community activity that was common when she was a child]" "It was a happier time than now. We would cut the grass, make the small bundles and put that outside to make those dolls. And then we sang, danced, it was a joy. It was happier than now." The discourse of the participants allows to contextualize their view on the agricultural activity within a specific time space. This space is marked by major social transformations that the rural spaces, and more specifically the territories of the Portuguese interior, have been experiencing . As we can see, these changes are not only limited to the professional context, but also extend beyond the social context, family dynamics and the community nature of family farming. In effect, these changes have confronted family farming with various threats and weaknesses to its continuity. Results from other works also refers to the discontinuity of the activity by household members as a result of occupations abroad, the disappearance of local markets and traditional marketing circuits, the devaluation of production in the agri-food chain, the aging of the farming population, and loss of property . --- Perceptions of farming as a profession Let us now focus on the professional context of the participants and their vision in relation to their professional activity. The first idea that emerges from the participant's discourse is that agriculture is an activity opposed to following, or carrying out, studies: "Many say "why did you want that life?" because many studied and only I stayed in agriculture!" "I was studying and when I got home from school I had a little paper saying that I should go with the cows here or there... and I took the books, I was obliged, because I didn't stay at home to study, there was no time to stay at home to study... "you take the books, put the cows away and go, you study if you want." In fact, this discourse indicates that the agricultural context of the family and the lack of access to certain types of services in rural territories constitutes a constraint to follow other life paths, namely those in which an investment in formal education would be necessary. In fact, Rodrigo , already have referred to traditional family farming dynamics, based on pre-determined gender roles, that restricted the woman to agricultural activity, while the man was offered more options outside this activity. On the other hand, this discourse refers to a preconception of agriculture as an activity related to low qualifications. This notion will be again mentioned in relation to life trajectories throughout the participants' relation with agriculture. --- Trajectories into farming In relation to this category, different types of trajectories of entry into agriculture were found. Let us begin with discourses that indicate entry into the activity via the family: "I have also always worked in agriculture, since I was young, I did a bit of everything... Yes, [PARENTS] were farmers and I also stayed here, also a farmer " "I was also born there, I was born in [Locality where she still lives] and my parents had animals. And it's like that, it was through them [the parents] that I learned." "I always worked in agriculture, since I can say almost since I was born, no, but almost. It was my parents' life, and so I continue, it has always been my life, to work in agriculture." Another way of entering and remaining in agricultural activity was through marriage: " I was studying and I would continue, it was a higher education course. Only as I got married and got that big holding.... and they said 'you can continue and stay with this'." Nevertheless, we also found participants that suggested entering into agriculture as a personal choice, either through free will or emotional reasons: " I was not a farmer it comes a little bit in the idea of me coming and learning something. I am from here , my husband works here so, at the time we decided to go ahead and do we have some small plots of land that were left to themselves and we decided then to do a project, we went ahead, the project was approved " "I took this life option also because of my three children, because when I came here to the village, I didn't have anyone here, my parents don't live here, my in-laws, nobody. this choice of life was for my children " . The discourse analyzed also indicate pathways marked by a large volume of work and time dedicated to agricultural activity. This results in work routines that take up entire days, with uncertainty regarding overtime, causing a certain relegation of time for rest and personal life. "I'm up at seven in the morning every day! Sometimes it's midnight or one o'clock in the morning and I have a cow to calve and I'm there in the field accompanying her..." " The difficulty is that we can never schedule holidays, when we are about to leave there can be a big surprise on the farm and it all hangs around. It's positive and negative, it's always swinging. schedules are difficult, with the weather and problems that arise on the farm, the days are never the same, every day is different." "It's true, we don't have holidays, we don't have Saturdays, we don't have Sundays, we have to work at night, we have to work during the day... if they [cattle] remember to give birth, we have to go, they are the ones in charge " " it's a life of hard work." Moving on to the difficulties experienced within the agricultural activity, the data collected reveals difficulties at the level of marketing the production. "Many times we do not have market for the product... it's [a problem]. In calf rearing, there are times, when there is no market for the calves." "We never have a right price for the animals, we never have a right market for the animals ." . The uncertainties and difficulties in terms of the flow of production are further explored in other discourses. The participants' highlight the role of factors external to the activity in conditioning economic resilience: " it's a profession of high economic risk. You're always subject to a lot of things: the weather, when the cows calve well or not. It's always a life in uncertainty the income at the end of the year depends on all these factors. It's always a life of great uncertainty and it takes a lot of courage to be a farmer, plus a woman." " we never know if we will harvest enough straw. It's always uncertain! Any work is always uncertain... a machine breaks down, a pipe bursts." "We only have money when we sell some calves and we only have money when we get subsidies " . Although the difficulties and uncertainty of agricultural labor are highlighted in these interviews, these appear, in some cases, associated with a discourse that emphasizes as a positive counterpoint the independence that this activity makes possible: Although the activity, as we saw above, is marked by external difficulties, there seems to exist an intrinsic dimension that somehow compensates these extrinsic factors . In fact, the pleasure and enthusiasm, are materialized in pride, pride that the participants feel in their farm and produce, especially from the recognition and opinions of others about it: "I have friends from all over and when they come here they say that this meat is spectacular and for some reason it is..." "I kill two calves a year and when I invite guys over to eat they say the meat is wonderful." Still in this domain, some participants characterize these perceptions and feelings as key tools for success within the activity: "Those who go into this activity with pleasure and with love that is a very great strength in all the problems that arise. If it's not with their own will, they don't make it." "Those who take the farms forward, it's with pleasure and love . Now there are those who go there just because, but after a year they give up." "Any profession, if you don't like it, you can't do it. Now, this one is a very demanding profession." This dedication is perceived as the source of energy for enduring long working routines, as well as for the necessary resilience in facing problems and difficulties and overcoming them, that are the "day to day" in agriculture. The discourse of the participants confirm that routines in agriculture are always changing, never being exactly as predicted or in the previous day . --- Gender division of labor in farming As the gender division of agricultural labor is a fundamental dimension to the study of gender issues and the understanding of existing inequalities in agricultural activity, we dedicate this section to the analysis of the discourse of the women farmers that participated on the focus groups on this topic. Eight interviewees stress the idea that there is no inequality or difference between men and women: "I think... whether woman or man, each one just does what he wants. [DEALING WITH CATTLE] we do everything the same, women still deal better with animals. [ON THE QUESTION OF STRENGTH] It's the same, you just have to pull for her. I can stand next to the man I have no fear at all." "I do everything like a man. in the matter of my husband, because if he does it I do it too." "There are no differences. The differences may be in the issue of strength, but that is not relevant." "The only thing my husband doesn't do, is molding. But he does everything, he peels, he waters " One trend is clear in these discourses: in general, the participants do not identify or do not perceive situations of inequality within their work context with their partners. They rather emphasize an equity between men and women, assuming little significant differences. However, despite of it, the analysis of the discourse presents several gender differences related with gender division of agricultural labor. Let's see: "We have an auction park if we look at the presentation of cattle, most are men. it is rare for a woman to go to the cattle show, even if she is the farmer... there are one or two. I could probably list half a dozen... that's all." "Now of course, the men.. "... it discards more for the man to do the business. We both work, he takes care of the selling and buying and I take more care of the notes and those things... the papers. In cases, where the man has another profession, of course the woman has to take care of everything" These discourses highlight differences between men and women with regard to the decision-making spheres, namely in public spaces . The adage found in other spheres of society , is also present in the social context of these women farmers: men still dominate the formal decision-making spaces. Nevertheless, and based on the experience of some participants, decisions at the informal level are taken by them. "I'm the one who does the business, I'm the one who decides, although we talk to each other. We talk between the two of us, but I'm the one who says... this comes from the beginning! " I have a person with me [PARTNER], but he is more in another area. I'm more with cattle and sheep then I'm the one who decides, I'm the one who treats, I'm the one who does the business, although I ask for his opinion but I'm the one who gives the last word. I don't even feel comfortable that someone else does it Now the last word is mine, always." "I happen to be the one who manages the holding... what little it is [LAUGHS], I don't give it up." "He [HUSBAND] collaborates a lot, but I'm the one who takes the decisions." It makes sense to find this type of independence in decision-making processes, since some of the speeches already highlighted the autonomy that the agricultural profession conferred to certain participants. However, there is a clear tendency to consult their partners before taking a decision, even though they imply that it is their word that counts the most. We thus find an inversion between formal and informal decisionmaking contexts, although on the informal level, the women as a protagonist is not a trend in the sample in question. In relation to the division of tasks, between men and women, in the agricultural activity carried out by these women, some participants refer that this is carried out in an egalitarian way. Although in some cases, there are tasks that belong to each member of the couple: " me and my [NAME OF THE PARTNER] have other professions and other things, so sometimes time management is not easy one day I go, another day he goes [to the farm] " "Yes, he works, yes he [THE HUSBAND] also does it he does it with the tractor, plows, mills, when it's the potatoes they have to go there to sow the potatoes, to help he also has to go there." The participants discourse also indicates situations where the woman is the only component of the couple that carries out agricultural tasks: "There's a cow to calve and my husband is like "never mind, it'll be fine", but I say "we have to go watch!" and he doesn't.... And I grab the car and go there to see" " I do everything by myself, everything from scarifying to gardening. Everything, because I can't wait for my husband " The discourses suggest situations of clear division of labor between the members of these couples, in which the woman takes the initiative and seems not to receive help from her partner. Also, other tasks are clearly a responsibility of the men, namely the tasks related with the use of agricultural equipment and specific tasks, usually considered to be skill demanding, such as pruning or applying pesticides/fertilizers: "But I see that it is like this, the man is more tractor and coring and pruning the woman is the one who does all the [MANUAL] work." " what [P7] was saying, that men work more with machines and women don't some of them are still afraid to take the tractor or to pick for the brushcutter this major distinction came from that. Of the man taking the artifacts and the machines and the women working more with their hands. In fact, the perception that the relation with machinery and equipment belong to the men's forum, is reinforced by the participants: Taking into account the participants' age, it seems that younger women are the ones who are not afraid to perform tasks using machines, compared to older women. Still at the level of the division of tasks between men and women, some discourses refer to social imaginaries that feed differences between men and women in the performance of their activities: " women still deal better with animals." "Men, in general, do not have the skills that women have to do several jobs at the same time... we do the house life, we still take care of this and that, but they don't! They do that and... one thing at a time " This last discourse is of particular interest, since it denotes inequalities in the volume of work between men and women, highlighting the double working hours of women . Finally, a positive change in gender inequality within the agricultural activity is acknowledged. However, this recognition is made by women in younger age groups : "Maybe in organic farming, even in older people, there is already a greater sharing of tasks." "[ON THE FACT THAT WOMEN IMPOSE THEMSELVES ON MEN] It's like that, it's like that within my age group. Now in the older ones, maybe not..., but the younger ones, we are already more resourceful " " As a rule, now there is not so much difference... women, we impose ourselves and that's it [LAUGHS]" --- Perceptions about their role and di culties as women farmers Finally, and because this appears to be an extremely important dimension of analysis in the study in question, we will analyse the perceptions about their role as women farmers, either by themselves or by others. The interviewees reported discrediting by men, which arises in comments, based on asymmetries in representation between the masculine and feminine. Other works related with gender divisions and agriculture, these social representations construct gender, and, when they are asymmetrical, they dictate not only a division of labor, but also gender inequality . Once again, it is possible to verify the social perception of agriculture as a male activity, based on socially shared ideas resulting from social representations of gender. These social representations are reflected in the strangeness of being a woman performing tasks, or occupying spaces intended for men. " just because we are women, I think it's a discrediting of our work. Why? Ah, she's a woman, she doesn't have as much strength as a man she won't be able to do it . When I started, they said I couldn't stand it or manage, just because I was alone and couldn't carry out the activity. [INTERVIEWER]: And did you hear that from family, friends? [P3] In general from the male person, first of all bearing in mind the age at which I started why I took up farming and the fact that I was so young, that I was a woman and they said that I couldn't carry out the activity as well as a man." . "When I had the sheep and when we started to sell the cattle, my husband wasn't there because the sheep were mine, my husband had his profession. And the guy [BUYER] arrive there like 'then your husband isn't here'? So, now how can I buy the lambs from him?' I was like "then if you have to buy them, you'll buy them from me"; [BUYER BY THE VOICE OF THE WOMEN] "and you sell me the lambs? and then your husband?" [P4 REFERRING TO HER OWN VOICE] "My husband doesn't have anything, so, I mean, this is mine, is he the one in charge now? " men respect a man more than a woman... all my life it was like that." --- Conclusions The exploratory data we present suggest that these group of Portuguese women farmers, from the inner territories, work in a social context that has undergone major changes over the last decades, whose impact is referred to in the discourses at the level of agricultural practices and activities, marketing of products and in community dynamics. In several cases, the trajectories of life in agriculture started very early, and the permanence in the activity was the result of external influence: family or marriage. On the other hand, the agricultural work of these two groups of women, as well as their own activity, is characterized by long, solitary and uncertain working days, that they value due to intrinsic dimensions, mainly the results of production, independence regarding the organization of the work or the possibility of making their own decisions. Also in the gender dimension, the public/private dichotomy is clear, especially in decision-making places: formal and public places are dominated by men; informal and within the couple are equal places, or dominated by the woman farmer, often with consultation with the male partner. Gender is also a reason for discrediting their abilities as women farmers, in the perception of some of the participants, making their activity even more difficult. The speeches of the interviewed women are compatible with the three types of discourses identified by Brandth . The premise of the first discourse that portrays the male farmer as the "public figure" of the family still holds true, an example of which is pointed out in reference to cattle marketing spaces. We also perceive that the agricultural tasks dominated by the man are the most mechanized ones, since many of the female farmers do not know how to operate the machinery and in their discourse assume these tasks as being masculine . Manual work is still performed by women farmers, which is related with the family-based and small scale portrait. The discourse "detraditionalization and diversity" is also present in younger women farmers , that choose agriculture as a profession, and invested in agricultural projects, and want an healthy and sustainable life for their families. With regard to the analysis of gender relations, lack of time and the need to attend to domestic responsibilities are the main obstacles that prevent them from participating in social and economic activities. This is aligned with other authors, such as Gomes et al. that mentioned that women's patterns of displacement and participation in activities stem from a demarcation of "gender roles, " which still remain traditional and restricted to the private space of the home. The discourses presented are not enough to allow wider deepening of some life dimensions of these women farmers, in particular the life trajectories and other dynamics related to gender roles and representations, with special focus on decision-making places. Also, the limits of the information collection technique become clear throughout the exposition of the data, namely the strong participation of some interviewees in relation to others, and reduced approaches to certain topics . In terms of limitations in the present sample, the representation of women from older age groups, influences the perceptions about the changes in agriculture, that are usually considered to have more knowledge on this topic. Probably, an effort of the moderators to encourage the participation of younger women in these interview topics, would allow to collect information to compare meanings and perceptions. These limitations can be compensated in future research in these areas, articulating the participation of younger women with older women, and thus promoting dialogues and data for intergenerational comparison. However, given the exploratory richness of the material, we believe that these offer new evidence and clues for future research and work in these meanderings, particularly at the Portuguese level, with special focus on portraits of the figure of the women in the family farming context in the first person. By making this undertaking, we will contribute to the construction of new knowledge on forms of gender inequality which have not been the target of intervention -making the invisible "visible" is the first step toward what follows: changing this invisible. Several international organizations recognize the fragility to which women farmers are subjected, while also recognizing the benefits, at local and global levels, that arises from the promotion of gender equality in family farming holds , since we are dealing with the most common type of agriculture, that contributes with undeniable importance for the world food systems and for the fight against malnutrition and hunger. Also, it is widely recognized that this sector support sustainable agricultural systems, mainly based on traditional and ecological practices , thus being pathways toward the Sustainable Development Goals and against the current climate crisis. In fact, the profound transformations of global realities such as agriculture can no longer be analyzed only from one dimension, but rather as a result of the intersection of different perspectives , challenging disciplinary boundaries and taking into account all the faces of a phenomenon. Only by doing so, it is possible to promote social wellbeing and contribute to the eradication of inequality. --- Funding --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- Ethics statement The studies involving human participants were reviewed and approved by COMISSÃO DE ÉTICA DO POLITÉCNICO DE VISEU. The patients/participants provided their written informed consent to participate in this study. --- --- --- 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 importance of family farming in food systems worldwide is recognized by di erent international bodies, as well as the leading role played by women and the inequalities they face in this sector of activity. The most recent data from Portugal highlight the importance of this type of agriculture in this Southern European country. In , % of the total agricultural workforce in the country was concentrated in family farming, with almost half of them being women. This high permanence of women in agriculture is the result of a long process of feminization on this sector that is similar to other contexts. Despite this strong feminization of family farming, there are few studies that portrait agricultural activity from the women's viewpoint, since the voice of men is always predominant in all references. Based on the exploratory qualitative data from two focus groups, carried out in two Portuguese inner regions, we intend to address the perceptions and meanings of a small group of women farmers regarding their activity, the role taken by them in agriculture and the di culties they experience. Issues such as changes in agriculture and the sexual division of labor will also be addressed in this article. Within these groups, women work in agriculture is perceived as long, solitary and uncertain. Also, the public/private dichotomy is evident, with decision-making and public places dominated by men. A prevalence of the discourse of "masculinization" still exists with certain tasks being attributed to men (e.g., operations with machinery). Younger women ( and years old) tend to overcome these gender di erences choosing agriculture as a profession and healthy and sustainable life for their families.

The past four decades have witnessed a plethora of studies on gender-role portrayals in advertising on television . From the perspective of marketers and advertisers, gender is a primary segmentation variable in developing marketing strategies and defining target groups . Also, gender portrayals have possible effects on corporate images and on purchase intentions of consumers . From the perspective of activists, advertising councils, or policy regulators, however, the stereotypical depiction of men and women in today's ads is problematic for many reasons . It is argued that advertisers create and perpetuate gender stereotypes, which may erode gender equality and harm society at large . The accumulated empirical evidence clearly suggests that gender roles are highly stereotypical in television ads . However, despite this strong research tradition around the world, it is less clear how a country's culture shapes gender roles in TV ads. This research deficit can be traced back to the research designs used in previous research. In fact, most research on gender stereotypes in television advertising is based on single-country studies . Because such studies work with a specific sample at a specific time of the year, we cannot use them to compare findings across countries. For instance, if we see a difference between two studies from two different countries, we may not be sure whether the observed dissimilarities reveal cultural differences or whether they can be traced back to differences in time frame, sampling, codebook, or other characteristics of an individual study . Comparative research is therefore urgently needed. Only a very few studies have analyzed gender roles in a comparative fashion allowing for a test of country and cultural differences . Most of these studies have relied on one or two comparative gender indices , and more recent indices have not been employed. This limitation makes it difficult to come to a definite conclusion about the role of cultural variables in explaining the portrayal of men and women in TV advertising. Even more importantly, almost all the relevant studies have looked at television ads in only two or three countries , which is a clear limitation in terms of detecting cultural patterns. In fact, only Paek et al. looked at television advertisements across seven countries and used Hofstede's masculinity dimension and the gender development index to explain gender-role portrayals. Although Paek et al.'s study is pioneering in many aspects, they only tried to predict the gender of the primary character and the voiceover and sampled the material from different months , Bwhich may reduce the generalizability and the comparability of [their] findings within and across the countries.^Also, their data are from 2002, and it remains unclear-as with most content analytical research-how the findings can be generalized to more recent years. Even more importantly, all the known prior comparative studies have not empirically modeled the influence of culture on gender stereotypes. It is not the same to interpret differences between countries by drawing on cultural differences as it is to empirically measure and confirm the role of culture in an adequate statistical model. If a specific culture shapes gender stereotypes, then a country's score on a cultural dimension should help to explain the degree of gender stereotyping. Unfortunately, such a multilevel analysis is not known to have been conducted in extant research. Therefore, the aims of our study were to observe gender-role portrayals around the world, using comparable measures, sampling strategies, and classic as well as recent gender indices to explain country differences. We analyzed a total of 1755 television advertisements from 13 countries, which were selected based on their scores on various gender indices: Austria, Brazil, China, France, Germany, Japan, Netherlands, Romania, Slovakia, South Korea, Spain, United Kingdom, and United States. To date, our study is the largest known study on gender portrayals ever conducted, and we are the first to employ the concept of gender egalitarianism from Project GLOBE and various other gender indices at the same time. --- Gender-Role Portrayals in Advertising Research on gender role portrayals in U.S. television advertisements started in the 1970s , followed by research in Great Britain and Europe in the 1980s and in Asia in the 1990s . Generally, this research has led to the consensus that gender roles are highly stereotypical in television advertisements across a range of commonly explored variables. The most frequently analyzed variables are the gender of the primary character, the gender of the voiceover, the age of the primary character, and the setting associated with the primary character. Analyses of the gender of the primary character led to rather mixed results in previous research, with some studies showing male predominance, others showing a female predominance, and still others finding almost no difference. Nevertheless, the majority of studies showed a predominance of male primary characters . Some research has indicated a relation between Hofstede's masculinity index and the gender predominance of the primary character , whereas others found the predictive role of Hofstede's masculinity index to be minimal . We thus hypothesize that there will be more men than women depicted as primary characters in our analyses . The age of the primary character is another widely studied variable. Most studies report a predominance of women in the younger age segment , whereas more men were found in the middle and older age segments . In a meta-analysis, Eisend found that the odds of women being younger are three times higher than for men. Hence, there are strong grounds to expect that female primary characters will be depicted as younger compared to male characters . Furthermore, the predominance of male voiceovers is one of the most consistent findings in the literature-a predominance that is even more pronounced in Asia compared to other regions . Previous research has indicated that a higher score in Hofstede's masculinity index increases the odds of a male voiceover . Thus, we predict that there will be more male voiceovers compared to female voiceovers in television ads . In terms of product categories associated with a specific gender, there are relatively few consistent findings; this may be because different studies often employ different product categories. One finding that was confirmed in most studies, however, was the association between women and body products, or as other studies called them, Btoiletries,^Bbeauty products,^and Bpersonal care products,^as well as Bhousehold and cleaning products^ . For men, product associations were less clear, but some studies found associations between men and television advertisements for cars, telecommunications, electronics, technology, and computers . Based on these findings, we expect that female primary characters will be more likely to be seen in ads for toiletries, beauty products, and cleaning products , whereas male characters will be associated more with telecommunications, electronics, technology, computers, or cars . The setting is another variable that has often produced clear gender divisions. Most often cited is the association of women with a home setting . A meta-analysis shows that the odds of women being depicted at home are approximately 3.5 times higher than for men . Another finding that was similar across most of the literature is that more men than women are shown in a workplace setting . Therefore, we hypothesize that female primary characters will be more likely to be depicted in a home setting , whereas male characters will be more likely to be shown at work . In addition to these commonly analyzed variables, we focused on the working role of the primary character . Although categorizations differed, several studies investigated whether the primary character was working or was a homemaker both leading to highly stereotypical results that suggested more men than women are working and more women than men are depicted as homemakers. Thus we expect female primary characters will be more likely to be seen in lower status working roles compared to male primary characters, who will be more likely to be seen in higher status roles . --- Cultural Models, Gender Indices, and Advertising To fully understand gender-role portrayals, scholars have repeatedly pointed to the important role of cultural differences. The most widely applied cultural model in advertising research is Hofstede's cultural dimensions , including four dimensions : power distance, individualism/collectivism, uncertainty avoidance, and the masculinity dimension . The most relevant dimension for the purposes of the present paper is Hofstede's masculinity dimension, which has been used in cross-cultural content analyses on gender in advertising, including studies comparing two countries and some comparing three or more countries . However, only a few studies have confirmed an association between the masculinity index and gender portrayals , whereas more studies have led to mixed results or to results that were mostly opposite from those predicted by Hofstede's masculinity index . Considering the mixed results of previous research in general and criticisms of Hofstede's study in particular-as being rather outdated and for its masculinity dimension that mixes two sub-dimensions -it is crucial to use additional indices, such as the more recent framework from the GLOBE project . Its theoretical importance and promise have been mentioned in several articles on theory in advertising research . Still, the GLOBE study has been used rarely in gender stereotyping research to date. In contrast to Hofstede's study, the GLOBE project differentiates between societal practices and values. Practices are measured through questions regarding Bwhat is,^while values are measured through questions regarding Bwhat should be^ . We have decided to use societal practices in our study because gender portrayals are about the way a society actually performs, whereas values are about how a society should perform . Although Hofstede's masculinity index influenced the GLOBE project , the latter separated this dimension into gender egalitarianism and assertiveness. Gender egalitarianism was defined as Bthe degree to which a society minimizes gender role differences while promoting gender equality^ . Gender egalitarianism reflects society's beliefs about whether biological sex should determine roles in society; gender egalitarian societies rely less on biological sex to make those determinations . In such societies, there is less occupational sex segregation, more women in the labor force and in positions of authority, and generally a higher status for women. Thus, gender egalitarianism is clearly related to our study. Despite the call to use Project GLOBE's dimensions in advertising research , only a few studies to date have employed them. These studies have included the dimensions of assertiveness , performance orientation , and humane orientation , and they have indicated an association between GLOBE dimensions and advertising evaluations. Thus, no known study to date has used gender egalitarianism as a theoretical framework or used Project GLOBE dimensions in content analysis. In addition to testing the predictive power of cultural models for gender stereotyping, we take into account other dimensions related to gender development because previous research has indicated that gender role portrayals may be influenced by a country's gender development . Paek et al. found that the predictive role of the Gender-related Development Index by the United Nations Development Program seems to be minimal for the gender of the prominent character in an advertisement. However, they also reported that the odds of using a male voiceover significantly increased as GDI scores dropped. In his meta-analysis, Eisend used another gender index created by the UNDP-namely, the Gender Empowerment Measure -and found a correlation between the GEM and gender stereotyping in advertising. Our research extends these studies by testing whether the GDI , the UNDP's Gender Inequality Index , which replaced the GEM due to criticism, and the World Economic Forum's Gender Gap Index can predict gender stereotypes . All of these indices are based on demographic data. The GDI is based on gender gaps in life expectancy, education, and incomes; the GII on reproductive health, empowerment and labor market participation; and the GGGI is the most inclusive, being based on gender gaps on economic, political, educational, and health criteria . Furthermore, besides Hofstede , our study uses GLOBE for the first time in the extant research on gender portrayals as a theoretical framework . Because all indices differ and previous evidence of their impact on gender portrayals is mixed at best, we ask as an exploratory research question how the five indices predict gender-role portrayals in television advertising. --- Method We analyzed gender role stereotypes across Asia, America, and Europe . We selected the countries based on the following criteria. First, we wanted to have a broad range of countries that have different scores on various gender indices. For that reason, we have included countries with a high score on Hofstede's masculinity index and with a low score , as well as countries with a high score on GLOBE's gender egalitarianism index and a low score . Second, we wanted to include the countries that were frequently sampled in previous studies, for instance, the United Kingdom and the United States. Finally, the selection was driven by practical reasons, such as access to TV channels and the language qualifications of our students/coders. The most recent data from all gender indices were used. In May 2014, 15 h of prime-time TV programming were recorded from those broadcasters with the largest shares of viewers for each respective country. We focused on private channels because we were not interested in the effects of country-specific regulations of public-service broadcasters. For Austria, we took the largest private channel as well as the largest public service channel because the audience share of the private channel is rather low. For China, we took CCTV-1 as the clearly dominating TV channel. The recording time was split into three typical weekdays of the same week, that is, 3 × 5 h per channel. The sample included weekdays and weekends to ensure a higher diversity of advertisements . We started the recordings after Mother's Day in most of the recorded countries to ensure that no large country-and/or region-specific events occurred during the days of recording. We focused on prime time because it was commonly used in previous studies . Because the definition of prime time varied by country, we used the most inclusive definition . Like in most prior research , duplicate ads, political ads, ads for films and CD's, public service announcements , and ads with children, animals, or comic figures as dominant actors were not considered in our study. After 150 ads were collected in one country, we stopped additional data collection; however, the 3 days sampled produced less than 150 unique advertisements for several countries. Our sample consisted of 1755 ads. These included ads from Austria , Germany , the United Kingdom , the United States , France , Spain , Brazil , Netherlands , Romania , Slovakia , China , Japan , and South Korea . --- Coding Procedure and Reliability The codebook was adopted from prior research . The following categories were included in the analysis: primary character, product category, voiceover/narrator, age, dominant setting, and working role. These are standardized measures in this research . The coding team consisted of 30 coders from two major universities in South Korea and Austria. Coders were one of the authors and 29 undergraduate students receiving compensation/course credit for their work. Students were unaware of the hypotheses and were native or bilingual in the language of the country they coded. Training sessions on using the codebook were held with all coders prior to testing reliability. Ads were randomly selected for the reliability test but had to involve a primary character so that all codebook categories could be included. We performed three reliability tests using Krippendorff's Alpha . One test was between coders for different countries on English-language advertisements, one test was between coders coding the same country prior to coding, and one test used the coded material without coders knowing they were tested. Although 65 % of the reliability measures in these three tests were above α = .80, the lowest intercoder results for the numerous intercoder reliability tests were for primary character , voiceover/narrator , age , dominant setting , and working role . This was still above the recommended chancecorrected agreement of .60 by Neuendorf . --- Results --- Primary Character and Voiceover In our first hypothesis, we stated that there will be more male than female primary characters. Among all spots with a primary character, 50.7 % of the characters were women. As can be seen in Table 1, in some countries , the share of male primary characters was slightly higher than those of female primary characters. In other countries, however, the share was almost identical. Thus, we cannot find a substantial male predominance of primary characters. We also hypothesized that female primary characters would be depicted as younger compared to male primary characters. As Table 1 reveals, this pattern was the case in seven countries . For the other countries, however, there was no significant effect. Based on previous research, we assumed in Hypothesis 3 that we would find more male than female voiceovers. When looking across countries , the share of male voiceovers was, in fact, significantly higher than the share of female voiceovers . Confirming Hypothesis 3, this result was mirrored in most countries. The opposite effect, however, was found for France, with 58 % female voiceovers. --- Product, Setting, and Work Role In line with prior research, we expected that female primary characters would be more likely to be seen in ads for toiletries, beauty products, personal care, and cleaning products, whereas male characters would more likely be associated with telecommunications, electronics, technology, computers, or cars. The findings are reported in Table 2. In all countries but Japan, the association of female primary characters with toiletries, beauty products, personal care, and cleaning products can be confirmed. The association of male primary characters with products related to technology and cars was observed for Brazil, Germany, the Netherlands, Spain, and the United Kingdom. The effect was not significant by the conventional p < .05 level for Romania, Slovakia, Austria, USA, China, Japan, and South Korea. Another prominent finding in previous research is that female primary characters are more likely to be shown in a home setting, whereas male characters are more likely to be associated with a work setting. Table 3 shows the findings for each country. The stronger depiction of female primary characters in home settings compared to male primary characters can be confirmed in Brazil, China, Germany, the Netherlands, Romania, South Korea, and Spain. There was no significant effect for six countries: Austria, France, Japan, Slovakia, USA, and United Kingdom. When it comes to the dominant depiction of male primary characters in work settings , we observed significant associations for Austria, Germany, France, Japan, the Netherlands, and the United Kingdom, but no significant effect for South Korea, Brazil, the United States, Spain, Romania, Slovakia, and China. As can be seen in Table 4, it was not the case that male characters are depicted in higher status jobs compared to female characters. This association was significant only for Japan. However, when interpreting our findings, the very small numbers of depicted working roles need to be taken into account. Therefore, we also checked whether or not a female or male character was depicted in any working role at all. One could anticipate that male characters will be more likely to be shown in any working role compared to female characters. As Table 4 reveals, the association between male primary characters and the depiction of a working role was statistically significant for Austria, France, Japan, the Netherlands, Slovakia, and the United Kingdom. The association was not significant by conventional levels for Germany, Brazil, China, South Korea, Spain, Romania, and the United States. --- Multilevel Analyses So far, we have observed how gender is related to the depiction of primary characters, and we have looked at single countries. Although such an analysis is useful, we are unable to explain why an association is found in one country and not in another. Thus, the question we want to ask is whether variations in the association between gender and character depiction can be explained by cultural differences between countries. In order to answer this question, hierarchical linear models are needed . Multilevel models are warranted when cases are clustered within countries. The advantages of multilevel analysis are that we can explain the individual-level variation in the dependent variable while statistically controlling the variation across levels of analysis and that we try to predict the variation of regression slopes by including constructs at the country level. In particular, we will examine whether the country differences in the relation between gender and character depiction can be explained by the five indices introduced previously. Because our outcome variables are binary, we ran a logistic hierarchical non-linear model with the Logit-link function using PQL estimation with the statistical package HLM 7. The level-1 model includes the gender of the primary character. The level-2 model includes the respective index . Because the level-2 variables are correlated, we ran a separate model for each index. In the first step, we computed the variance components in order to examine whether there is a significant amount of variance between the classes. The upper-level variance is significantly different from zero for the age of the primary character , the product category body and cleaning products , the product category technical products and cars , working role shown , and the status of the average level of a gender index . For most outcomes, the level-1 effect of gender was statistically significant, confirming hypotheses Hypothesis 2 , Hypothesis 4a , Hypothesis 4b , Hypothesis 5a , and Hypothesis 5b . However, we could not confirm the assumption that female primary characters are more likely to be seen in lower status working roles compared to male primary characters, who were theorized to be seen in higher status working roles . Yet, female primary characters were less likely to be depicted in any working role compared to their male counterparts. Beyond the effects of the level-1 predictor, the main focus of the multilevel model lies on the cross-level interactions between the gender of the primary character and the gender indices. This interaction tests whether the variations between countries in the effects of gender on the outcome variables can be traced back to variations in the five gender indices. In order to answer this question, we first looked at the random-coefficients model. For the dependent variable age of the primary character, no systematic differences in the regression slope between the countries were observed . The same was true for the dependent variables of product category body and cleaning products , setting: home , setting: work , presence of a working role , and status of the working role . However, for the category of technical products and cars, there was a statistically significant variation that could be explained by level-2 variables . Thus, for most outcomes, there were no differences in the regression slope that can be explained by a specific culture. As can be seen in Table 5, we found no substantial cross-level interactions for all five gender indices. That is, none of the five gender indices was able to explain why there was a stronger association between the gender of the primary character and the outcome variables in a given country. Put formally, an increase in a gender index did not lead to an increase in the association between gender and the outcome variables. --- Discussion Our study is the largest known to date on gender-role portrayals in advertising, and it is the first known with sample equivalence, using comparable TV programs to illuminate the effect of culture on gender-role portrayals. In addition, it is the first study known to test the role of gender indices for genderrole portrayals in advertising using multiple gender indices as independent variables and multiple gender-role variables as dependent variables. We have found significant differences among the countries investigated. Although every country showed traditional gender-role portrayals for some variables, some countries showed non-traditional gender-role portrayals for several variables and thus seem to use a more gender-equal approach toward gender roles. For example, in the United Kingdom, no significant age differences were found between the share of male and female primary characters as well as male and female voiceovers, and similar shares of men and women were shown at home. Similarly, in the United States, men were not stereotypically associated with car/ electronic products, approximately the same number of men and women were shown both at home and at work, and men and women were portrayed in work roles about evenly. These findings align with those of several previous research studies showing that in the United Kingdom and several European countries, gender portrayals have improved in recent years . By contrast, advertisements in several countries, such as Germany, were identified as highly traditional in the use of gender roles for almost all investigated variables. Across all countries, some variables tend to indicate more traditional gender-role portrayals than others. For example, for more than half the countries, the variables of voiceover, age, toiletries/household products, and setting produced significant gender differences. Although we were able to observe differences between countries, we found that these differences cannot be explained by cultural or gender indices. The effect of a specific culture in shaping advertising messages is, therefore, smaller than commonly thought. This finding stands in contrast to Eisend's meta-analytic results showing that Bgender stereotyping in advertising depends on developments related to gender equality in society rather than the other way around.^There are many potential explanations for why our study comes to a different conclusion. First and foremost, it is important to stress that no study of which we are aware has modeled the influence of culture in a multilevel model. As should be apparent, when looking at Tables 1, 2, 3 and 4, one could easily pick two or three countries and explain the observed differences by different scores on gender indices. However, such an analysis strategy does by no means confirm that an increase in a gender inequality index leads to an increase in gender stereotyping across countries. For this, a multilevel model is necessary. Second, it is possible that we have found no relationship between the cultural variables and stereotyping because gender portrayals in advertising are lagging several years behind actual developments in society . Unfortunately, this cannot be sufficiently tested with the present data because we would need to draw a sample of TV ads over time. Third, because gender stereotypes in advertising are decreasing over time , our findings may be different simply because our sample is the most recent one, reflecting a declining influence of culture. That is, although advertising and its gender-role portrayals may still vary across cultures, in some cases, they may become more universal due to global markets and networked publics . Fourth, our study used equivalent samples in all countries which is not possible in a meta-analysis such as Eisend's . Fifth and finally, gender stereotypes might not be measured sufficiently by gender indices, and it may be that another index should be considered as more appropriate for measuring stereotypes . --- Limitations and Future Research Directions As with every research project, our project has several limitations. These include a rather small sample size in some countries, which was also the case in several previous studies . More importantly, our sample includes countries from Asia, Europe, and the Americas, but none from Africa or Oceania. Related to this point, we were not able to sample all countries that we would have liked because of a lack of access to the TV channels. Generally, the number of countries was very small for a multilevel model. Larger and more diverse samples are therefore needed in future research. In addition, our sample was drawn in May 2014. Thus, it is able to represent only this specific period; additionally, seasonal variations might be a concern in research on advertising. Furthermore, although we strived to choose comparable TV networks, this is a daunting task because various countries have different broadcasting systems. In addition, analyzing only one TV channel for each country, even the most dominant one, might not be fully representative of the pool of TV ads from each country. Finally, we suggest that future research studies should attempt to analyze gender-role portrayals in television advertising over time using longitudinal approaches. --- Practice Implications Practitioners in the countries we analyzed are called to raise their awareness for gender stereotypes in television ads. Even when practitioners reside in countries with high gender equality, gender stereotypes still prevail in television advertisements. Obviously, current regulatory efforts do not seem to be successful in implementing an unbiased representation of men and women in television ads. We suggest that advertising councils as well as advertising professionals should work toward a clearly defined set of recommendations about how men and women should be presented. We also suggest that advertising educators should sensitize students about gender role depictions in commercials, how they are observed using scientific methods, and what effects they may have on women and men. --- Conclusion Our study was able to show that there appears to be a global pattern of gender stereotyping still at work. This finding is significant for two reasons. First, it is well known that gender stereotypes in advertising can influence gender-role stereotypes in society, further perpetuating gender roles and gender inequality . Second, our findings clearly suggest that gender stereotypes in TVadvertising can be found around the world, independent of a given gender equality status in a particular country. It follows that more progressive countries do not necessarily depict women-in terms of gender equality-in more progressive ways in television advertising. We hope our research helps to spur a discussion among scholars, advertisers, and regulators on the global dominance of gender stereotyping in advertising. --- working role . There was no significant amount of variance for the depicted setting: home and for the depicted setting: work . The results of the multilevel model are presented in Table 5. Because we included the grand-mean-centered terms for the gender indices, the effects of gender on the outcome variables must be interpreted as the effect of gender at the

Although there are numerous studies on genderrole portrayals in television advertising, comparative designs are clearly lacking. With content analytical data from a total of 13 Asian, American, and European countries, we study the stereotypical depiction of men and women in television advertisements. Our sample consists of 1755 ads collected in May 2014. Analyzing the gender of the primary character and voiceover, as well as the age, associated product categories, home-or work setting, and the working role of the primary character, we concluded that gender stereotypes in TV advertising can be found around the world. A multilevel model further showed that gender stereotypes were independent of a country's gender indices, including Hofstede's Masculinity Index, GLOBE's Gender Egalitarianism Index, the Genderrelated Development Index, the Gender Inequality Index, and the Global Gender Gap Index. These findings suggest that gender stereotyping in television advertising does not depend on the gender equality prevalent in a country. The role of a specific culture in shaping gender stereotypes in television advertising is thus smaller than commonly thought.

CHALLENGING AND DISMANTLING AGEIST ATTITUDES, BELIEFS, AND BEHAVIORS THROUGH INTERGENERATIONAL PROGRAMS Tia Rogers-Jarrell, 1 and Brad Meisner, 2 1. York University,Mississauga,Ontario,Canada,2. York University,North York,Ontario,Canada Age stereotypes are complex and multifaceted: individuals can demonstrate and embody numerous and varied positive and negative stereotypes. Therefore, solutions to combat age stereotypes must also be complex and multifaceted. Additionally, both social and physical forms of age segregation are common in our society. This causes fewer and fewer opportunities for younger and older people to interact. Intergroup Contact Theory suggests age stereotypes can be reduced through increased intergenerational contact. One way to encourage contact between younger and older populations is through intergenerational programming. However, there is a lack of literature investigating the effects of intergenerational programs on perceptions of aging. The purpose of this paper was to critically review and explore literature on intergenerational programs to understand how they influence age stereotypes and ageist attitudes. The available literature suggests that intergenerational programs involving young children , adolescents , or emerging adults interacting with older adults can significantly reduce age stereotypes towards older adults. Additionally, older adults negative beliefs and attitudes towards younger people can also be deconstructed after participation in intergenerational programs. Intergenerational programs act to break down age barriers and promote connections and understandings between generations. These programs challenge the belief that older and younger people should live and participate in spaces that are separate from one another. Providing opportunities for younger and older people to participate in intergenerational programs is one way to promote respectful relationships and enhance the quality of life and health of all generations. --- HEALTH DIFFERENCES AMONG PEOPLE WITH VARYING PROFILES OF AWARENESS OF POSITIVE AND NEGATIVE AGE-RELATED CHANGES Serena Sabatini, 1 Obioha Ukoumunne, 1 Clive Ballard, 1 Manfred Diehl, 2 Hans-Werner Wahl, 3 Allyson Brothers, 2 and Linda Clare, 1 , 1. University of Exeter,Exeter,England,United Kingdom,2. Colorado State University,Fort Collins,Colorado,United States,3. University of Heidelberg,Heidelberg,Germany Higher awareness of negative age-related changes is related to poorer mental and physical health whereas higher awareness of positive age-related changes is related to better mental health. Associations of health with AARC-gains and losses have been explored separately, but often people experience gains and losses concurrently. Using latent profile analysis, we identified at the cross-sectional level patterns of AARC-gains and losses and explored whether groups with distinct profiles of AARC-gains and losses differed in physical, mental, and cognitive health, and demographic characteristics. Analyses were based on the large-scale PROTECT study conducted in the UK ; 76% women). A four-group solution revealed the best model fit ; 45% of participants perceived many AARC-gains and few losses ; 24% of participants perceived moderate AARC-gains and few losses ; 24% of participants perceived many AARC-gains and moderate losses ; and 7% of participants perceived many AARC-gains and many losses . The four groups differed meaningfully in health; Group 1 was the most healthy, followed by Groups 2, 3 and 4. Participants in Group 1 were most likely to perceive their health as excellent, reported the lowest levels of depression and anxiety, and showed the best cognitive performance. On average participants in Group 1 were younger, and more likely to be female, employed, and married, compared to other groups. Considering the co-existence of gains and losses is important when relating awareness of age-related changes to health. Existing scholarship in social gerontology has surprisingly paid little attention to broader loving emotions, such as compassionate and altruistic love, as potentially meaningful mechanisms for improving later life psychological well-being. This study examined the influence of feeling love toward other persons and experiencing love from others on later life psychological well-being. We conducted a 3-wave longitudinal study of a representative sample of 340 ethnically heterogeneous community dwelling older residents of Miami, Florida. The increase in feeling of being loved and love for others led to decline in odds of reporting greater level of depressive symptoms over time. The odds of reporting higher level of positive affect were significantly greater for older adults who reported feeling loved by others and expressed love for other people . Older adults who felt loved had 0.92-point lower ordered log odds of reporting higher negative affect than those who reported lower level of love. The impact of compassionate love on depressive symptoms and negative affect remained statistically significant even after adjustment for altruistic attitudes and emotional support. The influence of loving emotions on positive affect was, however, explained by altruistic attitudes and emotional support. Our findings underscore the powerful influence of both receiving and giving love for the maintenance of later life psychological well-being. We offer support for the expectation that love is a significant force in the lives of older adults that transcends intimate relationships. --- LOVING OTHERS: THE IMPACT OF COMPASSIONATE LOVE ON LATER-LIFE PSYCHOLOGICAL WELL-BEING --- MEASURING SELF-PERCEPTIONS OF AGING: DIFFERENCES BETWEEN MEASURES WHEN PREDICTING HEALTH OUTCOMES Jordan Boeder, 1 and Dwight Tse, 2 1. Claremont Graduate University, Claremont, California, United States, 2. The Chinese University of Hong Kong, Hong Kong, China The majority of self-perceptions of aging research uses either a combination of the Age-related Cognition scales of Ongoing Development and Physical Loss, or the Attitudes Towards Own Aging subscale to assess views on aging. Although these scales are used interchangeably, the valence and the specificity of the view on aging being assessed are not consistent. This study investigates how different measures of SPA relate to one another and whether they differentially predict various types of health outcomes . Data from the 2008 and 2014 waves of the German Aging Survey , a population-based representative survey of adults aged 40 to 95, was used to examine the relationship between the AgeCog scales and the ATOA subscale, as well as the differences in the types of health outcomes each predicts. The correlations between the AgeCog scales and the ATOA were higher than the correlation between the AgeCog scales . The AgeCog scale of Ongoing Development significantly predicted psychological health outcomes across a six-year period, while the AgeCog scale of Physical Loss and the ATOA subscale predicted both physiological and psychological health outcomes. Evidence supports using the AgeCog scale of Ongoing Development to predict domain-relevant, psychological health outcomes. However, the multidimensionality of SPA is best measured by the ATOA subscale or a combination of the two AgeCog scales. Both forms of measurement were found to maximize the amount of explained variance for psychological and physiological indicators of well-being and ill-being. In the evolving situation of COVID-19, an outbreak of the contagious disease in a nursing home near Seattle prompted urgent calls for precautionary tactics in senior-living facilities. Worldwide, the USA and China are the countries with the largest and second largest populations of people aged 80+. More than two million older adults live in senior-living facilities in the USA and the number of beds in senior-living facilities in China has increased to 6.5 million in recent five years. The risk of infections including COVID-19 is tripled in senior-living residents because of age, close living conditions, and underlying health conditions. Infectious diseases account for one third of all deaths in people age 65+ in the USA. COVID-19 has a case fatality rate of 2.3% overall and as high as 15% in patients age 80+ in China. Together with health and services interventions, environmental interventions should be considered to prevent the possible spread of infections in senior-living settings. Based on a literature review and using empirical data of 12 senior-living facility designs collected in both countries, this research analyzed the advantages and disadvantages of existing facility environments in terms of infection control. Environmental interventions to promote infection control are suggested in the context of individual facilities. Proposed interventions are analyzed at two levels: spatial design and design details. Five factors are included: visitors screening, ventilation, isolation rooms, hand washing, and daily temperature checks. From the perspective of infection control, the cross-country similarities and differences of senior-living facility designs are discussed. --- SESSION 2996 --- DISASTERS AND EMERGENCIES: A FOCUS ON THE --- IMPLEMENTATION OF DISASTER PREPWISE, AN ONLINE DISASTER PREPARATION TOOL FOR OLDER ADULTS Lena Thompson, 1 Emily Henja, 2 Travis Beckman, 3 and Sato Ashida, 1 1. University of Iowa College of Public Health,Iowa City,Iowa,United States,2. Rush University,Chicago,Illinois,United States,3 Johnson County Homeland Security & Emergency Management Agency,Iowa City,Iowa,United States Older adults are less prepared for disaster situations than younger adults due to expenses, complicated preparation processes, and lack of support. We previously developed and tested a disaster preparedness program for older adults and showed its impact on improving preparedness and personal emergency support network. Using a 5-step communityengaged approach and in collaboration with our Stakeholder Advisory Board , we adapted this Disaster PrepWise program to an online platform and developed implementation

How people manage their goals is central to adaptation across the lifespan. However, little is known about the individual difference characteristics that predict how and why people use different self-regulatory strategies. The present study aimed to investigate associations of perceived age-related gains and losses, and their interaction, as predictors of flexibility in goal management in older adulthood. We also examined whether future time perspective (FTP) mediated the relationship between AARC and goal flexibility, such that awareness of aging impacts perceptions of time remaining, impacting how individuals evaluate and manage their goals. A community-based sample of 408 adults aged between 60 and 88 years was recruited via an internet-based research platform. Participants completed questionnaire measures of AARC-gains, AARC-losses, FTP, goal disengagement, and goal re-engagement. A flexibility index reflecting tendencies toward use of both goal disengagement and re-engagement strategies was also analyzed. Although AARC-losses was associated with lower goal re-engagement and goal flexibility, this association was weaker among those with higher AARC-gains, indicating that AARC-gains may be protective in the relationship between AARC-losses and goal management. Furthermore, the association between AARC and goal management was mediated by FTP. Higher AARCgains were associated with more open-ended FTP, which was associated with higher goal re-engagement and lower goal disengagement. On the other hand, higher AARC-losses was associated with more restricted FTP, which was associated with lower goal re-engagement, and higher goal disengagement. Results suggest that subjective awareness of aging (particularly awareness of gains), has important implications for goal management in older adulthood.

Background Globally, Family-Centered Care is a well-known healthcare approach for children and their families [1][2][3][4]. It has over the past decades been touted as the new paradigm by paediatricians, especially in the developed world [4][5][6][7]. The Institute of Patient and Family-Centered Care has identified four main concepts of it including respect/dignity, communication, participation and collaboration [1]. FCC is an approach to paediatric and child health care emphasizing respective collaborative partnerships between healthcare professionals and families of sick children in the paediatric health setting to meet their physical, emotional, social, and developmental --- Open Access *Correspondence: [email protected] 1 School of Nursing, Wisconsin International University College-Ghana, P.O Box LG, Accra, Ghana Full list of author information is available at the end of the article needs [8][9][10]. When clinicians accept and implement FCC in neonatal care, it can promote parental satisfaction and shorten the length of stay in the neonatal intensive care unit [11,12]. Yet, its application in the intensive care units is faced with several challenges due to contextual preferences across the world. The practice of FCC in many countries has been reported. For instance, in Asia, the main concepts adopted were support, visual information, collaboration, partnerships and mutual trust [13][14][15]. The fundamental concepts of FCC on the American continent are information sharing , participation , respect and dignity and shared decision-making [16,17]. Similarly, in Sweden, the training of nurses and physicians improved their support for parents to participate in the care of their children and mentorship to junior clinicians in the ICU was used to appreciate families as experts in the care of children [18]. Norway employed respect and empathy to yield family satisfaction [11], whilst Denmark used family support to address the barriers of FCC [19]. In South Africa, they employed family involvement and the provision of adequate information for infants and families to gain the satisfaction of parents in the ICU [20]. Flexible visiting times were allowed for parents to connect with their hospitalized children in Tanzania [21]. Apart from Europe and the United States which utilize and implement these four concepts, other parts of the world have implemented portions of them based on what works in their context. In the case of Africa, little or no studies exist on FCC in the NICU, especially in Western Africa and Ghana. These findings in the intensive care literature cement the argument for contextualizing the practices of FCC as different settings adopt what works best per their context. Furthermore, what is also evident in these studies is that the findings are largely emanating from families' perspectives, albeit a few from clinicians' perspectives. Meanwhile, the involvement of fathers, mothers, nurses, midwives, doctors and health managers in one study will broaden the contextual practices and appreciation of FCC in any setting. There is, therefore, a need to extensively explore the practices and experiences of both families and clinicians to gain a broader understanding of the contextual practices of FCC. In Ghana, the practices of FCC in the NICUs are poorly documented and hence its contextual practices and the experiences of families and clinicians are vague. The primary purpose of this study was, therefore, to qualitatively study the practices of FCC in the NICU to present the experiences and contextual practices of FCC from the perspectives of families and clinicians in Ghanaian NICUs. This may at least provide a dogma for future research on FCC practices in Ghanaian NICUs. --- Methods --- Study design The researchers adopted a qualitative exploratory descriptive design [22] to study the contextual practices of FCC among families and clinicians at the NICU. The rationale for adopting this design was to explain the phenomenon of FCC from the perspectives of families and clinicians such as nurses, midwives, and doctors in the NICU [23]. Additionally, the Family Care Theory was used as the theoretical framework [24,25]. This offered the opportunity to study the contextual practices of FCC in the intensive care units in the Ghanaian setting. The study was conducted between July 2020 and July 2021. --- Setting The NICUs of two public tertiary teaching hospitals in the northern and southern parts of Ghana were used for this study. These NICUs do not have any documented practices of FCC, albeit families are occasionally involved in the care via scheduled visitations. Families are not allowed to stay overnight at the NICUs in Ghana. These neonatal units have open cubicle wards with optimum logistics and separate kangaroo care rooms that admit all kinds of neonatal cases including birth asphyxia, birth injuries, neonatal jaundice, preterm, congenital abnormalities, and sepsis. These babies are medically and surgically managed by mainly general doctors, registered nurses, registered midwives, and a few specialists in neonatal care, paediatrics and intensive care. The cumulative bed capacity of the two NICUs used in this study was 105, although they often admit neonates to almost double their primary capacities. --- --- Data collection The approved ethics and introduction letters were used to seek permission from the departmental and unit managers at the NICUs of the two settings. The head nurses of the NICUs assisted the researchers in identifying clinicians who met the inclusion criteria of the study. Similar arrangements were made by the head nurses to sample families who stayed at least 24 h in the ICU. Subsequently, the participants were provided information sheets and informed consent, with additional consent for a voice recording if they agreed to participate. For data triangulation and to acquire diverse perspectives from the participants, the researchers used both interviews and focus group discussions as techniques of data collection. The first author conducted the interviews and FGDs with the help of six trained research assistants. The interviews and FGDs were conducted in a secured room at each setting provided by the head nurses of the ICUs. This was necessary to avoid interference as the data was audiotaped. The researchers purposefully chose 84 participants to take part in 24 individual interviews and 12 focus groups with five participants in each group. Each FGD composed of five family members or clinicians and lasted for at least 45 min. Each individual interview lasted for at least 30 min. The rationale for the collection of extensive multiple forms of data was to obtain thick data to provide a vivid description of the FCC phenomenon in the Ghanaian NICUs. Table 1 provides further details of the qualitative data collected for this study. --- Data analysis The researchers transcribed all the data into English text with the help of language experts, where the interview language was the local dialect of the participants. All transcripts were read severally by the researchers to check grammar and to get immersed in the data. To ensure anonymity and confidentiality, codes were attached to the transcripts, the setting and the participants. In this study, hospital K was assigned code K and hospital T was coded as T. Interviews were coded as I, FGDs were coded as D, families were coded as F and clinicians were coded as C. Serial numbers were added to these codes to generate the anonymous codes. The researchers employed open-inductive content analysis to extract fragmented data from the transcripts by comparing data transcripts and examining them for similarities, differences, and patterns. The initial codes were kept close to the participants' words, all in a bit to ensure methodological rigour [26]. The researchers then used focused coding to refine and theoretically sample the fractured data into groups by selecting key terms that subsume the initial codes created from the data. Finally, the researchers reflected on the categories emerging from the data to integrate and weave all the fractured data together to arrive at the contextual perspectives of the participants on the practices of FCC in the Ghanaian NICUs. These iterative content analysis processes were facilitated by importing all the 36 transcripts into MAXQDA version 2020 qualitative software. The lexical search, word clouds, comparison of retrieval patterns and code/sub-code model functions of the qualitative software were employed to conduct the analysis. --- --- Results --- Participants' backgrounds A total of 84 participants were recruited. They comprised of 42 families, 29 nurses/midwives, and 13 doctors. A total of 24 individual interviews and 12 FGDs for both families and clinicians were conducted. The ages of the families ranged from 18-54 years, with an average age of 31 years. Most of the family participants had at least a senior high school education, with about 42% of them having tertiary education. The clinicians were between the ages of 26 and 52 years with an average age of 38 years. The clinicians had a minimum of 5 years of working experience and a maximum of 26 years of working experience. --- Categories and sub-categories Three main categories emerged from the data: contextual practices of FCC, family experiences and ICU clinicians' experiences of FCC practices. --- Contextual practices of FCC This data produced three sub-categories to illuminate the participants' perspectives of FCC practices in Ghanaian NICUs: respect & dignity, culture and religion and multidisciplinary approach. FCC in this context is partly practiced and refers to shared decision-making and respect between families, clinicians and managers using a multidisciplinary approach to prioritize the provision of quality and satisfactory childcare. --- Respect and dignity To practice FCC, clinicians must respect families and strive to understand their perspectives on care. Respecting the opinions of families will promote their participation in ICU care. The approach to families should preserve their dignity since the sickness of a child can cause disorientation. However, some clinicians did not accord some families the rightful respect due to such families' poor sociocultural backgrounds. --- Culture and religion According to the participants, families should be accepted into ICUs regardless of their race, ethnicity or cultural background. Some families will refuse treatment for their children, such as blood transfusions because of their religious beliefs. In this context, the gender of a child had a substantial impact on most families' participation in the care process. Due to their cultural preference for male children over female children some families may abandon their female infants at the hospital and such practices may have an impact on the family's full participation in care. As a result, the participants stated that before FCC can be implemented, clinicians should endeavour to learn and accept the cultures and religions of their patients and families. --- Multidisciplinary approach Participants touted FCC as an important concept in child health that must employ a multi-disciplinary approach, including community health nurses and social welfare in the provision of childcare in the ICUs. The CHNs, for example, will promote continuity of care through the identification of community support groups for discharged patients from the ICUs. This will provide family support and integration of the sick child into the family and community, especially for those with congenital abnormalities. However, there is a gap in FCC practices as clinicians seldom involve families in decision-making about childcare in the Ghanaian ICUs. This was due to the challenging nature of ICU services even though the clinicians recognized the importance of involving the families in decision-making about the care of their critically ill children in the ICUs. --- Family experiences This particular category had three sub-categories: emotional stress, lack of information and coping strategies. --- Emotional stress Anxiety and emotional stress were common among families with seriously ill children hospitalized in the intensive care unit. "It feels empty," "very anxious," and "very awful," they said, describing their experiences. The phenomenon of going home to sleep without the child generated this anxiety: "you can't sleep," "you feel like your baby is crying," and "boxes are carried with dead babies." --- Lack of information The absence of an open flow of information and feedback on the processes and progress of their children's illness were unpleasant experiences according to the families. This hampered their ability to fully participate in ICU care and exacerbated their anxiety. Families in the intensive care unit desire more information about the care process to feel more at ease. --- Coping strategies Prayers, crying, taking time off work and receiving occasional assistance from the staff were among the coping strategies used by families to deal with the anxiety associated with the ICU phase of treatment. Even though some mothers grieved as a result of these events, crying was also a way for them to vent and deal with the stress. The following are some of the participants' accounts of their experiences: --- Clinicians' experiences The experiences of the clinicians relative to the practices of FCC in the Ghanaian ICUs were described by three sub-categories: support, counselling and education as well as funding challenges. --- Support The clinicians narrated that families need the support of staff and the system to deal with the stress of participating in the care of their critically ill children in the ICUs. Most mothers go through caesarean section and are often left alone to do laboratory and pharmacy errands. The staff usually assists the families to meet these needs. In our case, some families were helpful in caring for their critically ill children, while others were not. Some anticipated early discharge regardless of the outcome of their children's condition, which is challenging for the care providers. Such families sometimes requested discharge against medical advice because the mothers were left alone to support the care with limited resources to sustain their stay at the ICU: "… My experiences with mothers in the care of their newborns have been okay; some are ready and supportive, and some are not supportive in the care of their newborns…"TCI2."You can just imagine a mother who has just delivered, probably through a caesarean section. Her husband has to be away to work and bring money. So, she is left alone with no sister and no support"KCI1. "The mothers are left alone to take care of the baby… the issue that you will encounter is that the mother is looking to be discharged irrespective of the baby's state of health because of a lack of resources to take care of the baby. "TCI6. --- Counselling and education There were counselling rooms used for sharing information with the families at the NICU. Families were counseled by clinicians by reassuring them and explaining the child's condition to them. The counselling sessions were also used to educate families and answer all their questions to allay anxiety. Due to personnel challenges, this was not done for all families admitted to the intensive care unit. The clinicians, however, indicated that permanent clinical psychologists in the ICU would be helpful in addressing the emotional stress on both families and clinicians. The clinicians educated families on the clothing of the babies, feeding the critically ill neonates and maintaining the neonates' body temperature via Kangaroo Care and extra clothing. "We have a counselling unit and every patient who comes goes through a first-time counselling session… we explain to them the processes here and their children's condition" KCD3E.": .... we need a clinical psychologist in the ICU because the ICU is a very stressful place, hence the role of a clinical psychologist cannot be under emphasized... "KCI1. --- Funding challenges Clinicians intimated that in the ICUs, services are very expensive. This challenged the provision of care, especially for teenage parents and those with congenital abnormalities requiring prolonged NICU stays. They recommended strengthening institutional-based funding, including social welfare and setting up a national child health fund to support such needy families. "Per expert assessment and interaction with families especially those who come with congenital issues, it is identified that they have challenges like financial issues…"TCD1C. "… intensive care is expensive and is quite a new concept in this part of this country, where they are not able to afford the care and people don't really appreciate that a lot of resources are required to take care of babies"TCI6."…the social welfare should work, because some of the parents are teenagers who cannot fend for themselves let alone their critically ill children" KCI4"Our facility has a fund for child health support, contributed by clients who come to the facility and some other donations, but that fund is inadequate to meet the financial needs of families' especially needy families with critically ill children requiring intensive care, because it's very expensive. We need a national fund to support the family in the care of their critically ill children" KCI5. "We could have funds where there will be donations for us to use to support the needy ones"TCI4. --- Discussions FCC in the Ghanaian context is partly practiced at the NICUs. Participants defined FCC as shared decisionmaking and respect between the clinicians, managers, and families using a multi-disciplinary approach and education to prioritize the provision of quality childcare regardless of the family's sociocultural background. The shared decision-making aspect of the finding is consistent with the philosophy of FCC in the Canadian [27] and Norway [11] contexts. In the work of WHO, decision making and patient satisfaction are essential components of ensuring quality health care [28]. Conceivably, the increased ICU admissions, with their attendant workload on clinicians, inadequate spaces and personnel in the Ghanaian NICUs may be accountable for the occasional involvement of families by clinicians in decision-making. Health managers, the Ghana Health Services and the Ministry of Health must take immediate steps to build more NICUs across the country and expand as well as equip the existing ICUs with adequate logistics and specialized personnel. The clinicians restricted the definition of FCC in the ICU to only the father and mother of a sick child and therefore granted access to them alone. Yet, respectful and dignified care [1] in our context is considered to be care that accepts all family members, irrespective of their sociocultural backgrounds. Contrary to these findings, the acceptance of all family members, including extended family into Danish ICUs improved health outcomes for preterm babies [19]. Perhaps, this finding in the Ghanaian setting was attributed to a lack of space and personnel at the ICUs to fully engage families as experts as proposed by the FCC concepts [1]. Maybe they would have attached more meaning to it if the bottle necks of space and inadequate personnel were removed. This suggests that health professionals, managers and institutions must create the needed spaces and train the professionals to build collaborative partnerships with families of sick children in the ICUs in making decisions on the care processes. In that way, quality care may be guaranteed as the families may feel involved and satisfied with the care. The study findings also advocate for a multi-disciplinary approach towards FCC practice in the Ghanaian context. A multi-disciplinary approach to FCC has been recommended in a qualitative study conducted in Finland [12]. Possibly, the participants recognized the diverse roles played by different professional groups in supporting families in NICU care. This means the implementation of FCC in the health system should be approached by all stakeholders, including clinicians , managers , specialists , and institutions like MOH, GHS, and Health Facilities Regulatory Authority . Thus, the implementation of FCC practices should not only be left in the hands of nurses and doctors, but all these parties must be fully integrated into it to be successful. Community health nurses, for example, can be stationed in the NICU to follow up with critically ill children and their families after discharge via home visits. Furthermore, the inclusion of community health nurses in NICUs will help immunize babies and those with nonimmune-related conditions under observation to prevent vaccine-related diseases. Similarly, a clinical psychologist in the ICUs will help both clinicians and families manage the emotional and psychological stressors, including anxieties associated with the ICU phase of care. By so doing, the health system will be in a better position to address the non-pathological aspects of maternal and child health that may affect their physical health. This may also help to improve the overall health and well-being of ICU patients' families and clinicians. Additionally, the study revealed that clinicians are willing to accept and support families to fully participate in the NICU phase of care. Clinicians recognise the significant roles families play in the NICU, for example in providing information and purchasing medicine and supplies to support the care of their critically ill loved ones. This finding resonates with the concept of FCC practiced in Japan [29]. However, families were seen to be helpful in complementing the efforts of clinicians in the NICUs, in most cases, to provide quality care at their best. Thus, clinicians are not against the policies on the concepts of FCC practices in the ICU. The clinicians showed empathy to families with critically ill children in the ICU. But, they maintained that the provision of funding for intensive care units will facilitate the successful integration and implementation of FCC into the ICU since it will, for example, require more space and strict protocols of infection prevention and control for both parties. Families with critically ill children in the ICUs described their own experiences as being anxious [30], awful, and painful. This finding buttressed the initial call for a multi-disciplinary approach to FCC practice where the services of a clinical psychologist, including professional counselling, can be provided for families to manage their anxieties. Further research might focus on monitoring the quality of ICU care and evaluating client satisfaction in our context to better appreciate the drivers of quality care, synchronize best practices across settings and harness the benefits of FCC. --- Strengths and limitations The study draws its strength from the multiple forms of interviews and focuses on group data collected to arrive at the findings presented. However, our findings are limited in their qualitative nature and also by the fact that the data was collected from only the NICU setting, but the inclusion of 24 interviews and 12 FGDs resulted in data saturation. Again, data collection from different settings could have enriched the findings. Some of the family data were collected in local languages and translated into English with the assistance of a language expert; this may have resulted in some data loss. --- Conclusions Family-Centered Care is shared decision-making and respect between the clinicians, managers, and families using a multi-disciplinary approach and education to prioritize the provision of quality neonatal care regardless of the person's sociocultural background. Interventions such as emotional support via counselling by a certified clinical psychologist, regular information from staff, and funding support from the government may help families cope with the NICU phase of care and build their confidence for continuity of care. Future research should apply multiple methods to study FCC in different settings of child health practice to help harmonize best practices for improved child health and family outcomes. of Health; GHS: Ghana Health Services; HeFRA: Health Facilities Regulatory Authority; WHO: World Health Organisation. --- --- Abbreviations FCC: Family-Centered Care; IPFCC: Institute of Patient and Family-Centered Care; ICU: Intensive Care Unit; CHN: Community Health Nurses; NICUs: Neonatal Intensive care Units; FGDs: Focus Group Discussions; MOH: Ministry --- --- --- --- Competing interests The authors declare that they have no competing interest. • fast, convenient online submission • thorough peer review by experienced researchers in your field --- • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year ---

Background: Families, whether at home or at the hospital, should be a vital part of newborn care. However, most families are excluded from hospital care, particularly in neonatal intensive care units (NICUs). This is incompatible with the concepts of Family-Centered Care (FCC) and may compromise care continuity and family satisfaction following discharge from neonatal intensive care facilities. The purpose of this study was to examine FCC practices in Ghanaian neonatal intensive care units and provide the experiences and contextual practices of FCC from the perspectives of families and clinicians.The study qualitatively examined the contextual practices of FCC from the perspectives of families and clinicians in neonatal intensive care units using an exploratory descriptive design. With the help of MAXQDA software, 36 transcripts were generated and their contents were analyzed. Results: Contextual practices of FCC, family experiences of FCC and clinician experiences of FCC emerged as three main categories from the data. Respect and dignity, culture and religion and a multidisciplinary approach were the contextual practices. Emotional stress, lack of information and coping strategies were all common family experiences. Support, counseling, education and financial problems have all been experienced by clinicians. Conclusions: Shared decision-making, counseling and education, as well as respect/dignity amongst clinicians, managers and families using a multidisciplinary approach are the fundamental concepts of FCC approach in Ghana. Acceptance and integration of FCC approach into neonatal intensive care units may reduce the burden of care as well as improve the quality of care. Further studies are needed to map out strategies and interventions for the integration of FCC into intensive care units.

public expenditure in higher education. This reduction in funding has had a far-reaching effect on the quantity and quality of research in most African universities. The virtual lack of research has serious implications on the role of the university which is characterised by disciplinary specialisation and basic research; which means public universities in Africa are increasingly losing out on their role as producers and disseminators of researched knowledge for the development of their countries. --- Résumé Avec quelques exemples précis tirés d'universités kenyanes, cet article passe en revue le rôle de l'université africaine post indépendance dans la recherche et le développement et l'effet du néo-libéralisme et le financement de ces activités. It a été établi que depuis leur création pendant l'ère coloniale, la mission académique des universités en Afrique était essentiellement celle des universités partout dans le monde ; enseigner et faire avancer la connaissance par une recherche désintéressée et maintenir des normes d'enseignement à un niveau qui pourrait clairement être mis en relation avec ceux établis dans d'autres pays. Suite à la réalisation des indépendances, les universités furent désignées sous le vocable « universités de développement », ce qui voulait dire, qu'il était attendu d'elles d'entreprendre la recherche et de participer au développement de leur pays respectif. La plupart des universités essayèrent de diverses manières d'amener plus loin l'idée de l'université de développement, mais du fait de structures internes inhérentes, ainsi que du climat politique prévalent, celle-ci manqua d'émerger en tant qu' « université de développement ». Cependant, de tels défis à l'université de développement ne réduisirent pas le rôle central des universités africaines dans la recherche et le développement. Il est demandé aux universités africaines, comme aux autres partout dans le monde, de répondre à une variété de besoins et de remplir beaucoup d'objectifs ; et ceci n'est une question de demande externe, mais l'engagement multidimensionnel enraciné dans les traditions des universités elles-mêmes et de la profession académique. Il est démontré que l'idéologie néolibérale qui exigeait un retrait significatif de l'Etat de l'offre social à travers des réductions drastiques des dépenses publiques dans l'enseignement supérieur. Cette réduction dans le financement a eu des effets profonds sur la quantité et la qualité de la recherche dans la plupart des universités africaines. Le manque de recherche virtuel a une sérieuse implication sur le rôle de l'université qui est caractérisé par la spécialisation disciplinaire et la recherche de base, ce qui veut dire que les universités en Afrique perdent de plus en plus sur leur rôle de producteurs et disséminateurs de connaissances de recherche pour le développement de leurs pays. --- Introduction The early African universities in both the Anglophone and Francophone Africa were designed to train the elite for leadership and to provide breadth and depth, rather than narrow professional training. However, the purpose of these universities was, essentially, that of universities the world over; to teach and advance knowledge by disinterested research and to maintain high standards of teaching at a level which could be clearly related to those universities established in other countries. Many of the universities were therefore established as small elite institutions for training high-class personnel. With independence, universities in Africa were perceived to have responsibilities which were in many ways different from those of the universities in Europe and North America on which they had been modelled, and an interpretation of these roles and related issues were expected to be characteristically different. Such universities and others which were established later were designated as 'development universities,' which meant, they were expected to undertake research and participate in the development of their respective countries. These expectations stressed the key responsibility of the university as one of serving its society in direct, immediate and practical ways that could lead to the improved well-being of the national populace . Although the development universities appeared to be the popular expectation of universities in Africa, leading African scholars highly questioned the capacity of universities to undertake the development role, especially since, structurally, virtually all of them were based on one or more Western models, the use of foreign languages as primary media of instruction as well as instructional materials, among others. In addition, while there had been some changes in curricula, they were still largely based on assumptions about knowledge from the North . Despite such challenges, many of the universities in Africa tried in a variety of ways to further the idea of the development university. In varying degrees of imagination and conviction, they embarked on efforts to enhance the social relevance of what they were doing in many areas of study. However, research is showing that the neo-liberalisation ideology which favours free market economics and advocates for privatisation, marketisation and performance as well as the shift of the cost of higher education from the state to the individual is having a major effect on the traditional roles of universities and their management practices . With some specific examples from Kenyan universities, this paper reviews the role of the post-independence African university in research and development and the effect of neo-liberalism and the funding on these activities. --- Role of African Universities in Research and Development As pointed out above, since their inception in the colonial era, the academic purpose of universities in Africa was essentially one of teaching and advancing knowledge by disinterested research and to maintain standards related to those established in other countries. It is in that context that the early university colleges in the Anglophone countries, except for Fourah Bay College, which was already associated with the University of Durham, the level to be reached in degree examinations had to be explicitly related to international standards through the special relationship established with the University of London. Nairobi, for example, was established in 1956 as the Royal Technical College in conjunction with that university. This arrangement which was based on collaboration between university colleges in Africa and foreign universities in syllabuses and examinations was expected to ensure that examinations and standards set at the degree level were those set in the foreign universities and led to the award of degrees of those universities . With the achievement of independence in the1960s, it however, became increasingly evident that African universities had social purposes deriving from the influences to which they owed their own existence. This was reflected in the universities' attitude towards education as a public service and their readiness to undertake extra-mural responsibilities in subjects of study or those special aspects which seemed peculiarly relevant to an African context or even in the levels at which courses could be offered such as lectures in African studies which were attended by all undergraduate students in some universities. Furthermore, a majority of the universities in Africa were essentially public institutions, created and maintained by national governments and planned to serve the needs of the nation rather than those of particular groups in the society. Unlike Western and American universities, African universities were expected to be instruments for change of the existing order, and not to preserve it. In some countries where they had been closely associated with the nation-building mission of the governments, universities were regarded with considerable affection as well as esteem . Among the early influences on the emergence of post-independence African universities' role was the Tananarive Conference on the Development of Higher Education in Africa of September 1962, under the auspices of UNESCO and the United Nations Economic Commission for Africa which played a complementary role to the Conference of African States on the Development of Education in Africa, held in Addis Ababa, Ethiopia in May 1961 and had placed priority on the expansion of higher education. The Tananarive Conference, in particular, addressed the role of higher education in the development of African countries in the context of cultural, social and economic fields, noting that apart from teaching and research functions, higher education institutions had to assist in the building up of African nations as well as the unification of the continent. The Report stressed that in order to accomplish these tasks, African institutions of higher learning should not become 'ivory towers' detached from the society in which they are situated, but must contribute to national unity within the states they serve Another important influence on the development of higher education in Africa, especially towards the achievement of independence was the Report of the Ashby Commission on post-secondary education, which emphasised that higher education was a national investment, and established links between high education and economic development. The report recommended substantial expansion of higher education systems and the specific introduction of manpower planning as the rationale behind African educational planning. This was in tandem with the national aspirations of newly independent nations, and the process of expansion was taken up on a large scale . The exhortation that universities in developing countries in general and Africa in particular were to be demonstrably relevant for and totally committed to national development became so incessant and all-engulfing that it saturated all speeches, studies, debates, and discussion about these institutions. One of the most eloquent exhorters of the role of the African university was the former President Julius Nyerere of Tanzania. In one of his speeches, he said: The University in a developing society must put the emphasis of its work on subjects of immediate environment to the nation in which it exists, and must be committed to the people of that nation and their humanistic goals…We in poor societies can only justify expenditure on a University-of any type-if it promotes real development of our people…The role of a University in a developing nation is to contribute; to give ideas, manpower, and service for the furthering of human equality, human dignity and human development . These perceptions in part gave rise to the notion of the 'Development University', in which universities were expected to undertake research and participate in development projects in the rural areas. The development university was widely held by a set of expectations concerning the distinctive and practical role in the task of national development. These expectations stressed the singular responsibility of the university for serving its society in direct, immediate and practical ways that could lead to the improved well-being of the national populace. Although universities were to continue improving the relevance of teaching and research and contribute to human resource development, their role should however, go beyond these traditional functions to incorporate an expanded sense of social responsibility and policy relevance and to adopt new forms and purposes for their realisation. Universities were to take responsibility for such things as increasing food production, addressing poverty of rural populations, advising governments on house construction, as well as social engineering to improve ethnic balance and national integration. The new touchstones of university quality were its vocational and service contribution and its social commitment. To demonstrate the intricate relationship between the state and universities and the implications for national development, several governments attached the name of the nation-state to their universities, for example; the University of Malawi, University of Zambia, University of Sierra Leone and others . However, as Mazrui pointed out, the expectation that African universities should serve as major instruments of development in their societies by producing high-level human resource, relevant research and training appropriate skills and become potential innovators seemed to ignore some fundamental ethos and values underlying their foundation. For example, there were some elements of academic dependency on the northern institutions which were unmistakably clear. He pointed out that structurally, virtually all African universities in Sub-Saharan Africa were based on Western models and use Western languages as media of instruction. Relevant curricula, to a large extent, were still based on assumptions about knowledge copied from the North. While aspects of international subject matter could be embraced, specifically indigenous subject matter could only have very little place. In terms of materials, many universities relied overwhelmingly on books and materials published in the West, while student admission and staff recruitment continued to put a high premium on prior assimilation into Western culture . Despite the heavily embedded Western foundation, African universities embarked on some efforts to fulfil their new role as 'development universities.' In East Africa, for example, following the establishment of the University College, Dar es Salaam, in 1962, the Federal University of East Africa was established in 1963, consisting of Makerere College in Uganda and the Royal Technical College, Nairobi. The expansion of the federal university was driven by the human resource development, with the rallying point being rapid growth in higher education, especially university education. Like many other African universities, the University of Nairobi, the oldest in the country, tried in a variety of ways to further the idea of the development university. In varying degrees of imagination and conviction, it embarked on efforts to enhance the social relevance of what it was doing in areas such as an expanded role in extension work and community service, a considerable contribution to national policy, an effective fulfilment to human resource and development, especially with regard to scientific and vocational careers, and enhancing of national integration. The independent government of Kenya, in particular, placed great emphasis on the expansion of higher education and geared it towards the manpower needs of the modern sector of economic life. Although, this particular task was expected of all tertiary institutions, the University of Nairobi, being at the apex of the education system at the time, had to play a major role in the development of the required human resource. It took the lead in the provision of qualified persons to man the burgeoning economic and administrative institutions as the oldest and largest university in the country. Among the University of Nairobi's expected role was the development of outreach and extension activities or programmes. On the whole, such activities were not widespread although it embarked on increasing access to university education. Its College of Education and External Studies at Kikuyu launched a wide range of adult and further education programmes through its regional Extra-Mural Centres in the provincial towns of Mombasa, Kisumu, Kakamega, Nyeri, Embu and Nakuru and, lately, they have become colleges and campuses of the university. Furthermore, to increase relevance and address among the main concern that university students graduate from the university, knowing practically nothing about the intricate political and social structures of their own communities, it established the Institute of African Studies to offer courses and programmes in culture and development. The promotion of African culture and related activities were not confined to the student body within the university, but included their responsibility for helping to promote a cultural awakening among the people or communities, a purpose which is served best by considerable expansion of the normal range of extension or outreach activities. Although this was a function which falls outside the university's customary responsibilities, a number of the university schools, faculties and departments/institutes have embarked on extension or outreach programmes with adult groups as a way of promoting a cultural awakening with communities and enhancing nation building as well as furthering their education through classes and study groups. In many cases, the target groups have included an effort directed towards the vast majority who live and work on the land as well as the slum dwellers in the urban areas . Despite such efforts, the University of Nairobi did not fully live up to the expectations and ideals of the development university, partly due to a number of factors. First, was the lack of training among the bulk of teaching force to teach development studies, followed by the inherent conservatism regard-ing structural change and the functional overload because most of the new developmental functions had to be performed by the same academic staff as the traditional functions of teaching and research. Second, for a long time, there was a strong mistrust between the university and the national political leadership emanating from the notions of academic freedom and institutional autonomy which were hardly appreciated by the latter. The Kenyan regime's overriding concern for stability and its own survival at the time, heightened its inherent suspicion that the university was the main or potential source of hostile criticism and serious opposition. Such suspicion seemed to be increasingly confirmed by events of the time. There were widespread student and academic staff challenges to the regime during the late 1960s and 1970s which only strengthened its mistrust of the university as a base of opposition and discontent. This contributed to a greater questioning of the fundamental purpose of the university, and deeper penetration by the regimes into the vital areas of decision making previously within the realm of university autonomy. The prevailing climate of caution and fear coupled with the general belief that the regime had informants in most classes, prevented the emergence of a critical function of the University of Nairobi as 'development university' . However, such challenges to the concept of development university did not diminish the central role of the African universities in research and development. Much is expected of universities of the twenty-first century in all counties. African universities, like others the world over, are required to respond to a variety of needs and fulfil many at times incompatible aims, and this is not a matter of external demands, but of the multifaceted commitment rooted in the traditions of the universities themselves and of the academic profession . An excellent example of how universities, especially in developing countries, find themselves pulling in all different directions came from a speech given by Thabo Mbeki, the then president of South Africa to the Association of Commonwealth Universities. The theme of his speech was the need for the revival of the African University to underpin the regeneration of Africa. It was noted that, 'Our entire continent remains at risk until the African university, in the context of a continental reawakening regains its soul. The new Africa can only be a product of the creative interface between the public, private and civil sector domains. At the centre of this interface is education ' Smith . It is further noted that the system of education is to furnish society with a steady stream of citizens of vision and commitment; it is not expected to be an enclave or an ivory tower whose curriculum has little relevance to the society in which it operates. As an Indian Minister of Resource Development once noted, education, or more specifically, higher education, is the pathway to the empowerment of people and the development of nations. Knowledge generation has replaced ownership of capital assets and labour productivity as the source of growth and prosperity. Innovation is the mantra for development. This realisation is so pervasive that nations are scrambling to create institutions and organisations that would facilitate the process of knowledge creation. Knowledge creation requires a network of scholars actively engaged in its pursuit because the search for the unknown is a product of engaged minds, constantly challenging the known in an enabling environment. The modern university is the ideal space for the ecosystem of scholars to search for new ideas in a spirit of free inquiry . The positive contribution of tertiary education is increasingly recognised as not being limited to middle income and advanced countries, because it applies equally to low-income countries as it could help them become more globally competitive by developing a skilled, productive and flexible labour force and by creating, applying and spreading new ideas and technologies . A World Bank study on how to accelerate economic growth in Sub-Saharan Africa spelt out the crucial contribution of tertiary education in supporting development. It observed that the key for success in a globalised world increasingly lies in how effectively a country can assimilate available knowledge and build comparative advantages in areas with higher growth prospects and how it can use technology to address the most pressing environmental challenges. Higher level institutions in Sub-Saharan Africa that are equipped to provide quality education and conduct relevant applied research can play a key role in producing workers with skills to assimilate technology and make effective decisions that help industry to diversify into a broader range of products. Good quality and relevant tertiary education is also key to stimulating innovations to produce new varieties and new materials and to develop sources of energy which can facilitate progress towards reducing poverty, achieving food security and improving health . Another World Bank study further noted that within the tertiary education system, research plays a critical role in training professionals, high-level specialists, scientists needed by the economy and generating new knowledge in support of the national innovation system . --- Neo-liberalism and State Funding of Higher Education in Kenya With regard to funding, during the era of 'the development university,' in Kenya as in other parts of Africa, the university was viewed as the key engine which powered African development, and hence, the levying of fees was perceived as an unnecessary obstruction to that process. For many African governments, economic transformation of the continent was to follow from university education. As a result, after the achievement of independence in 1963, public higher education in Kenya has been free with public expenditure covering tuition and students' living allowances, development costs, instruction and research needs. The rationale for such state subsidies of higher education, especially tuition, was based on, among other things, on the country's desire to create highly trained personnel which could replace colonial administrators as well as ensure equity of access. It was reasoned that unless the state subsidised the high cost of higher education, many students would not be able to benefit from it, and therefore, the creation of highly qualified human resource would be seriously compromised. In this regard, from independence in 1963 to 1974 was the era of free higher education and its financing as part of public expenditure. In addition, the government met tuition fees and provided other allowances for students. However, as from the mid-seventies, the Kenya government went ahead to introduce its first attempt at infusing cost into its public higher education through a student loan scheme which was rolled out in the 1974-75 academic year as part of the 1974-78 Development Plan . The loan scheme was introduced within the context of a free higher education, which was, however, coupled with increasing student numbers that rose from 571 in 1964 to 3,563 in 1973, and the economic difficulties the country has been experiencing since the early 1970s, caused partly by the rising oil prices in 1973. It was noted that the economy declined from a GDP growth rate of more than 8 per cent annually between 1963 and 1972 to 4 per cent annually in the following year. The student loan scheme was the first government's attempt to transfer the cost of higher education to students and their parents, although the loans were meant to only cover personal expenses such as accommodation, meals, textbooks and stationery, travelling and other effects; while the government continued to fully fund tuition and capitation. However, while higher education generally remained tuition free, the loan scheme heralded the advent of cost-sharing, not only in higher education, but in other sectors of education as well. The loan scheme was generously administered, as obtaining it was automatic. The socio-economic background of the applicant did not seem to matter much . The Kenya government's shift in the funding policy in higher education seemed to coincide with extensive research findings on the contribution of education to economic growth, its costs and economic benefits , and rates of return. On the basis of such research as Woodhall points out that, 'the highest rates of return are usually for primary education, followed by secondary education, with higher education apparently being the least profitable investment in terms of social return' . Such a conclusion had far-reaching effects on some key international funding institutions. The World Bank, for example in its paper, 'Financing Education in Developing Countries', made some key recommendations, which included: recover the costs of higher education through user fees and reallocate these resources to the primary level; develop a credit market in higher education; and decentralise the management of schools and encourage private and community schools in order to increase competition and generate a demand-side push for better quality and efficiency.' The paper was emphatic that the funding arrangements at the time, contributed to a misallocation of resources devoted to education because higher education was the relatively less socially efficient . This position greatly contributed to the shift in donor priorities away from higher education to primary education, leading to more extensive cost-sharing in higher education, especially through the introduction of increases in tuitions and the use of student loans as opposed to grants and scholarships. It was further reasoned that the argument that individual students or graduates should finance a greater share of the costs of higher education and that the share of the state should be reduced did not solely depend on the rate of return analysis. It is shown that many studies had concluded that high dependency on state funding were simply unsustainable considering the competing demands and the often declining budgetary expenditure in many African countries. In addition, there were also powerful equity arguments in favour of changing the balance between public and private finance, as participation in higher education was far much greater for children who came from upper income families, especially from urban areas who have access to high quality secondary education, than children from the poor, disadvantaged rural areas. It was noted that continued state financing was exacerbating inequalities . In the World Bank's policy on education in Sub-Saharan Africa in particular made a number of recommendations which were supposed to improve both the internal and external efficiency of higher education in Africa. They included increasing student and staff ratios, expanding access for part-time fee-paying students, and assigning to non-public sources the full cost of housing, food and other welfare services provided to staff and students as well as expanding opportunities and improving quality by privatising institutions and functions. However, a more far-reaching recommendation was the one on cost-sharing or cost recovery. In particular, African governments were called upon to relieve the burden of public sources of financing higher education by increasing the participation of beneficiaries and their families . This paper was key in setting a stage for major adjustments in public university education in Sub-Saharan Africa. The Higher Education paper seemed to be a reinforcement of the previous paper, as it was noted that the extent of government involvement in higher education had far exceeded what was economically efficient as it had become a burden to the public finance. In this regard, countries were called upon to adopt policy reforms that could lower public costs to higher education which included cost-sharing and government withdrawal from meeting capital and recurrent expenditures . In this regard, the Kenya government's shift in the financing of higher education since the early 1970s reflected the broad international thinking. It was in tandem with neo-liberal economic ideology which de-emphasised government intervention in the economy and a belief in progress through markets or deregulation rather than state control, liberalisation of trade and capital movement and privatisation of public enterprises and others. This was made quite explicit in the following statement: …the central thrust of the new policies is to rely on market forces to mobilize resources for growth and development with the role of the central government increasingly confined to providing an effective regulatory framework and essential public infrastructure and social services. The government will limit direct participation in many sectors and instead promote private sector activities . In emphasising privatisation and marketisation, the neo-liberal ideology requires a significant withdrawal of the state in social provision through drastic reductions in social expenditure. At the same time, the World Bank pushed through the cost sharing policies in higher education, by which parents and students had to assume a portion of the costs of higher education in the early 1990s, following the granting of an emergency loan of US$ 55 million to finance public universities in Kenya . With the usual characteristic of World Bank loans to poor countries, some conditionalities were attached to the loan, which included, the institution of new financing strategies for higher education. It actually made specific reference to cost-sharing. In this regard, the World Bank effectively prescribed reduced funding by government to the higher education sector and the introduction of cost-sharing. Which meant that due to the World Bank loan conditionalities as well as other related factors such as the poorly performing economy, and implementation of structural adjustment programmes , the Kenya government was literally forced to shift its education financing by reducing its expenditure to higher education. The government had therefore to depart from its own previous form of cost-sharing initiated in 1974/75 which did not include the payment of university fees and introduced a direct form of university fee payment as part of the cost-sharing strategy beginning in the 1991/92 academic year. The new cost policy required parents and students to cover both tuition and student upkeep. This cost-sharing policy also witnessed the abolition of all personal allowances which students had been enjoying . It is important to also mention that before the World Bank demands to introduce a new cost-sharing policy, the Kenya government had been contemplating making changes in the financing of higher education, especially the discontinuation of tuition-free higher education. This was first signalled by the Sessional Paper No. 1 of 1986 on economic management which pointed out the need to put some tight limit on ministry expenditures which was expected to grow by less than 2 per cent a year of inflation through 1988-89. The paper particularly identified the ministries of education and health as targets for reduced recurrent expenditures . However, the government's Sessional Paper No. 6 of 1988, formally abolished tuition-free higher education several years ahead of new form of cost-sharing put in place in 1992 . It also needs to be pointed out that the change from free higher education to cost-sharing did not actually signal major financial responsibilities to parents and students. The cost-sharing seemed to go hand in hand with a heavy subsidisation of the system and low-level cost recovery. Heavy subsidies applied to all students admitted through the then Joint Admissions Board , which covered, among other things tuition and accommodation, irrespective of their ability to pay. Such subsidised students paid around US $229 as tuition fees irrespective of their programme of study. At the same time, while public universities began levying fees for extra services such as food and accommodation, the charges were below the market prices, which meant that the government still continued to subsidise these services heavily. It needs to be pointed out, however, that as changes were being effected in the state funding in higher education, the insatiable demand for it in the country continued to grow as most public universities enrolled more and more students well beyond their capacities. The government did not seem to respond to the situation with increased funding, but instead embarked on a policy of financial cutbacks. For example, as a percentage of Gross Domestic Product , public funding of higher education averaged 0.94 per cent between 1996 and 2000 and declined to 0.74 per cent from 2001 to 2005. For the individual public universities, in particular, this meant that for the University of Nairobi, the decline from 1998 to 2005 was from 70 to 39 per cent while Kenyatta University declined from 67 to 50 per cent . As a result of the state's insufficient allocations, many of the public universities were in a state of financial crisis from the 1990s through 2000s. The type of cost-sharing implemented by the Kenya government which ensured minimal financial contribution by students seemed to exacerbate the crisis. Consequently, most of the public universities could not meet their financial obligations and continued to pile pressure on the government to increase its expenditure on higher education. In response to the universities' persistent pressure for more funding, the government began admonishing them to turn to other sources to meet their costs such as learning and research as well as capital development expenditure. Through policy papers, the government exhorted public universities to seek more funding from markets and related sources. For example, in the Master Plan, 1997 to 2010, public universities were called upon to develop non-public sources of their revenues, including income-generating activities such as returns from research and consultancies with industries and employers, services to the community, agro-based production, manufacturing for the market, including making equipment for use in schools, hiring out university facilities; grants and donations from non-governmental organisations and well-wishers; and funding from alumni associations. Hence, the government pointedly discouraged public universities from solely relying on public sources and the nominal fees they charged government-subsidised students . --- Research Activities and Output As already discussed, among the key roles of African universities was the need to develop and promote knowledge through teaching and research. In this regard, it was an important function of universities to analyse, interpret, and explain the prerequisite conditions which would enable a society to rise to a higher quality of life for all its members . African systems and institutions have the crucial role of knowledge generation, synthesis, adaptation and application to ensure the advancement of the national interest on all fronts be they economic, social, cultural as well as political. Central to such knowledge systems are the universities and their research and advanced training programmes. Africa's universities continue to provide the bulk of their research and the training of virtually all key echelons of personnel. Admittedly, alternative sites for the generation and adaptation of knowledge are emerging and assuming prominence in public research institutes, private research centres, firm-based research units, regional and sub-regional centres, non-governmental organisations and so on. However, the trend is only begin-ning and has yet to pose a serious threat to the dominance of the universities as the core of knowledge generation, reproduction and dissemination system in Africa. In this regard, the strength of African universities and their research institutions is a key condition for the continent's development . Hence, the formulation of appropriate policies and mobilisation of the necessary resources in the support of universities' research institutions has remained a key factor in development. On the whole, since independence in the early sixties, most African universities have given a lot of prominence to research as a key function. Taking the example of the University of Nairobi, from the outset, it placed itself as an important centre of research by establishing some institutions which focused mainly on research. For instance, the Faculty of Education at Kenyatta University College, then a constituent college the university had the responsibility of training all undergraduate and post-graduate students in the country. One of its key departments was the Bureau of Educational Research which had the explicit task of conducting and promoting educational research. In addition, the bulk of academic staff in the university obtained their first degrees in the University of East Africa, with its constituent colleges at Makerere, Dar es Salaam and Nairobi, and followed with Masters and Doctoral work at a diverse array of schools and departments abroad as well as at Nairobi. It was, however, noted that while the university at the beginning encouraged research as a means of effecting change and demonstrating its relevance in the development of the country, the measure of its support for research through financial resources was generally weak. Although the University of Nairobi provided a number of staff establishment positions for the research institutions like the Bureau of Educational Research and the Institute of Development Studies , it provided very modest funds for research itself. For example, by the late seventies the funds in the research vote ostensibly earmarked for allocation by the Deans' Research Committee were absorbed into the general running of a financially stricken institution. In the face of expanding enrolments and soaring costs, university administrators inevitably gave priority to teaching rather than research needs . Of course, the problem of financial resourcing was not entirely that of the university, but of the government. While the importance of research was very much emphasised in official pronouncements and echoed in the official documents like the Development Plans, the practice was quite contrary to the official rhetoric. Hence, the university was not allocated adequate funds for its key activities. The position of the university progressively got worse both in material and goodwill termsfrom 1982 following the failed coup d'etat of August of that year which students and many academics seemed to welcome . When faced with budgetary problems and the reordering of priorities, therefore, the university administrators made research grants the first casualties whether already allocated or not. From the early 1980s, the finance officer froze the Deans' Research Grants to members of staff. This action virtually halted research production by members of the academic staff. At the Institute of Development Studies, the university's main centre for the conduct of social science research and one of the leading institutions in this particular area in Africa, serious research production by individual scholars or by the centre came to a complete standstill, giving way instead to consultancies and short-term contract research . The research situation at Nairobi was further exacerbated by continued budgetary cutbacks throughout the 1990s, during which research virtually ceased being an important component of the institutions, except for a few projects largely funded by donor agencies. Hence, Kenya, like many other African countries, ceded the strategic area of research under pressure from the international financial institutions, donor community and its weak economic situation. The deteriorating economic conditions combined with international donor agencies policy bias against public financing of higher education, seriously contributed to the under-sourcing of research. The underfunding of these institutions has continued since 1990s. Public or private resources devoted to research and research capacity building have remained inadequate in Kenya, just like in many other African universities. For example, the Association of African Universities study found that by 1993-1994, none of the responding universities spent up to 4 per cent of their recurrent budgets on research; research funding generally ranged between 0.33 and 3.78 per cent. Even then, much of the research was funded through donor grants .Closely related to funding of research activities is the provision research infrastructure, such as laboratories, equipment, libraries, and an effective system of information storage retrieval and utilisation. These include, appropriate management systems and policies which facilitate and support research enterprise, including incentives that recognise and reward high calibre research. At the same time, it is interesting to note that the provision of more revenue through parallel programmes in some universities, especially in Kenya, has ignited an infrastructure construction boom in some of the public universities which had stalled since the 8-4-4 construction project in the 1980s due to public funding cutbacks, especially for capital development. Kenyatta University for example, has constructed a 5-storey post-modern library, a new administration block, a graduate school centre, among other facilities using internally generated resources, while Nairobi University is constructing a multi-storey plaza using similar resources as well as some external support in addition to purchasing some properties for academic use in Nairobi. The two universities have also used additional revenues to undertake repairs and maintenance of physical facilities which generally were quite dilapidated as a result of underfunding by the exchequer. They also now look much neater and better maintained than a few years back, but little finding has been tailored towards research. However, they continue to face some serious challenges with regard to the provision of equipment and specialised teaching and learning resources due to very high student enrolments. Among other key challenges of the research enterprise in African universities is the management of postgraduate programmes. On the whole, there are serious weaknesses in postgraduate programmes of most African universities which strongly limits institutional research capacity and development. While there is a general lack of relevant data which makes it difficult to confirm the actual numbers of postgraduate students in the various universities, the Association of African Universities mentioned above found out that, in the early 1990s, the proportion of graduate students out of the total enrolment at the responding institutions was between 7 and 1 per cent at a Francophone university with enrolment exceeding 40,000 students . At the University of Nairobi for example, postgraduate research also became a casualty of government financial cutbacks in higher education. In the early 1980s, both the government and university suspended funding postgraduate students. The government also followed by scrapping scholarships for graduate studies. The main effect of these decisions was to change the nature of the postgraduate programmes in the revenue earning faculties and schools. The withdrawal of state funding of postgraduate education left only two alternatives for faculties and schools which wanted to initiate them. They were either to turn to donor support to continue with research-based postgraduate programmes or launch course work-based postgraduate degrees which required no research and could be funded on the basis of tuition from fee-paying students. The general trend has been that only a few strategic departments and units can secure donor funding to continue with research-based postgraduate programmes. However, most faculties and schools opted for non-research postgraduate programmes. The non-research programmes are intended to meet the market demands. In addition, the increasing number of postgraduate students poses a major challenge of supervision given the limited number of qualified staff. The poor state of postgraduate programmes is a reflection of their underfunding as well as poor research content. The graduate stipend was withdrawn in most institutions, and where it is still provided, it is not enough to support full-time study, while the job market, to a large extent, does not adequately reward advanced study. Apart from the failure to ensure the training of adequate teaching staff, the inadequate numbers of graduate students at any one time in any institution implies not only the absence the natural foot soldiers of any research enterprise, but also a severe shortage of potential teaching assistants required to help the release of more of the time for senior faculty staff for undertaking research . However, while the University of Nairobi and other public universities in Kenya have put in place research policy documents which places considerable emphasis on the role of research for development and established units for coordination of research work as well as establishing the office of the deputy vice-chancellor in charge of research innovation and outreach, what seems unclear from such research policies is how resources will be mobilised to implement them as continued reliance on the government makes such lofty plans a pipe dream. Although these universities are commended for making efforts to generate funds for research locally, the funding has generally remained inadequate in comparison to their expenditure on infrastructure development. The University of Nairobi, for example, was recently reported to have raised around 8 billion Kenya Shillings for research in the last ten years and has undertaken a good number of research projects with the help of donor funding. Part of the key research challenges is not only the non-availability of resources, but also the lack of the research culture among the academic staff . A vice-chancellor is on record to have observed that despite the considerable amount of ongoing research at the University of Nairobi, most academic staff seem to view research largely as a vehicle for upward mobility on the academic ladder. Consequently, often after one has been promoted to the level of full professor, there appears to be reduced interest in research and publications due to lack of incentive for it . As Munene and Otieno have pointed out, Kenyan universities' shift towards low-cost high-demand teaching programmes puts at risk a fundamental role of universities in knowledge production through a culture of quality research. This is a serious threat to the reputation of these institutions. This is because as the demand for twining academic programmes to the labour market's immediate requirements increases and as government subsidies to public universities continue to dwindle, the temptation to expand this type of knowledge production will continue to be irresistible. The implication of this is that the country's public universities will be failing increasingly in fulfilling their role as producers and disseminators of research knowledge. This is because budgetary allocations for research both internally and externally have declined considerably and undertaking research is no longer considered to be a key function in the operations of public universities in the country . --- Summary and Conclusion With some specific examples from Kenyan universities, this paper has reviewed the role of the post-independence African university in research and development and the effect of neo-liberalism and the funding on these activities. It was established that since their inception in the colonial era, the academic purpose of universities in Africa has remained essentially the same with other universities the world over, namely, to teach and advance knowledge by disinterested research and to maintain standards of teaching at a level which could be clearly related to those established in other countries. Following the achievement of independence, universities were designated as 'development universities,' which meant, they were expected to undertake research and participate in the development of their respective countries. These expectations stressed the key responsibility of the university as an institution serving its society in direct, immediate and practical ways that could lead to the improved well-being of the people. Most African universities tried in a variety of ways to fulfil this notion of the development university. However, due to inherent internal structures as well as the prevailing political climate, they failed to emerge as 'development universities.' However, such challenges to the development university did not did not totally eradicate the central role of the African universities in research and development. Much is expected of universities of the twenty-first century in all countries. African universities, like others all over the world, are required to respond to a variety of needs and fulfil sometimes incompatible objectives; and this is not a matter of external demands, but of a multifaceted commitment, rooted in the traditions of the universities themselves and of the academic profession. The paper further demonstrates that the neo-liberal ideology was responsible for the significant withdrawal of the state in social provision through drastic reductions in social expenditure including the funding of education. This has contributed to a drastic reduction in public expenditure in higher education. The reduction in funding has had a far-reaching effect on the quantity and quality of research in most African universities. This virtual lack of research has a serious implication on the role of the university. It means that public universities in Africa are increasingly losing out on their role as producers and disseminators of researched knowledge for the development of their countries.

With some specific examples from Kenyan universities, this article reviews the role of the post-independence African university in research and development, and the effect of neo-liberalism and funding on these activities. It was established that since their inception in the colonial era, the academic purpose of universities in Africa was essentially similar to that of universities the world over; to teach and advance knowledge by disinterested research and to maintain standards of teaching at a level which could be clearly related to those established in other countries. Following the achievement of independence, universities were designated as 'development universities', which meant, they were expected to undertake research and participate in the development of their respective countries. Most African universities tried in a variety of ways to further the idea of the development university, but due to inherent internal structures as well as the prevailing political climate, it failed to emerge as a 'development university.' However, such challenges to the development university did not diminish the central role of the African universities in research and development. African universities, as others the world over, are required to respond to a variety of needs and fulfil many aims, and this is not a matter of external demands, but of the multifaceted commitment rooted in the traditions of the universities themselves and of the academic profession. This article demonstrates that the neo-liberal ideology which required a significant withdrawal of the state in social provision through drastic reductions in social expenditure, which includes education, contributed to drastic reduction in

Introduction Oral health disparities are a significant public health concern, particularly among tribal populations [1]. These disparities are influenced by a range of factors, including limited access to dental care, cultural beliefs, poverty, and lack of oral health education. Addressing these disparities requires a multifaceted approach that takes into account the unique needs and circumstances of the tribal population [2]. In this context, a combined implementation of focus group discussion , mobile technology networking , and creating a supportive environment is an effective strategy that can improve oral health outcomes among the tribal population. By identifying the population and their oral health needs, developing an oral health promotion program, implementing the program through a community-based approach, and creating a supportive environment, this strategy can help participants adopt healthy oral hygiene habits and adhere to oral health recommendations [3]. This approach has the potential to improve the oral health of tribal populations and reduce the oral health disparities that exist within these communities [4]. Regular evaluation of the program is also essential to ensure its effectiveness and sustainability. Literature has data on the oral health status of various tribal communities in India [5][6][7]. But none exist on the Gond tribes in the Raisin district area. These represent a sect who are isolated from the hustles of city life. Health education interaction done at a single point and by a Socratic approach cannot effectively retain the learned behavior. FGD is a form of research methodology that brings together a group of people to respond to questions in a moderated environment. It will give them a chance to put forth their views and problems and help bring in suitable solutions. This form of discussion is totally different from that of mass education, wherein the health educator only speaks and there is minimal or literally no interaction at all. Mobile phones are extensively used even in remote areas of community dwellings. Presenting short messages in mobiles on a regular basis will further reinforce what was discussed during FGD. Making "healthier choices the easier choices" is the baseline of creating supportive ecology in health. In our context, it was achieved by educating the tribals about appropriate use of indigenous oral hygiene aids. Generally, changes in oral health bought after interactive sessions are subjectively measured, which always has a hidden element of bias. This study is the first of its kind that assesses oral health changes brought about by the combined implementation objectively by reliable quantitative indices, thus eliminating any errors. Hence, the present study was undertaken to answer the research question "Is there an improvement in gingival and oral hygiene status after implementing the combined model of FGD, mobile networking, and creating a supportive environment using indigenous oral hygiene aids in a tribal population?" --- Materials And Methods The study design was a community-led trial using a convergent parallel mixed method model. Ethical clearance to conduct the study was obtained from the Institutional Ethical Committee of People's College of Dental Sciences and Research Centre, Bhopal . Informed consent from all 100 tribal volunteers was taken after explaining the study details. Confidentiality of every subject was maintained. --- Sample size and technique A convenient sampling technique was employed to recruit the study participants. Random recruitment was difficult in our study as we needed participants who were willing to actively participate and respond in a group. Convenience sampling is a non-probability sampling technique commonly used in pilot studies and exploratory research. The researcher selects participants based on their convenience or proximity to the research setting. A total of 100 tribal volunteers were chosen for the study. The study population was recruited from village habitats of tribes in Raisin district, Madhya Pradesh. A set of 10 FGD teams were made, with 10 in each group. The samples were conveniently chosen after checking for their eligibility criteria. --- Eligibility criteria Participants between 18 and 45 years of age of both genders who remained in their tribal habitats throughout life were recruited. The respondents were chosen only when they were willing to participate in FGDs and engage with MTN. Three examiners who were calibrated for codes and criteria of the indices conducted the clinical examination. The Kappa score showed an inter-examiner reliability of 0.87 and an intra-examiner reliability of 0.91 suggesting good agreement in scoring the codes. --- Method of intervention It included both quantitative and qualitative aspects. Clinical examinations for the gingival status made up for the quantitative evaluation while FGD was categorized as the qualitative assessment. Data collection was conducted in three phases. The first phase included the evaluation of the gingival status of all included participants through gingival indices. The second phase constituted regular and systematic FGDs and mobile networking. FGD was conducted by the examiners who performed clinical evaluation. In the last phase, gingival health status was re-evaluated. --- Quantitative phase or oral health status examination or first phase Gingival and oral hygiene status outcomes were measured using the gingival index [8] and oral hygiene index-simplified [9]. The gingival index was scored as "0 = normal gingiva", "1 = mild inflammation", "2 = moderate inflammation", and "3 = severe inflammation". Oral hygiene index-simplified was scored as "0 -1.2 = Good", "1.3 -3.0 = Fair", and "3.1 -6.0 = Poor". --- Qualitative phase or second phase Participants were categorized into groups of 10. Groups were arranged to include similar gender and age ranges for better discussion. The facilitator conducted the discussion in the local language to ensure that the participants were comfortable and could express their opinions freely. FGD aimed at topics such as oral health habits, oral health education, access to dental care, community oral health, oral health, and overall, health, oral health, and technology. These questions and concepts guided a productive discussion on oral health in a focus group setting. The themes or topics of FGD were put forth to all groups and open discussion was encouraged for a session of 45 -60 minutes. Discussions were done regularly at monthly intervals for a period of three months. A social media platform group was also formed of all the participants. Subsequently, videos related to oral health and appropriate oral hygiene practices were shown and shared with all via mobile phones. Following the FGD session, demonstration of appropriate use of indigenous oral hygiene aids such as datun sticks and plain mouth water rinsing were taught by the authors. The collected data were analyzed using IBM SPSS Statistics for Windows, Version 25 . Oral hygiene levels and gingivitis before and after intervention were measured by applying the paired 't'-test at p <0.05. --- Results All 100 study participants completed the intervention. FGD was conducted twice in the three-month span. The mean age of the participants was 36.04 + 10.11 years. A clear female predilection was noted. The majority of them were into agricultural farming followed by poultry and craft work. It was observed during the study that participants were enthusiastic and keenly interacted with the facilitator. Table 1 enlists the various sections of FGD, the questions in each section, and the themes deduced from the discussion; 93.8% of the sample felt that oral health was not related to general health suggesting poor dental health awareness. Oral hygiene practices in the family did not differ between its members. Neither technology was not thought to improve oral health nor the significance of diet was known to the study respondents. The tribal population was clueless about mental health awareness and its relation to oral health. Each theme of FGD was elaborately discussed, and the main deduction was noted down. FGD identified that oral health awareness was compromised in the tribal sect evaluated. Overall, tribals were not well aware of oral health and the factors associated with it. --- Themes Deductions Oral hygiene habits Half of the population used twigs and neem sticks to clean their teeth. A negligible portion used a toothbrush and paste. Oral health education Oral hygiene practices were learnt from family members in all the participants. Though mobile phones were used commonly, they did not influence their knowledge or practice of oral hygiene Access to dental care There was no access to dental care in their habitats. Distance and cost were the major reasons for avoidance of dental treatment. Community oral health The importance of oral health was not considered at par with general health by 93.8% of the tribal population. --- Challenges to oral health Elderly members complained of compromised mastication and nutrition due to edentulousness. Young adults and females were more concerned about aesthetics. --- Oral health and technology None of them thought technology could be used to improve oral health. Oral health and diet None in the target population were aware of the role of diet in improving oral health. --- Role of mental health in oral health Role of sound mind in maintaining their oral health was first heard from the facilitator of FGD. --- TABLE 1: Themes and deductions of FGD --- FGD: Focus group discussion Table 2 presents the findings of oral hygiene practices in tribal samples. Fifty-four percent of the population used neem sticks and datun to clean their teeth and only 21 % used toothpaste. Charcoal was also used in 13%. This suggests that oral hygiene practices of the tribals were subpar. Thirty-seven percent of the study sample brushed lesser than once daily, while a majority brushed once a day, thus highlighting the lack of appropriate oral hygiene practices. --- Discussion The present study was conducted on 100 Gond tribal volunteers of the Raisin district and is the first of its kind. It was noted that 54% of the sample used neem twigs for oral hygiene maintenance suggesting decreased accessibility to oral health care products. Knowledge levels regarding dental health were also lesser with only 21% of the population using toothpaste. A definite improvement in gingival health was noted with the decrease in both oral hygiene index-simplified and gingival index scores suggesting the effectiveness of the combined intervention strategy. FGD aimed to understand the oral health knowledge, attitudes, beliefs, and practices of the population. FGD was facilitated in the local language to ensure that participants were comfortable and could express their opinions freely. A volunteer from their habitat during FGD helped us to easily integrate the program into the community. The use of MTN was integrated into the program to ensure that the participants received ongoing support and reminders. Practices such as appropriate use of datun sticks and mouth rinsing with water after every meal remains crucial to sustaining oral health promotion. By creating a supportive environment, participants are more likely to adopt healthy oral hygiene habits and adhere to oral health recommendations. The findings from this study might help in the development of an oral health promotion program that addresses the specific needs of the population. Our study reported that greater than half of the population used neem sticks and twigs to clean their teeth. The study by Asif et al. reported similar findings with only 22% of Koya tribes and 30.80% of Lambada tribes using toothpaste and a good number using sand and charcoal [7]. Similar outcomes were observed in the rural population of the Gambia in West Africa by Jordan, where a large proportion of people utilized chew sticks and toothbrushes [10]. In contrast, Naheeda et al. observed that the majority of the population used a toothbrush and toothpaste and brushed their teeth once per day in their study conducted among tribals of the Khammam district [11]. Considering the economic constraints of this population, a simple toothbrush and paste were also difficult to afford by most of them. For those who were already using a toothbrush and paste, they were strongly encouraged to follow the same. The sect of the population who could absolutely not afford was taught the rightful usage of neem sticks and datun. OHI -S ratings reduced from "Fair " to "Good ", which was significant at p=0.000. The positive change in oral health bought by the combined strategy can be well appreciated. As the study design in itself is novel, we could only compare our pre-FGD with existing literature. Pre-FGD scores of OHI-S were in accordance with the study by Asif et al. who also reported "Fair score" for Koya and Lambada tribes [7]. This is also in concordance with tribals residing in Telangana [12]. Kumar et al. showed 57.0% of their study respondents showed poor oral hygiene. The oral health disparities of the tribal population can be attributed to various factors such as limited access to dental services, lack of oral health education, poverty, and cultural beliefs [13]. Seeking prompt dental treatment and proper oral hygiene practices enhances oral health. Improving oral health can have a significant positive impact on oral health-related quality of life [14]. While the combined implementation is an effective strategy to address oral health disparities among tribal populations, there are some limitations to this approach. One limitation is the availability of resources to implement the program. The implementation of this approach requires significant financial, material, and human resources, which may not be available in all settings. Additionally, the program's sustainability may be affected if these resources are not sustained in the long term. Another limitation is the language barrier. The approach requires conducting the FGD and providing oral health education in the local language, which may be challenging if there is no standard written language or if the language is not widely spoken. This limitation can be overcome by employing interpreters or utilizing bilingual staff. The approach may also be limited by cultural beliefs and practices that may influence oral health behaviors. Some cultures may not prioritize oral health, or traditional practices may contradict modern oral health recommendations. Addressing these cultural beliefs and practices requires sensitivity and cultural competency on the part of the program implementers. Though the combined implementation is an effective strategy to address oral health disparities among tribal populations, it is essential to consider these limitations and tailor the program to the specific needs and circumstances of the population. The utilization of FGD allowed us to gain in-depth insights into the oral health challenges faced by the tribal population. It provided a platform for open discussions, allowing community members to express their concerns, beliefs, and knowledge regarding oral health. The FGD sessions helped us understand the specific needs and priorities of the community. The integration of MTN played a pivotal role in enhancing access to oral health information and services. MTN has the advantage of reaching a larger population, even those in remote areas. It also provides educational materials, oral hygiene tips, and appointment reminders, empowering individuals to take charge of their oral health. In fact, it can act as a facilitated communication between healthcare providers and community members, enabling timely consultations and referrals. Creating a supportive environment can indeed be a crucial aspect of an intervention aimed at addressing oral health disparities in a tribal population. A supportive environment plays a significant role in promoting positive oral health behaviors and outcomes. Based on the current literature and the experience of implementing the research, several recommendations can be made for future efforts in this area. • In order to identify service gaps and enhance the efficacy of the strategy, it is crucial to frequently examine the oral health needs of indigenous groups. Periodic surveys, focus groups, and community-based participatory research are effective ways to accomplish this. • There is a need to expand relationships between public health organizations, tribal administrations, and academic institutions in order to increase the resources available for putting the strategy into practice. • Further research on the use of mobile technologies is warranted, especially in terms of reaching out to tribal populations that have little access to oral health care. This can involve the use of mobile applications for oral health education and support, text message reminders, and telehealth services [15]. • In order to make oral health promotion programs more acceptable to these tribals and culturally suitable, it is necessary to incorporate traditional knowledge and practices. This can be done by carefully collaborating with local community leaders and healers to incorporate ancient practices into current oral health recommendations. --- Conclusions Our combined approach of FGD, MTN, and creating a supportive environment yielded promising results. We observed improved gingival health among the intervened tribal population. Furthermore, there was a notable reduction in oral health disparities, as evidenced by improved oral health outcomes among the tribal population. However, it is important to acknowledge that addressing oral health disparities is an ongoing process, and there are still challenges to overcome. Sustaining the interventions and ensuring their longterm impact will require continued support from healthcare providers, policymakers, and community stakeholders. Additionally, further research is needed to evaluate the long-term effectiveness and costeffectiveness of the interventions, as well as to explore other potential factors contributing to oral health disparities in the tribal population. --- Additional Information Disclosures Human subjects: Consent was obtained or waived by all participants in this study. People's College of Dental Sciences and Research Centre, Bhopal issued approval EC-202111. The Institutional Ethical Committee in its complete perspective and is of the conscientious opinion that the above study can be conducted without any legal, moral, or ethical encumbrances. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Background and objective: Oral health disparities generally exist among tribal populations, prompting creative solutions to tackle these challenges. By using a combined implementation strategy of including focus group discussion (FGD), mobile technology networking (MTN), and creating a supportive environment, this study aims to assess and bring positive changes in oral health in these populations. Methods: The current study employed a mixed-method approach on a sample of 100 tribal volunteers. Qualitative assessment included FGD conducted regularly for three months based on themes such as oral hygiene habits, access to oral health, technology in oral health, the relationship of oral health to general health, and the role of diet in oral health. Quantitative evaluation included recording of the oral hygiene index-simplified and gingival index to measure gingival status. Messages on oral health were routinely posted to mobile phones to reinforce oral health education. Appropriate use of indigenous oral hygiene aids (neem and datun) was also taught during the discussion session. Clinical examinations were compared before and after FGD. Data were analyzed using IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). A paired 't' test was used to find significant differences in gingival status at p<0.05. Results: The FGD sessions deduced observations such as limited access to dental care, inadequate oral hygiene practices such as usage of neem sticks and twigs, and lack of oral health awareness. The implementation of MTN facilitated the dissemination of oral health information and enhanced communication between community members and healthcare providers. The gingival index score significantly improved from pre-FGD to post-FGD with a mean difference of 0.41700 significant at p=0.000. Oral hygiene of the target population shifted from "Fair" oral hygiene status to "Good" oral hygiene status.The combined implementation of FGD, MTN, and creation of a supportive environment demonstrated promising results in addressing oral health disparities among the tribal population. The interventions led to improved gingival status and better utilization of oral hygiene practices. These findings highlight the importance of tailored interventions, community engagement, and mobile technology in addressing oral health disparities in tribal populations. Ongoing support, sustainability, and further research are necessary to ensure the long-term impact and effectiveness of these interventions.

Introduction Mental health is gaining recognition as one of the priority areas in health policies worldwide and has also been included in Sustainable Development Goals [1,2]. Nevertheless, most countries globally are exposed to multiple psychosocial stress factors nowadays [3]. For this reason, mental disorders are a high priority in healthcare as major contributors to the global burden of disability, especially in developing countries [4,5]. Estimates of the 12-month prevalence of mental disorders vary between 27.4% and 38.2% in the general European adult population [6,7], due to the inclusion of new disorders and of new European member states. In fact, European countries show that they suffer relatively more from mental health disorders than the rest of the world, although these may be significantly underdiagnosed in many countries [8][9][10]. Common mental disorders refer especially to anxiety and mood disorders, which are highly prevalent in the global population (with a range from 3.6% to 19.8% for anxiety disorders [7,[11][12][13] and from 5.4% to 7.8% for mood disorders [7,12,13]. Approximately one in five adults experience a CMD yearly and 29.2% at one point in their lifetime [12]. In Spain, the prevalence of CMD in adults ranges from 16% to 22% [14][15][16]. CMDs not only pose a threat to people's quality of life, but they also pose serious challenges for health systems and entail considerable societal and financial costs [17,18]. Therefore, both researchers and policy-makers have identified decreasing the prevalence rates of CMD and disability costs as a key priority [7,[19][20][21]. It seems that the factors associated with a high prevalence of CMD include sociodemographic and economic conditions, lifestyle habits and clinical variables [22,23]. Another characteristic which must be taken into account is the gender differences in relation to CMD, whereby women are more prone to experience CMD than men in most countries [12,24]. Nevertheless, these factors are not the only ones that influence the mental health of individuals [25], which also depends on the environmental context in which people are born, are raised and live their lives [26][27][28]. In short, there is a growing consensus that buildings, and the natural and social environments where people live, can affect mental health [28,29]. Conversely, certain environmental factors, such as green areas, could reduce stress and exert protective effects against mental disorders [30,31]. In contrast, air pollution and traffic noise have often been linked with poor mental health [32]. Moreover, stressful places, such as overcrowded urban areas, contribute to psychological stress [28]. In addition, Echeverría et al. [33] and Barnes et al. [34] analyzed people's subjective perception about environmental problems and how it relates to mental health, and concluded that self-reports may be used as a good source of information even when they differ from objective measures. In fact, self-report perception of the environment is a more relevant measure of CMD than objectively-measured environmental factors. Since the majority of studies assess environmental factors that could be related to CMDs jointly [35][36][37], making it impossible to know how each factor contributes to the presence or absence of CMD, the present study aims to investigate numerous different sociodemographic, clinical, lifestyle characteristics and environmental problems independently and simultaneously in a large, representative sample of Spanish population. The main objectives of the present study were to report the prevalence of CMD among the adult population in Spain, to analyze time trends from 2006 to 2017 and to explore the associations between CMD and gender in regard to both perceived environmental problems and sociodemographic, clinical and lifestyle factors. --- Materials and Methods --- Study Design A quantitative, observational, nationwide, cross-sectional study carried out from December 2019 to April 2020. --- Data Source and Study Population Data were obtained from the personalized interviews of the Spanish National Health Survey 2006 [38], 2011/2012 [39] and 2017 [40]. The SNHSs are interview-based surveys of the non-institutionalized population carried out by the Ministry of Health, Consumer Affairs and Social Welfare in partnership with the National Institute of Statistics. The sampling design was multistage probabilistic, stratified by census areas , family homes and individuals . For the purpose of this work, we limited our study to people aged 16 to 64 years living in Spain. The initial sample consisted of 52,469 subjects, but due to a lack of data for some of the variables studied, 3964 individuals were excluded when the descriptive, bivariate and multivariate statistical analyses were carried out. Based on the sociodemographic, clinical, lifestyle and environmental variables and the presence of CMD, the subjects we excluded did not differ systematically from the rest of sample. Therefore, the study was finally based on 48,505 participants, as follows: 19,868 in SNHS 2006; 13,798 in SNHS 2011/2012; and 14,839 in SNHS 2017. --- Variables --- Dependent Variable The dependent variable was the presence of common mental disorders . This variable was evaluated using the General Health Questionnaire , validated in Spain [41][42][43]. The GHQ-12 scored on a Likert-like scale from 0 to 3 . These answer categories were scored according to the original GHQ method [44], with the first two response options having a score of 0 and the last two having a score of 1, in other words, in bimodal fashion . The points were added up make to a global score ranging from 0 to 12 points. The GHQ-12 scoring method with a cut-off at ≥3 points was used, so that the final score is a dichotomized measurement of common mental disorders: absence of CMD and presence of CMD , the latter being used to indicate risk for psychological distress. --- Sociodemographic Variables The independent variables, such as the sociodemographic variables, were: year of survey , gender , age group , marital status , level of education , nationality , size of town of residence and employment situation , using the International Labour Organization criteria [45]. Social class was assigned according to the categories proposed by the Spanish Society of Epidemiology [46]. This independent variable was classified into: Class I , Class II . Athletes and artists), Class III , Class IV , Class V , Class VI . In this study, these six original classes were formed into three groups . --- Lifestyle Behavior Lifestyle behavior included physical activity during leisure time . --- Clinical Variables The clinical variables were evaluated using a self-developed questionnaire proposed by the Spanish Ministry of Health, Consumer Affairs and Social Welfare [47][48][49] and included self-perceived health status and limitations due to a health problem for at least 6 months . Another clinical characteristic was type of chronic disease as assessed by a physician. This variable was classified as number of chronic conditions . The chronic diseases included in the present study were: hypertension, myocardial infarction, angina pectoris/coronary disease, other heart diseases, varicose veins in the legs, osteoarthritis , chronic back pain , chronic back pain , chronic allergy , asthma , chronic bronchitis/emphysema/chronic obstructive pulmonary disease, diabetes, stomach ulcer/duodenum ulcer, urinary incontinence/problems controlling urine, high cholesterol, cataracts, chronic skin problems, chronic constipation, cirrhosis/liver dysfunction, depression, chronic anxiety, other mental problems, stroke , migraine/frequent headaches, hemorrhoids, malignant tumors, osteoporosis, thyroid problems, kidney problems, prostate problems and menopausal problems. --- Social Support To collect perceived personal social support information as an independent variable, the Duke-UNC-11 questionnaire [50], validated in Spain [51,52], was used. This scale includes 11 items which are scored on a Likert-like scale ranging from 1 to 5 . The overall perceived social support is obtained by adding the scores of the 11 items. The results range from 11 to 55 points. The final score is a dichotomized measurement of the perceived social support, classified into optimal support and sup-optimal support . --- Perception of Environmental Problems This variable was derived from the section "Problems the person has with the environment of their dwelling" [53][54][55]. This section includes the following problems: noise from outside bothers you, bad smells coming from outside, drinking water is of poor quality, little street cleaning, air pollution caused by a nearby industry, increased air contamination by other causes, lack of green areas, presence of animals that could be a nuisance ". Each is problem scored on a Likert-like scale from 0 to 2 . In addition, the number of environmental problems perceived was collected. This number was obtained by adding together all the environmental factors. --- Ethical Aspects The data obtained from these surveys are available on the National Institute of Statistics and Ministry of Health, Consumer Affairs and Social Welfare websites [38][39][40] in the form of anonymized microdata; no special authorizations are therefore required for their use. According to the SNHS methodology, the microdata files are anonymous and are available to the public. In accordance with Spanish legislation, when secondary data are used, there is no need for approval from an Ethics Committee. The research data are available as a Supplementary File. --- Statistical Analysis A descriptive analysis was performed by calculating the counts and percentages for the categorical variables and the continuous variables by calculating the arithmetic mean and standard deviation . Differences in the prevalence of CMD within the three time points were compared using the Chi-square test for contingency tables or Fisher's exact test if the number of expected frequencies was greater than 5. Linear regression models were used to identify statistically significant trends in the prevalence of CMD, sociodemographic, clinical, lifestyle characteristics and the perception of environmental problems in the period of 2006-2017. The regression coefficient and the coefficient of determination were calculated to assess the direction, average magnitude of the change and performance of the models. In addition, a logistic regression was performed to identify the variables associated with CMD by gender. All variables with a significant association in the bivariate analysis were included in the multivariate analysis. Crude and adjusted odds ratios were obtained for all sociodemographic, clinical and lifestyle habits variables and perception of environmental problems, with 95% confidence intervals . The Wald statistic was used to exclude one by one from the model any variables with a p ≥ 0.15 . All the hypothesis contrasts were bilateral and in all the statistical tests, those with a 95% CI were considered significant values. The statistical analysis was carried out using IBM SPSS Statistics version 25 . --- Results --- Sociodemographic, Clinical and Lifestyle Habits Variables The study population included 48,505 individuals, of whom 26,462 were women and 22,043 were men between 16 and 64 years old. The most frequent sociodemographic, clinical and lifestyle characteristics of the participants were that they were married , Spanish and employed , belonged to middle-class families , had secondary or professional training , lived in towns with a population of over 100,000 inhabitants , had a good self-perceived health status , had one or two chronic conditions , had not reported any limitations due to a health problem for at least 6 months , did physical activity during their leisure time and had normal social support . --- Perception of Environmental Problems According to Figure 1, the vast majority of participants had not perceived environmental problems. Furthermore, within those who did perceive them, the most common environmental problems were distressing levels of noise from outside the home , poor quality drinking water , and dirty streets . --- Results --- Sociodemographic, Clinical and Lifestyle Habits Variables The study population included 48505 individuals, of whom 26462 were women and 22043 were men between 16 and 64 years old. The most frequent sociodemographic, clinical and lifestyle characteristics of the participants were that they were married , Spanish and employed , belonged to middle-class families , had secondary or professional training , lived in towns with a population of over 100,000 inhabitants , had a good selfperceived health status , had one or two chronic conditions , had not reported any limitations due to a health problem for at least 6 months , did physical activity during their leisure time and had normal social support . --- Perception of Environmental Problems According to Figure 1, the vast majority of participants had not perceived environmental problems. Furthermore, within those who did perceive them, the most common environmental problems were distressing levels of noise from outside the home , poor quality drinking water , and dirty streets . --- Common Mental Disorders The overall prevalence of CMD was 19.4% . Over the different years of the study, the prevalence of CMD was 20.4% in 2006, 20.8% in 2011/2012 and 16.9% in 2017 . By gender, the prevalence of CMD in women was 24.5% in 2006, 24.1% in 2011/2012 and 20.1% in 2017 and in men was 14.4% in 2006, 17.4% in 2011/2012 and 13.5% in 2017 . --- Evolution of Sociodemographic, Clinical and Lifestyle Habits Variables and Perception of Environmental Problems As regards the sociodemographic, clinical and lifestyle habits variables of the sample according to the year of the survey , a decrease in the number of people who were between 25 and 44 years old was seen ). There was also an increase in separated or divorced people [2006: 6.3%, 2011/2012: 7.6%, 2017: 9.0% (β = --- Common Mental Disorders The overall prevalence of CMD was 19.4% . Over the different years of the study, the prevalence of CMD was 20.4% in 2006, 20.8% in 2011/2012 and 16.9% in 2017 . By gender, the prevalence of CMD in women was 24.5% in 2006, 24.1% in 2011/2012 and 20.1% in 2017 and in men was 14.4% in 2006, 17.4% in 2011/2012 and 13.5% in 2017 . --- Evolution of Sociodemographic, Clinical and Lifestyle Habits Variables and Perception of Environmental Problems As regards the sociodemographic, clinical and lifestyle habits variables of the sample according to the year of the survey , a decrease in the number of people who were between 25 and 44 years old was seen ). There was also an increase in separated or divorced people [2006: 6.3%, 2011/2012: 7.6%, 2017: 9.0% ]. The overall number of environmental problems perceived was 2.10 . In addition, it should be noted that there was an increase of participants who did not perceive any noise from outside the home ). --- Association between Sociodemographic, Clinical and Lifestyle Habits Variables, Perception of Environmental Problems and Common Mental Disorders In women, the adjusted logistic regression model showed that the probability of having CMD was higher in those who were widowed , separated or divorced , foreigners , unemployed , did no physical activity during their leisure time and perceived a low social support . In addition, the probability of having CMD was greater as the distress caused by noise from outside the home increased , as perceived health was worse and the number of chronic conditions increased . Moreover, for each increase in a perceived environmental problem, the probability of CMD increased 1.29 times . By contrast, the probability of CMD decreased in women who were not limited by a health problem . In men, the probability of having CMD increased in those who were foreigners , unemployed , did no physical activity during their leisure time and perceived a low social support . Furthermore, the probability of having CMD was greater as perceived health was worse and the number of chronic conditions increased ; ≥3: OR = 1.70, 95%CI 1.51-1.92). In addition, for each increase in a perceived environmental problem, the odds of CMD increased 1.18 times . On the contrary, the probability of having CMD decreased as the level of education increased and in those who were not limited by a health problem . --- Discussion --- Main Findings The results of this study based on a large and representative adult population between 16-64 years old in Spain are unique in showing the relationship between perception of environmental problems, sociodemographic, clinical and lifestyle characteristics and CMD from 2006 to 2017, taking into account potential gender differences. The overall prevalence of CMD was higher among women than men . These percentages were similar when compared to previous studies conducted among the general and non-institutionalized population living in Spain, which ranged from 18% to 30% in women and 9% to 18% in men [14][15][16][56][57][58][59][60][61]. Although the causes of these differences are still not understood completely [62], the variation observed may be due to multiple potential factors, such as hormone mechanisms [63], gender-based violence [64], traditional gender roles [65], discrimination in the workplace or during professional careers [66], low social support [67] and more likelihood of them being willing to talk about their feelings and to seek help from healthcare services [68,69]. Particular attention should be given to the socio-economic situation in the European region, which has deteriorated markedly since 2007-2008 [70]. For this reason, the economic crisis had a particularly adverse impact in Spain, negatively affecting mental health [71][72][73]. This confirms our results which showed higher percentages of CMD in 2006 and 2011-2012. Nonetheless, from 2015, as the Spanish economy improved [74], the consequences of the previous recession were felt not the same by everybody [75]. In other words, unemployed individuals and people without studies suffered a more detrimental effect on their mental health from the economic crisis [76][77][78]. For that reason, the low percentage of CMD obtained in 2017 compared to previous years may be explained by the higher percentages of people who had a job and a high level of education in the same year. During the economic crisis in Spain, workers who had lost their jobs decided to return to education [79], perhaps because some men held traditional views about their role, as the family bread winner [60,77]. This corroborates the results obtained, in which the probability of having CMD decreased as the level of education increased in men. Among the higher educated, more rational coping strategies allow the individual to raise questions, solve problems and progress in their lives [80]. It was found that people with a low level of perceived social support had an increased probability of suffering from CMD, in line with other studies in Spain [15,58,61,81,82]. Perceived social support refers to people's beliefs about how much support is potentially available from their relationships and social contacts and about the quality of this support [83,84]. Its beneficial effects for health are either direct, allowing the individual to enjoy a sense of general wellness, or indirect, as a stress-buffering process [85,86]. Foreigners had an increased likelihood of suffering from CMD. There may be many reasons for this: the emotional burden of the migratory process, unfavorable living conditions, general ignorance of the country of residence, a precarious socioeconomic situation, the difficulty of learning and communicating in a new language, family upheaval or the strong cultural shock they experience [87][88][89]. In the present study, in both genders, the likelihood of suffering from CMD was higher when the self-perceived health status was worse, as concluded by Henares-Montiel et al. [16]. Moreover, low self-perceived health can lead to problems of physical functional status and concurrent problems with certain chronic diseases [90,91]. Similarly, our results showed that adults without limitations due to a health problem had less probability of having CMD and those with at least one chronic condition were more likely to suffer CMD, as shown in other studies [58,61,81]. Limitations due to a health problem are a serious source of strain and have a direct influence on CMD [92]. On the other hand, there is a broad consensus in the scientific literature regarding the association between the presence of some chronic disease and poor mental health [93][94][95]. There are many reasons for this, including chronic pain, restrictions on social life or somatic discomfort, which are common consequences of chronic diseases that increase the risk of mental problems [96]. Regarding marital status, women who were widowed or separated/divorced had more probability of suffering from CMD, as is also reflected in the extensive body of literature [97][98][99]. Marital disruption can be an extremely stressful event [100] and may result in poorer mental health [101][102][103]. In this context, the level of psychological anxiety among divorcees and widowers is on average 36% higher compared to people whose marital status has not changed [104]. Gender differences in the impact of separation or divorce are driven by women's poorer prospects of remarriage. Given that the decline in the probability of remarriage after separation or divorce with increasing age is steeper and starts earlier for women than for men, this potential source of gender differences is relatively pronounced among separated and divorced individuals [105]. On the other hand, the results of research show that the worse mental health status for widowed women is caused by the decline of socio-economic status after a spouse's death [104]. It was found that the probability of suffering from CMD was higher in women who perceived a great deal of or somewhat noise from outside the home than in men. In general, women show higher levels of impaired mental health when exposed to all noise sources and annoyance levels than men [106]. Nevertheless, no gender differences have been found in relation to noise sensitivity [107], although some studies have shown that it was higher in women [108][109][110]. In fact, our results may be explained by attitudes towards noise: women are more attentive to the risk of hearing loss, especially when exposed to loud noise, and are four times more prone to use protective devices [108]. In this study, distressing levels of noise from outside the home were a common environmental problem perceived by participants. It has been hypothesized that the quality of a person's environment has been linked to their levels of psychological distress, which entails a reduction of CMD [111]. Although there are disparities in the results [112], distressing levels of noise from outside the home are associated with impaired mental health [113][114][115]. Besides the damage to hearing caused by loud sounds, noise can lead to extra-auditory effects, such as stress reactions, or can interfere with communication or concentration [116]. Noise from outside the home is usually caused by nearby traffic, while distressing noise inside the home is usually caused by home appliances, heating, ventilation and air conditioning systems [110,117]. This noise impacts on sleep patterns, therefore adversely affecting health [118]. In fact, several studies have documented the relationship between distressing noise and sleep disturbance [119][120][121][122] and the latter is considered a risk factor for CMD [123]. Moreover, long-term exposure to distressing noise at home could also lead to several health problems such as mental illness [117]. --- Strengths and Limitations Some limitations to this study need to be recognized. Firstly, due to the cross-sectional design, it was not possible to assign causality between the sociodemographic, clinical and lifestyle characteristics, perception of environmental problems and CMD. Secondly, it should be noted that our indicators of mental health were constructed from self-reported survey questions, which can be affected by memory and/or social desirability bias. Nevertheless, the recall period is the past 12 months, which is relatively short for the dependent variables in GHQ-12. Thirdly, all participants were living at home; we do not possess data on institutionalized populations. Furthermore, it should be noted that people aged over 65 years were not included in this study, and therefore, the sample was not representative of all Spanish adults. On the other hand, one strength of our study is that since the data were derived from a national survey, they were obtained using a carefully planned methodology, including sampling, well-designed forms, preparation of the survey participants, supervision of the survey and filtering of the data, all of which guarantee a representative sample of the population between 16-64 years old and lead to a greater understanding of this problem in today's society. In this study, we identified vulnerable groups, such as unemployed people, foreigners or those who were limited due to a health problem. Nevertheless, longitudinal studies are needed to determine the best ways to reduce and prevent CMD in these groups. Finally, further prospective studies using experimental methods are needed to study the effects of distressing noise level and their consequences on the mental health of the population, for example, studies using sound meters to measure noise from outside the home. --- Implications for Research and Practice This large, representative sample of the Spanish population between 16 and 64 years old enabled us to investigate a considerable number of associations with factors from different domains simultaneously. Thus, this research provides valuable insights which will be useful for conducting future studies. Our findings show that the prevalence of CMD in non-institutionalized people in Spain from 2006 to 2017 was higher among women than in men. Furthermore, the overall prevalence of CMD was lower in 2017 compared to 2006 and 2011-2012, which represents a 4% decrease. Even so, further studies are needed to try to explain these gender differences in mental health in order to reduce them and promote equality. Our results show that foreigners, those with limitations due to health problems or chronic conditions and unemployed individuals were more likely to suffer from CMD in both women and men. These findings suggest that mental health policies should focus on vulnerable groups in Spain and apply health measures to prevent or reduce mental disorders. For example, work-or school-based mental health prevention programs could be implemented to promote physical activity and healthy nutrition [1]. Moreover, it would be desirable to offer training programs for unemployed people on coping strategies to help to reduce stress while job hunting [124,125]. It is equally important to pay sufficient attention to social support for people with common mental disorders, because learning about its beneficial effects may help these people to seek support from the healthcare services [126]. In fact, social activities are often overlooked in health consultations, despite the recent growing demand to investigate social factors in mental health [127]. In addition, effective plans to promote social support in policy guidance are required [128]. Finally, our results confirm the negative impact of noise from outside the home on women's mental health. It is necessary to adopt political and social measures to try to reduce distressing noise levels, for example, creating more green areas, which play an important role in reducing noise and contribute to mental health well-being [129]. --- Conclusions The overall prevalence of CMD in the adult population living in Spain is 19.43%, with a decrease in CMD in this population from 2006 to 2017. The probability of having CMD decreases as the level of education increases in men. In women, the probability of having CMD is higher in widowed and separated/divorced women compared with single participants and lower as the perception of distressing noise levels from outside the home decreases. In both groups, there is a clear increasing gradient in the probability of having CMD in adult foreigners and in those with some sort of limitation due to a health problem, and also when the self-perceived health is worse and the number of chronic conditions increases. By contrast, the likelihood of suffering from CMD decreases in employed people, in those who do physical activity during their leisure time and in those who perceive a normal level of social support. --- Supplementary Materials: The following are available online at http://www.mdpi.com/2077-0383/9/7/2199/s1, File S1: Research Data. ---

Common mental disorders (CMD) represent a serious, growing public health concern, especially in women. The aims of this study were to report the prevalence of CMD among the adult population in Spain, to analyze the time trends from 2006 to 2017 and to explore the associations between CMD and gender, in relation to the perceived environmental and sociodemographic problems and clinical factors. A nationwide cross-sectional study was conducted including 48,505 participants aged 16 to 64 years old who had participated in the Spanish National Health Surveys in 2006, 2011/2012 and 2017. A logistic regression analysis was performed to identify the variables associated with CMD by gender. The prevalence of CMD was 20.4% in 2006CMD was 20.4% in , 20.8% in 2011CMD was 20.4% in /2012CMD was 20.4% in and 16.9% in 2017 (p = 0.36) (p = 0.36). In women, the probability of having a CMD was higher in widowed or separated/divorced compared with single individuals and as the perception of distressing noise levels from outside the home increased. The probability of CMD was lower as the level of education increased in men. Foreigners and those with limitations due to health problems, chronic conditions and worse perceived health were more likely to suffer from a CMD in both women and men.

Introduction Social fragmentation caused by widening differences among constituents has recently become a highly relevant issue to our modern society, as various forms of gaps and conflicts are emerging from cultural, political, economic, ethnic, religious, linguistic, and other driving factors. Researchers have developed theoretical models of social fragmentation using the adaptive network framework [1][2][3][4][5], where the topologies of social ties between constituents and their states co-evolve simultaneously through homophily, social contagion, and/or other social processes. Such adaptive social net-work models are known to either converge to a homogeneous, well-connected network , or fragment into many disconnected subnetworks with distinct states . From a viewpoint of social capital and innovation, however, neither of these two social states would be desirable, because the former would mean the loss of information and the latter the loss of communication. In order to keep our society active and innovative, we should maintain cultural/informational diversity within our society high while also maintain information exchange and communication actively ongoing. This can be conceptualized as a structurally well-connected network with diverse node states. Earlier theoretical models of adaptive social network dynamics did not succeed in demonstrating how such outcomes could occur. We note that those earlier models typically used stylized assumptions that behavioral attributes of social constituents were spatially homogeneous, and therefore, they may not have fully reproduced richer macroscopic outcomes, such as potential coexistence of diverse cultures within a connected network structure. To overcome this limitation, here we introduced the diversities of behavioral attributes among social constituents into an adaptive social network model, and computationally investigated their effects on social network evolution. The rest of the paper is organized as follows. Section 2 describes our networked agent-based simulation model. Section 3 describes the design of our computational experiments and outcome measures. Section 4 summarizes the results. Section 5 concludes the paper with a brief discussion on the implications of the results for relevant research fields and real-world socio-cultural dynamics. --- Model For the purpose of this study, we developed a computational adaptive social network model of cultural diffusion dynamics by using our previous work on cultural integration in corporate merger [6,7] as the basis and implementing some revisions to it to allow representation of social constituent diversity. In this model, we simulate the dynamics of an adaptive social network made of two initially distant cultural groups, each consisting of 50 individual constituents . Individuals are connected to each other through directed weighted edges, which represent the direction and intensity of cultural information flow. Constituents within each group and across the two groups are initially connected randomly with 20% and 2% edge densities, respectively, to represent initially modularized social structure. Edge weights are initially random, with weights sampled from a uniform distribution between 0 and 1. This initial network structure captures the state of two groups that is distant from each other both structurally and culturally. Each individual constituent has its cultural state as a vector in a 10-dimensional continuous cultural space, based on previous empirical studies on measuring organizational cultural dimensions [8,9]. The distance between two cultures is characterized by the Euclidean distance between their two vectors in the cultural space. The cultural distributions among individual constituents are initialized as follows: First, two cul-tural "center" vectors are created for the two groups, separated by 3.0 in the cultural space. Then individual cultural vectors are created for individuals in each group by adding a random number drawn from a normal distribution with a mean of 0 and a standard deviation of 0.1 to each component of the cultural center vector of that group. This creates an initial condition in which the average between-group cultural difference is approximately seven times larger than the average within-group cultural difference. Such an initial condition made of two distant, distinct cultural clusters may not be a popular choice for models studied in complex systems, network science, and statistical physics, where more randomized, homogeneous initial conditions are typically preferred. However, such random homogeneous conditions are extremely rare and unrealistic in real society, even for initial conditions. Rather, large-scale social systems emerge and evolve through numerous encounters and interactions between multiple smaller communities that are often culturally distinct from each other at the beginning. The heterogeneous, clustered initial conditions adopted in our study were intended to capture such social encounter situations, with the aim to increase the realism and applicability of our model and results in view of actual social selforganization and evolution. Each iteration in simulation consists of simulating actions for all individual constituents in a sequential order. In its turn to take actions, an individual first selects an information source from its local in-neighbors with 99% probability , or with 1% probability, from anyone in the connected component to which the focal individual belongs. If there is no edge in the latter case, a new directed edge is created from the source to the focal individual with a minimal edge weight 0.01. Then, the individual decides to either accept or reject the source's cultural vector based on the distance between the received cultural vector and its own. The probability of cultural acceptance PA is an exponentially decreasing function of the cultural distance, defined as 𝑃 = | | , where vi and vj are the cultural vectors of the individual's own and of the selected source, respectively, and d is the cultural tolerance, or the characteristic cultural distance at which PA becomes 50%. If the received culture is accepted, the individual's cultural vector is updated as 𝑣 → 𝑣 + 𝑟 𝑣 , (2 ) where rs is the rate of cultural state change, and the edge weight from the source to the focal individual wij is updated as 𝑤 → logistic logit 𝑤 + 𝑟 , (3 ) where rw is the rate of edge weight change. Or, if the received culture is rejected, no change occurs to the focal individual's culture, but the edge weight is updated in an opposite direction as 𝑤 → logistic logit 𝑤 -𝑟 . (4 ) The above formula that combines logit and logistic functions guarantees that the updated edge weight is always constrained between 0 and 1. When the edge weight falls below 0.01, the edge is considered insignificant and is removed from the network. Additional details of these model assumptions, parameter settings, and their rationale can be found in our earlier work [6,7]. In the present study, we use d = 0.5, rs = 0.5 and rw = 0.5 as their mean values within the social network, and we systematically vary their variances among social constituents as the key experimental parameters. More details are given in the following section. --- Experiments We computationally investigated how the resulting social network states and topologies would change as social constituents' behavioral attributes were systematically diversified within the simulated society. The standard deviations of d, rs, and rw were varied from 0 to 0.5 at interval 0.1, which makes the total number of parameter value combinations |{0, 0.1, 0.2, 0.3, 0.4, 0.5}| 3 = 6 3 = 216. We ran 100 independent simulation runs for each specific combination of parameter values . Each run was simulated for 500 iterations. After each simulation run was completed, the following two quantities were measured as outcome variables on the final network configuration:  <CD> : average cultural distance between constituents in the initially distant two groups  <SPL> : average shortest path length within the whole network In these two measures, social fragmentation transitions can be captured as a positively correlated increase or decrease of both quantities. Namely, = implies social fragmentation, while = implies social assimilation with loss of cultural diversity. --- Results Figure 1 shows the baseline behaviors of the proposed model in the low behavioral diversity parameter region , in which previously reported social fragmentation transitions are clearly observed as transitions between = and = behaviors . Meanwhile, none of the simulation results showed = behaviors when social constituents were behaviorally homogeneous. Figure 2 shows the same plots for different standard deviations of d , rs and rw . It is seen that greater diversity of d and rs helps maintain <CD> at higher levels. In addition, greater diversity of d also helps lower <SPL> more , which corresponds to the = behavior that was not previously recognized in the literature. Meanwhile, the effect of diversity of rw is not as clearly seen in this visualization compared to the other two parameters. These results strongly imply that having a broad distribution of cultural tolerance levels within society can help promote the coexistence of cultural diversity and structural connectivity. Figure 3 shows typical final network configurations for two experimental settings. In a situation where culturally heterogeneous constituents remain connected , constituents with different levels of cultural tolerance typically occupy different positions in the network. For example, less tolerating constituents tend to form clusters of their own, acting as cultural memory, while more tolerating ones tend to act as a "glue" to connect such culturally distinct clusters, serving as bridges. We also conducted linear regression analysis to regress each of the two outcome variables onto the three experimental parameters and their interactions. Results are given in Equations and , and their ANOVA tables are shown in Tables 1 and2: The linear terms in Eq. imply that the average cultural distance is maintained by having the diversities of d and rs, while the diversity of rw has a negative effect on the cultural distance. Meanwhile, the linear terms in Eq. indicate that the average shortest path length is reduced by having the diversities of d and rw, while the diversity of rs has only a marginal effect on the average shortest path length. Table 2. ANOVA table of linear regression of <SPL> shown in Eq. . All terms were statistically extremely significant. There were several simulation runs in which some individual nodes became disconnected, and such cases were excluded from the calculation . The nonlinear interaction terms in Eqs. and imply that the interaction between the diversities of d and rs has a negative effect on both outcome measures, while other interaction terms generally have positive effects on them. Their interactions were visualized in more detail in the 3D scatter/surface plots shown in Fig. 4. These plots illustrate that the interactions of diversity parameters are much more significant on <CD> than on <SPL>, and that greater diversity of either d or rs maintain <CD> consistently at a higher level. --- Sum of Among all the terms included in these regression models, the only term whose coefficients point to the = direction is the diversity of cultural tolerance . This result suggests that enhancing the diversity of cultural tolerance has the single most effective way to achieve the social state that maintain high cultural diversity and high structural connectivity simultaneously. --- Conclusions In this brief paper, we computationally studied the effects of behavioral diversities of social constituents on the resulting cultural diversity and social connectivity using a networked agent-based simulation model. Our results indicated that allowing cultural tolerance levels to differ broadly within society helps promote the coexistence of cultural diversity and structural connectivity, which is a novel macroscopic state of the adaptive social network models that was previously not known in the literature. Our key finding above is interesting and relevant to network science, complex systems and social/organizational sciences in a couple of distinct ways. First, it offers a clear demonstration of the risk in assuming that agents in a social system are identical and homogeneous. In view of the complexity of real-world systems, such a simplification is apparently wrong, but it is still widely used in many complex systems/network models of social dynamics. Our results show that inclusion of variations in individual attributes even in the simplest manner may already have huge impacts on the macroscopic outcomes of the system's evolution. Second, our results point out the importance of behavioral diversity, not demographic or other surface-level diversities that are often discussed in the context of social, organizational and political studies. In contrast to demographic properties that cannot be altered easily, behaviors of people are by a large part acquired traits, and therefore, they can be trained and modified through proper intervention. This indicates that our finding may eventually lead to some education/intervention strategies to promote the maintenance of informational diversity and communication, possibly enhancing the creativity and innovation of our society as a whole. Third, we note that our finding indicates the importance of the diversity of cultural tolerance levels, and not the tolerance itself. In today's socio-political climate, cultural tolerance is highly encouraged, but our model does not imply that simply increasing the cultural tolerance levels globally within the social network would lead to beneficial outcomes. Additional experiments with globally enhanced cultural tolerance levels of all the constituents did not generate the same outcome as presented in this paper, because such a condition would quickly lead to a loss of cultural diversity. This implies that, at least from the perspective of enhancing both informational diversity and communication, telling people to be just tolerating does not produce the desired outcomes. These findings and implications collectively illustrate the highly non-trivial nature of the cultural dynamics in our society. This study is still far from completion, and there are several future tasks to conduct. One obvious limitation of our present model is that it is fairly complicated and is not suitable for mathematical analysis. We plan to develop a much more simplified model of the same adaptive social network dynamics so that its behavior can be analyzed and explained mathematically. The other important direction of future research is to compare the dynamics of these adaptive social network models with real-world data of information exchange in order to validate and revise the model assumptions. For this purpose, we are currently working on collecting empirical data of cultural dynamics from social media and other online/offline sources. Recent machine learning tools for content analysis [10,11] allow researchers to quantify similarities and differences between contents posted by users, and this information can be examined with regard to its potential correlation with temporal changes of future contents posted by the same users as well as their social relationships [12]. Our future goal is to use such empirical data to determine the role and importance of individual behavioral heterogeneity in real-world adaptive social networks, as predicted in the theoretical model presented in this paper.

Social fragmentation caused by widening differences among constituents has recently become a highly relevant issue to our modern society. Theoretical models of social fragmentation using the adaptive network framework have been proposed and studied in earlier literature, which are known to either converge to a homogeneous, well-connected network or fragment into many disconnected subnetworks with distinct states. Here we introduced the diversities of behavioral attributes among social constituents and studied their effects on social network evolution. We investigated, using a networked agent-based simulation model, how the resulting network states and topologies would be affected when individual constituents' cultural tolerance, cultural state change rate, and edge weight change rate were systematically diversified. The results showed that the diversity of cultural tolerance had the most direct effect to keep the cultural diversity within the society high and simultaneously reduce the average shortest path length of the social network, which was not previously reported in the earlier literature. Diversities of other behavioral attributes also had effects on final states of the social network, with some nonlinear interactions. Our results suggest that having a broad distribution of cultural tolerance levels within society can help promote the coexistence of cultural diversity and structural connectivity.

Introduction Globalization, technological advancement, and market openness have created an entrepreneurial eco-system where more and more immigrants are launching their business ventures. Challenging job market in the host country have also pushed many immigrants into entrepreneurial activities. Wage earning employment for immigrants in the current job market becomes uncertain, and they constantly seek out new opportunities to become entrepreneurs. The formation of immigrants' entrepreneurial intention is a process that starts with an awareness of, and initial interest in entrepreneurship, and culminates in starting that new venture . There are both pull and push factors of IEI along with need of learning skills and knowledge to function effectively in new business eco-system. IEI is a learning process in which an individual learns the appropriate norms and behaviours to function better in the business culture of the host country. This involves an active willingness to learn and understand the host "entrepreneurial culture, " take risks to try out new, and uncertain entrepreneurial activities . Although over the last two decades, the study of EI in general has received great attention, studies on IEI in particular have been rather scarce . Moreover, studies on how immigrant entrepreneurs think, and how they develop their EI and their decision to become an entrepreneur have been lacking . Immigrants come from a different socio-economic and cultural background with various types of experiences and skills. Their thought process might be different and need an in-depth analysis to enhance our understanding as well as for policy formulation to better integrate them into the host society. This study addresses this research gap by exploring antecedents of IEI formation process which is different from EI of local entrepreneurs. There are several studies with a greater focus on understanding the factors influencing people's intention to start a new business venture . They have been explored from different perspectives, including the presence of economic and social dimensions that influence the level of Total early-stage Entrepreneurial Activity , the individual and psychological dimensions of market participants, and the processual dimension . While those works had contributed significantly to enhance our understanding , the question of whether the generic determinants of EI can be generalized to all categories of individuals is still relevant . Specifically, immigrant entrepreneurs are seen as distinct from local entrepreneurs , and deserve more attention from researchers and policy makers. Understanding how they think, perceive business opportunities, and make decisions to start and succeed in entrepreneurial ventures requires the development of an integrative models and consideration of specific factors that are being dispersedly addressed in current literature . In this study, we are exploring the factors that contribute to developing IEI from a holistic perspective. Immigrant entrepreneurship is described as the process by which an immigrant establishes a business in a country of residence which is different from their country of origin . Immigrant entrepreneurship can also be an important way of integrating into the socio-economic life in the adopted country, which is also the objective of public policy in the host country. From the socio-cultural perspective, immigrants face various challenging situations that make them to be psychologically and cognitively distinct. Thus, since individuals make up their own minds "holistically" , considering that individual factors or contextual conditions alone is inadequate in studying their entrepreneurial intention. To better understand their intentions and behaviours, it is necessary to broaden the scope of antecedents that are commonly taken into consideration in entrepreneurship research by incorporating specific factors that appropriately contextualize it. This could help to deepen the understanding of IEI construct. What are the particular factors that are relevant to the immigrant entrepreneurship context? What are the effects of the selected determinants on immigrants' entrepreneurial intention? These are the questions that we attempt to address in this study. An in-depth understanding of the determinants of IEI is important since immigrants and their descendants can play an important economic role through the creation of new businesses and jobs. Although many studies have identified the influence of culture on IEI models , those studies did not explain how a culture gap impacts people's propensity to start a new business. This is a weakness of the way culture was conceptualized in those models by an extensive use of cultural dimension grid designed to examine cultural differences between nations . In a migration context, exposure to different ideas and environments can affect and even transform cultural beliefs . Given the increased migration and socio-professional integration problems, it becomes necessary to understand how the difference between the entrepreneurship culture of both the home country and host country influences IEI. The study intends to make following significant contributions. First, addressing the concerns of authors such as Fayolle and Liñán , Krueger and Day , and Liñán and Fayolle on the paucity of IEI research, this paper extends the theory of planned behaviour by adding more variables that are essential for immigrant entrepreneurship intention . Beyond individual factors , the cultural distance between the country of origin and host country as perceived by immigrants as well as institutional supports for entrepreneurship, have an impact on the development of the IEI. Moreover, distinct from the models of cultural value dimensions, the cognitive approach enabled us to verify that immigrants perceive cultural distance through a cognitive prism of planned behaviour that stimulates the feasibility of their entrepreneurship project. In addition, the existing literature lays emphasis on psychological factors such as risk perception . By integrating psychological and economic dimensions, our findings advance the contextualized approach in immigrant entrepreneurship and illustrate that the integrative effects of individual and contextual factors is critical for improving the quality of IEI. Therefore, we advance the research on the value of contextualizing EI and on the role of cognition in explaining this process. Secondly, we conceptualize the learning-based entrepreneurial intention following the study of Douglas . Thus, it can assist scholars in empirically studying immigrant entrepreneurship intention in a way that is consistent with the cross-cultural understanding that reflects the reality of their research. Finally, this learning approach enables us to consider entrepreneurial culture as a shared liability issue: the liability of foreignness which requires immigrants to learn the local entrepreneurial culture and the liability of the host country which consists of finding effective mechanisms that can overcome liabilities of foreignness of newcomers to entrepreneurship. The article proceeds as follows. In the next section, we develop its theoretical basis and the hypotheses. Then, we go further to test the hypotheses by using data from 250 participating immigrants. Thereafter, we discuss the results by highlighting the important contributions and limitations of the study before drawing a conclusion. --- Theoretical foundations and hypotheses The process of IEI development is not a linear phenomenon. Some immigrant entrepreneurs are forced to establish their own businesses as an economic survival strategy. Some others engage in ethnic enclave business and serve people from similar backgrounds and experience as them, and some other immigrant entrepreneurs belong to specific ethnic minority community that do not share the characteristics of the majority local population. Our study employs the principle of TPB and extends it by including additional predictors . Moreover, Ajzen states that the approach offered by the TPB provides "a conceptual framework for thinking about the determinants of the behaviour under consideration, " i.e., immigrant entrepreneurship intention, "and which can be submitted to empirical test. " However, there is scarce research attaching importance to integrating these conditions into the holistic framework of immigrants' entrepreneurial intention formation process. --- Theories in immigrant entrepreneurship Early research described immigrant entrepreneurship as the process by which an immigrant establishes a business in the country of settlement different from his or her country of origin . Several studies have addressed the importance of entrepreneurship on the social and economic integration of immigrants . Immigrant entrepreneurship refers to the process whereby immigrants identify, create and exploit economic opportunities to start new ventures in their host nations" . Conceptual understanding of immigrant entrepreneurship implies to pin down several frameworks and models that extant research provides. These theoretical views allowed researchers to explore the particularities of factors enabling or impeding immigrants to start a business venture. Rather than suggest mono-causal and then multi-causal approaches to make the bill consistent, Peroni et al. classified theories that seek to explain the relationship between immigration and entrepreneurial involvement into two broad groups: the first group focuses on the specific characteristics of immigrants for explaining differences in the propensity to start a business compared to non-immigrants; the second group relies on the institutional and cultural environment of the host country. Theories in the first group spotlight higher probabilities that make immigrants to start a new business due to several forms of disadvantages in the host country pushing them to necessity of self-employment instead of low paid jobs, cultural traits that immigrants inherit from their home countries driving them to use ethnic resources in areas where they run business belonging to the same ethnic group , role played by certain immigrants seen as foreign traders, specifically middlemen or intermediaries between market actors . Among this group, the second theory has received considerable attention through the fact of maintaining networks and connections with the country of origin. Theories in the second group focus on the interaction between individual characteristics of immigrants and the institutions and features of the hosting societies and markets. The interactive model explains immigrants' involvement in entrepreneurship as the outcome of the interaction between their own resources and societies' opportunity structures; so, immigrants mobilize their specific characteristics called ethnic strategies to access these opportunity structures. "The latter are historically shaped circumstances such as market conditions that do not require mass production or distribution, characterised by decreasing return to scale in which ethnic goods are in demand" . One decade later, Kloosterman and Rath refined the former model to account for country-specific institutional frameworks. Their so-called mixed embeddedness suggests that immigrants are not solely belonging to ethnic networks, "they are also embedded in specific market conditions, socio-economic and politico-institutional environments" . By and large, most scholars in the field of immigrant entrepreneurship research base their arguments on the mixed embeddedness theoretical approach . However, the conceptualization of this approach did not take into account the effects of countries of origin . Yet "immigrants are in a unique position to create opportunities by combining and adapting ideas, products, and processes from different socio-cultural contexts" , including but not limited to the host country. Accordingly, while scholars found immigrant entrepreneurs to be embedded in multiple contexts, literature has ignored the need to focus on the embedding process itself , disregarding the learning which is necessary to achieve the embeddedness . --- Personal attitude, subjective norms and perceived behavioural control and immigrant entrepreneurship intention Entrepreneurship crystallizes the business creation process. To understand this entrepreneurial process, authors such as Bird and Krueger and Carsrud identify EI as the link between ideas and action; that, therefore, makes it so crucial in this process. For Ajzen , intention captures how people exhibit their motivation and willingness to carry out the desired behaviour. Intention is one of the best predictors of planned behaviours . However, understanding the consequences of intention requires an understanding of intention's antecedents . There are various theoretical frameworks for EI proposed by previous studies; each of them claims that every entrepreneurial behaviour is preceded by the intention to develop such behaviour and that several specific different factors influence this intention. The TPB is probably the most applied, widely supported, and robust intention model . The theory suggests three factors that contribute to forming entrepreneurial intention: attitude towards behaviour, subjective norms, and perceived behavioural control. Attitude towards behaviour is defined as the individual's evaluative effect towards creating a new business. The subjective norms suggest that individuals are more likely to adopt a family and close friends or mentors' behaviours, and/or behaviours that these reference individuals/groups approve. Perceived behavioural control reflects the perceived ease or difficulty of engaging in that behaviour. Control factors include, along with many others, skills and abilities, experience, cooperation by other people, money and other resources the immigrant is supposed to have acquired or learned. Several previous studies in various countries and contexts have shown the vital role played by EI . Using the TPB, other studies have empirically analysed and adequately shown the positive impact each of these three antecedents has on EI . According to Urban and Chantson , the beleifs, values and capabilities of an individual influence the choices and decisions they make. Immigrants who believe and know that they can succeed in their entrepreneurial drive will do the needful to succeed. Immigrants with greater control of exhibiting a behaviour will have a greater intention or efforts to achieve that goal or behaviour. Attitudes, subjective norms, and perceived behavioural controls collectively form behavioural intentions, and so lead to actual behaviours . Based on the results of these studies, we formulate the following hypotheses: H1a: Immigrants' Personal attitude positively impacts their Entrepreneurial Intention. H1b: Immigrants' Subjective norms positively impact their Entrepreneurial Intention. H1c: Immigrants' Perceived behavioural control positively impacts their Entrepreneurial Intention. Our model aligns with the TPB on two grounds. Firstly, that there is an interaction between subjective norms and personal attitude on the one hand and behavioural control on the other hand . Hui-Chen et al. found a positive impact of personal attitude and perceived behavioural control on subjective norms. Still, this effect was not significant on EI. However, although the predictors of intentions are conceptually independent, empirically they are free to correlate with each other . Consequently, we assume an effect of personal attitude and perceived behavioural control on subjective norms. Theoretically, attitude is conceived as personal in nature and subjective norms reflect external social influence. However, attitudes have two components: personal attitude and social attitude. Behavioural outcomes can be social in addition to personal because an immigrant entrepreneur's behaviour often has consequences for other people. Subjective norms is different from social attitude, and deals with what reference groups think about the behaviour itself. Put together, social attitude and subjective norms refer to a person's behaviour in relation to other people and show the relatedness of social attitude to subjective norms. Immigrants are considered high in self-consciousness and selfmonitoring, social attitudes significantly and positively influence their behavioural measures . It implies that a positive attitude towards entrepreneurship of the immigrant and his own perceived feasibility of the project can contribute to the increase of perceived social pressure to engage in the entrepreneurship. This leads us to formulate the following hypothesis: H2a: Immigrants' Personal attitude positively impacts their subjective norms. H2b: immigrants' Perceived behavioural control positively affects their subjective norms. Secondly, it aligns with the TPB in that those external factors, such as demographic or environmental characteristics, do not directly influence intentions, but are mediated by the three antecedents of intentions . Furthermore, in light of Ajzen , this study theorizes that the degree to which immigrants have control over the entrepreneurial behaviour will depend on their ability to overcome entrepreneurial culture distance and on the presence of such facilitating factors as past experience and assistance provided by social networks and institutional context. --- Individual variables and the antecedents of immigrant entrepreneurship intention --- Entrepreneurial experience Economic integration of immigrants depends on human capital which needs to be demonstrated by official qualifications . Bureaucratic red tape and difference in international qualifications make it difficult for immigrants to assert their human capital based on foreign qualifications. To overcome this impasse, some entrepreneurs are likely to use their previous experience to carry out the entrepreneurial process, . Building on their learning, experienced entrepreneurs can identify more opportunities and generally explore more innovative opportunities with more potential for wealth creation than unexperienced entrepreneurs . Because experience improves their capacity to deal with liabilities of newness, effectual reasoning, and attitudes towards failure , experienced entrepreneurs must rely on it to make informed and effective decisions. Entrepreneurial experience can have a critical value in the host market. As Entrepreneurial learning transpires through, and is emergent from, practices and their relations , prior entrepreneurial experience is expected to play a crucial role in the formation of entrepreneurial intention. This view has been empirically supported by several studies . Wiklund and Shepherd argue that both EI and behaviours can be conceptualized in entrepreneurs' capabilities. Knowledge and accumulated skills of each entrepreneur are, in fact, predictors of entrepreneurial activity . Such is the case with experience, whether direct or indirect, which is part of human behaviour and stimulates EI. Work experience is even seen as a factor that attracts people to self-employment because it can motivate varied, well-perceived, and approved initiatives . The diversity of experience may benefit startuppers, since it increases the probability of being a habitual businessperson with setting up more than one entreprise . Based on the above and considering Ajzen's view about background factors in the TPB as assumed to influence intentions and behaviour indirectly by affecting its determinants, we expect that experienced immigrants will exhibit higher personal attitude, subjective norms, and perceived behavioural control to induce the intention to start a business. Thus, we formulate the following hypothesis: H3: Immigrants' Experience positively impacts their personal attitude, subjective norms, and perceived behavioural control towards undertaking an entrepreneurial venture. --- Perceived risk and immigrant entrepreneurship intention Among the personality traits considered as an antecedent of intention, the notion of risk is of particular importance . Risk is defined as the probability of a substantial financial loss, but the same dollar amount of possible loss could be more severe for one entrepreneur than another . While risk may also involve non-financial threats like damage to reputation, it is our view that high risk seen as a threat among immigrants may arouse their own epistemic curiosity . Generally, risk perception has been conceptualized as an assessment of risk by the decision-maker in a given situation . It is perceived as a determinant of risky behaviour and entrepreneurial decision-making . Despite the importance of risk on entrepreneurial intention, relatively few studies have addressed this issue . Perceived risk plays an important role in the course of undertaking an entrepreneurial venture by immigrants in a new environment of their newly adopted country of residence. They must assess their abilities as well as the environment in which to create and develop the new business. The idea inherent in the evaluation process is that individuals evaluate stressful situations in terms of their well-being and especially, risk. It is important to understand to what extent perceived risk influences the formation of entrepreneurship intention. We can only assess the risk and even anticipate it when we know it, and are exposed to it, then we can have a conscious approach, called risk taking . When forming entrepreneurial intention, risk taking allows the potential entrepreneur to temper over-optimism by determining the rate at which it will influence performance . Risk perception is considered as something that slows down entrepreneurial activity as it might create perception of potential losses from business activities. Thus, risk perception will negatively affect the immigrant entrepreneurial intention. Immigrants' willingness to take risks should be very high early in the entrepreneurial process or they would never get started. Then, this willingness may decline over time probably when they will realize that entrepreneurial projects are exposed to many risks that require entrepreneurs to deal with and manage . In addition to the assessment of possible damage and loss , it is the fact of being a foreigner that creates the additional risk. A new approach to risk in business creation argues that risk perception is context-dependent and multidimensional with two meanings: risk as a threat and risk as an opportunity . The results of a recent empirical study in a recessionary economic context indicate that both types significantly influence EI. It means that perceptions of risk as an opportunity tend to increase EI but few empirical studies have supported it. On the other hand, it is widely believed that perceptions of risk as threat tend to reduce EI . A similar line of reasoning can be applied to immigrant entrepreneurs who should perceive risk more as a threat than an opportunity in the host country. This can weaken the desirability and feasibility of launching such a new venture. Moreover, personality traits are background factors that are assumed to indirectly affect behavioural, normative, and control beliefs. Hence the following hypothesis: H4: Immigrants' perception of risk as a threat hurts their personal attitude, subjective norms, and perceived behavioural control towards undertaking an entrepreneurial venture. --- Contextual variables and the antecedents of immigrant entrepreneurship intention --- Social network Context is a multi-faceted concept, its social dimension reflects both the perspective of social network as well as household and family integration . Turkina and Thai define social network as a set of actors and their links. Both "social and cultural factors may be important in the creation of entrepreneurial events and are most felt in the establishing of individual values systems" . Generally, an entrepreneur considers his entrepreneurial social network to be a medium through which he may gain access to different resources. Links in social networks are often divided into two types: close or strong ties are intimate bonds that exist between an entrepreneur and family members, very close friends, or other members of ethnic group, and loose or weak ties form social ties that are more diffuse, less intense, and often short-lived than is true for close or strong ties . Bonding social networks emphasizes on the density and tightness of the existing social network of an individual, while bridging social networks concentrate on an individual's scope and type of social network ties and their impact on the several outcomes including venture creation and nascent behaviour. Literature on immigrant entrepreneurship insists on the propensity of entrepreneurs to rely on ethnic networks to mobilize resources that are useful for the creation of their business . This understanding enlightens Granovetter's use of the social embeddedness concept to measure the effects of social networks on economic behaviour. The cultural anchoring of immigrants would facilitate the mobilization of ethnic resources as well as a vertical integration with co-ethnic producers, resellers, and customers . This vertical social embeddedness provides physical and emotional support through internal interactions and promotes trust among internal ethnic group members by sharing information. Beyond the kinship-based connections in the host country, high-quality social relationships are supposed to be built and nurtured with purpose. What we think of as horizontal social embeddedness facilitates entrepreneurs to obtain accurate information from outside the community and identify opportunities in the wider society, as well as gain decision-making advantages. For this purpose, healthy entrepreneurial bridging social networks should provide contacts and relationships to improve entrepreneurial capability building . Nowadays, following the sobriety of ethnic enclaves and the boom phenomenon of entrepreneurial digital social networks, this can allow immigrants to update information about new markets and opportunities, leading them to a more adequate decision . Ultimately, what is important is the strong entrepreneurial awareness to which the interaction of the role of potential entrepreneurs and the social context leads . Moreover, since "Mobilities are applied to immigrant entrepreneurship to investigate the ways immigrants build links and bridges through spaces and places" , such horizontal social embeddedness is beneficial for immigrants particularly in establishing reputation, improving performance and enhancing legitimacy. Different levels of networks can promote the circulation and exchange of resources . Research evidence suggests "a statistically significant relationship between bonding social capital and perceived desirability, bridging social capital and perceived feasibility, and entrepreneurial intentions and both perceived desirability and perceived feasibility" . Current research on bridging social capital derived from entrepreneurs' social networks indicates that it indirectly influenced EI through the positive mediation of entrepreneurial selfefficacy, with strong significant relationships between it and entrepreneurial self-efficacy . Following the above literature and drawing on the TPB, apart from the internal co-ethnic network, we postulate that external network, which goes beyond ethnicity, will have positive impact on personal attitude, subjective norms and perceived behavioural control translating into higher level of IEI. Those who develop diverse, outwardly oriented networks will be more likely to show higher intentions than their counterparts who have less or no such network within the social system. The following hypothesis is then formulated: --- Cultural difference Institutional context which draws on the concept of formal and informal institutions, as coined by North in terms of "the rules of the game in a society, " are humanly designed systems that shape human interaction. When it comes to informal institutions , the strand of literature studies its influence on relationship to entrepreneurship. Such research draws attention to the impact of culture . Culture has been described as "the interactive set of common characteristics that influence the response of a human group to its environment" . International entrepreneurship scholars argue that a country's values, beliefs, and norms affect its residents' entrepreneurial orientation . Therefore, entrepreneurs' effectual behaviour differs due to their national cultural traits . Regarding entrepreneurial culture, it is seen as one that values the personal characteristics associated with entrepreneurship . Hence, conceptualization, manifestations, and consequences of entrepreneurial culture are inherently central to entrepreneurial intention research. From a microlevel standpoint, this concept refers to an organizational culture embodying and upholding entrepreneurial attributes and characteristics . From a macrolevel viewpoint, entrepreneurial culture is found as a component of national culture that enables the success of economic growth . Accordingly, GEM Reports on Canada experts' opinion claim that cultural environment is one of the most favorable conditions for entrepreneurship in the country . Many developed and developing economies have allocated and spent vast amounts to promote and cultivate entrepreneurial culture, a valuable entrepreneurial ecosystem dimension . For institutions to foster the entrepreneurial spirit among people seeking to enter business, it becomes important to do so by focusing on empowering the individuals to carry out their entrepreneurial tasks . We consider entrepreneurial culture as an important factor in forming and promoting immigrants' entrepreneurial behaviour and their integration in the entrepreneurial ecosystem of the host country. Thus, immigrant's entrepreneurial acculturation should be placed in a lifelong perspective and started before business creation. Moreover, if foreignness is inherent to mobility, distinguishing between entrepreneurial cultures is central to immigrant entrepreneurship where culture is seen to be a liability issue. As with the liability of foreignness, which depends mainly on the social, relational and institutional factors, the difference in entrepreneurial cultures of the home and host countries can give rise to unfamiliarity and lack of embeddedness, discrimination by host country actors, and relational hazards for immigrants in their host countries . Lack of social legitimacy associated with information asymmetry and economic nationalism in host countries can give rise to a lack of trust in immigrants' entrepreneurial ventures, and sometimes even discrimination against them . On the other hand, in a new country, immigrants might have certain emotions vis-à-vis this environment. Hofstede et al. suggest that the tension created by the differences between the cultural dimensions and the country's institutions can also be a source of dissatisfaction . Generally, this perspective suggests that dissatisfaction among individuals who do not conform to the predominant cultural dimensions at the country level would induce the tendency to start their own business. Dissatisfaction could arise when there is a cultural clash between the immigrant and the informal environment of his host society. Missing the cultural embeddedness boat, some immigrants may feel that they are not affected by some of the values and practices that underpin the social fabric of their host country. Overall, this distancing could somehow influence the entrepreneurial decision in the same theoretical and empirical logic as in the recent studies results . The former confirmed the importance of entrepreneurial culture and education to promote entrepreneurial self-efficacy and then develop EI. The latter revealed entrepreneurial culture has a positive influence on attitude. Based on the foregoing, we assume that the perceived culture distance will decrease the IEI levels by lowering the effects of personal attitudes, subjective norms and perceived behavioural control. Instead of leveraging EI, it will hold a negative impact on both attitude, subjective norms, and perceived control. The following hypothesis is therefore formulated: H6: Immigrants' perceptions of Distance in entrepreneurial culture lower their personal attitude, subjective norms, and perceived behavioural control to undertake an entrepreneurial venture. --- Formal institutions When it comes to formal institutions, the critical role that institutional context plays in venture creation process has been welldocumented in the wider entrepreneurship literature . Formal institutions as political and economy-related rules which create or restrict opportunity areas for entrepreneurship provide the framework and structure to facilitate some types of exchange and the framework in which people have confidence in determining outcomes . They reduce uncertainty by providing a stable platform for human interaction , and affect the costs of interactions in such an environment by providing incentives for some behaviours and discouragement for others . The availability and quality of institutional context that produce human capital through education, training, and/or learning-by-doing should be likely to generate a strong propensity for new businesses. Therefore, in this study, we argue that institutional support for entrepreneurship has established itself as a critical policy direction to address the structural issue of the lack of employment opportunities, particularly in a hostile or corrosive environment of immigrants. The literature conceptualizes formal institutions in terms of the financial and educational support attributed or attributable to entrepreneurship and related regulations and the perception of corruption . These factors that motivate entrepreneurship are generally evoked from either a positive angle or a negative angle . According to Zhang et al. , government support falls into two categories: to give policy support and to provide service support for solving problems . In this vein, entrepreneurship training program as examined by Lyons and Zhang is informative. The authors found that the effect of such program was small for minorities in the short run, more pronounced for minorities' likelihood of longer run start-up activity, whereas for non-minorities the effect was small and statistically insignificant. Entrepreneurial supports have a positive influence on entrepreneurial intention . The more an immigrant perceives an institutional support and the more training he receives, the more entrepreneurial attitude he will have . Thus, drawing on the TPB, we expect institutional support for immigrant entrepreneurship will positively influence both attitude, subjective norms and perceived control of the immigrants for their entrepreneurial career intention. Based on the above, it can be inferred that immigrant entrepreneurs who have favorable perceptions of formal institutional environment and supports for entrepreneurship will have higher EI. The following hypothesis is then formulated: H7: Immigrants' perceptions of Entrepreneurial supports have a positive impact on their personal attitude, subjective norms, and perceived behavioural control towards undertaking an entrepreneurial venture. --- Methodology --- Empirical setting This study focuses on immigrants living in Canada regardless of their countries of origin. Recently, innovations in the GEM methodology have made it possible to assess the quality of an economy's entrepreneurial ecosystem or the entrepreneurship environment, graded over 10 points. According to the 2019 NECI , out of the 5 participating economies that we consider as traditional countries of immigration , Canada is the second country with the most favorable environment for entrepreneurship after the United States of America. Moreover, in its 2019 Budget, the Government of Canada extended its support for inclusive entrepreneurship . With the proven success of economic-class immigrants in entrepreneurial activities, it is clear that this economy has an environment that is the most conducive . This is the reason why we decided to base our work on immigrants in Canada. The following procedure and instruments were known to and approved by the ethics committee of the Laval University. --- Sample and procedure Our data draw from a survey conducted from June 2018 to July 2019 through the following sampling procedure. We were able to contact the immigrants through MIFI , where we accessed the TCRI to obtain a list of immigrant associations registered in their database. The list enabled us to contact the presidents of several African, European, Latin-Caribbean, and Asian immigrant associations. With the help of the associations' presidents, we were able to send our questionnaire to a total of 444 participants. The questionnaire was developed in English and French, the two official languages of Canada. To administer it to the participants, we combined two data collection techniques, namely an online survey via an electronic link and manual completion of printed copies of the questionnaire. For the online survey, an email with the electronic link to the survey was sent to association presidents, who then forwarded it to their respective members. Printed copies of the questionnaire were distributed to participants during association gatherings such as community fairs, general meetings, and open events. The questionnaire items were formulated in such a way as to minimize social desirability bias. Also, respondents were assured of the anonymity of their responses . Out of the 444 distributed questionnaires, 275 were returned by respondents. Out of these 275 returned questionnaires, we had to reject 25 based on incomplete answers. Therefore, 250 valid questionnaires were finally retained. This sample of 250 respondents was made up of 54% Africans, 26% Europeans, 10% Latin-Caribbeans, and 10% Asians. From a gender perspective, the sample was made up of 27% men and 73% women. As for the sectors of activity envisaged for their future businesses, among the 101 participants who answered this question, 18% targeted restaurants, 15% groceries, 12% services related to new technologies, and 9% retail sales . --- Measurement of the variables --- Measurement of EI and its antecedents Entrepreneurial intention and its antecedents were measured using the items developed by Liñán and Chen on a 7-point Likert scale ranging from 1 to 7 . Thus, a set of 4 items, including statements such as "I am ready to do anything to be an entrepreneur" and "My professional goal is to become an entrepreneur, " were used to measure respondents' EI. An analysis of this construct's reliability shows that it has good internal consistency with a Cronbach's alpha of 0.77. The immigrants' attitude towards entrepreneurship was measured using four items indicating their attractiveness and the level of benefits they perceive for entrepreneurship. These items include statements such as "Being an entrepreneur would give me great satisfaction" and "A career as an entrepreneur is attractive to me. " This construct has a Cronbach's alpha of 0.68. To measure subjective norms, we used four items including statements such as "My immediate family would approve of my decision to start a business" and "My friends would approve of my decision to start a business. " Cronbach's alpha associated with this construct is 0.75. Perceived behavioural control was measured with three items, including statements such as "If I tried to start a firm, I would have a high probability of succeeding" and "I know how to develop an entrepreneurial project" with a Cronbach's alpha value of 0.72. Frontiers in Psychology 09 frontiersin.org --- Measurement of individual variables Two variables -risk perception and entrepreneurial experience -were used to analyze individual factors' effect on immigrants' EI. We adapted the items developed by Nabi and Liñán to measure the perception of risk as a threat on a 7-point Likert scale ranging from 1 to 7 . These items include statements such as "Starting a new business is very risky" and "The probability of a new venture doing poorly is very high, " giving us a Cronbach's alpha of 0.68. To measure Entrepreneurial experience, we asked respondents to indicate the number of years they have already spent doing business in Canada. --- Measurement of contextual variables To analyze the effect of contextual factors on immigrants' EI, we used three variables: Social network, Distance of entrepreneurial culture, and Institutional context. Social network was measured using three items adapted from Lancee on a 7-point Likert scale ranging from 1 to 7 . Lancee identifies two types of networks: Bonding network and bridging network. However, in the present study, bonding network items do not have an excellent internal coherence. We, therefore, had to select only bridging network, which enables us to assess the extent of immigrants' weak social ties with the host society. The items used include statements such as "I establish relationship more with native Canadians than with my ethnic group, " and the construct's internal reliability test shows a Cronbach's alpha of 0.69. We used four items from St-Jean and Duhamel in terms of distance of entrepreneurial culture. They postulate that entrepreneurial culture can be perceived through the media coverage given to entrepreneurship and entrepreneurs' social status. The other two items are from Langford et al. , for whom a society's entrepreneurial culture can be perceived through the entrepreneurial spirit and propensity to risk that characterizes individuals and their creativity and ability to innovate. Since our focus in this work is the difference in entrepreneurial culture between Canada and the immigrants' countries of origin, we adapted the items developed by St-Jean and Duhamel and those of Langford et al. in the same manner as Saha et al. who studied the role of cultural distance in the medical field. Thus, we asked respondents to indicate the magnitude of the difference they perceive between Canada's entrepreneurial culture and that of their countries of origin on a 7-point Likert scale ranging from 1 to 7 . Items used include statements such as "Media attention towards entrepreneurship in Canada and my country is…" and "The way status is accorded to successful entrepreneurs in Canada and my country is…, " with a Cronbach's alpha of 0.88. Formal institution variable was measured by asking respondents to indicate their perception of entrepreneurs' assistance by formal institutions . A set of five items was used to measure this variable on a 7-point Likert scale ranging from 1 to 7 . These items relate to several aspects of institutional support, such as access to funding , support for innovation , networking arrangement , etc. For example, the items used include statements such as "In Canada, training to be an entrepreneur makes funding available for business start-up" and "In Canada, support structures enable joining or developing social networks. " For this construct, the internal reliability test shows a Cronbach's alpha of 0.74. --- Results --- Validating the measurements We tested the different scales used to ensure their convergent validity, discriminant validity, and reliability. To this end, an exploratory factorial analysis was carried out on all the items making up each of the multi-item variables used in our IEI model. We first verified the relevance of the factorial analysis by using the Kaiser-Meyer-Olkin test to evaluate the homogeneity of the items. The results presented in Table 2 below show that there is a factorial solution for each of the variables because the KMO values are more significant than 0.5 . In addition, the factor analysis confirmed the unidimensional structure of the scales used because, for each of the variables, only one eigenvalue is greater than 1. The proportion of the total variance explained by each factor is also consistent with the recommendations in the literature . In addition to the exploratory factorial analysis, we used Cronbach's alpha to examine the internal reliability of each of the constructs used in our model. The results of this test reveal that the different constructs have an acceptable level of internal consistency. In addition, the mean, standard deviations, and bivariate correlations between the independent and dependent variables are presented in Table 3. In this study, correlations analysis confirmed a statistically significant relationship between EI and all its three antecedents, according to the TPB. There is also a statistically significant relationship between some exogenous variables and EI antecedents . Testing further for structural validity , the square root of the variance shared between the constructs and their measures was analysed. --- Path model's test It should be stated from the outset that we tested two models in succession, one with a social network and the other without a social network . Since social network ties were all found to be insignificant, this variable and all other insignificant relations were removed from the initial model to test whether the adjustment would, at best, improve or, at worst, be maintained. The results presented in Table 4 below show that the structural model proposed without considering the network is overall well fitted and can therefore be used to test our different research hypotheses. All the models were tested with MPlus 6.1 . The criteria used to assess the fit quality of this model are the Chi-square ratio to the degree of freedom , the Root Mean Square Error of Approximation = 0.040, the Comparative Fit Index = 0.968, and the Tucker-Lewis Index = 0.923. A comparison of these different indicators' values with those recommended in the literature: χ2/df ≤ 3, RMSEA ≤0.1, CFI ≥ 0.90, TLI ≥ 0.90 shows that the estimated model is well fitted. Moreover, Chi-square is insignificant. In addition, most of the estimated relationships are significant. Except for H1c and H2b, all the other research hypotheses are validated. Thus, our results show that immigrants' attitudes toward entrepreneurship and their perception of subjective norms positively affect their EI. Hypotheses 1a and 1b are therefore validated. The results also indicate that H3c, H4a, and H4b on the relationships between individual variables and the antecedents of intention are validated. Similarly, the hypotheses on the relationships between contextual variables and perceived behavioural control are validated. As for the relationships between EI antecedents, Hypothesis 2a, which postulates that attitudes towards entrepreneurship positively affect subjective norms, has been validated. The results of Model 1 are also presented in Table 3; they show that the structural model incorporating social networks is generally well-fitted, as was the previous model. The adjustment indices show that the model fits well with the data: the Chi-square ratio to the degree of freedom = 1.296, the Root Mean Square Error of Approximation = 0.034, the Comparative Fit Index = 0.967, and the Tucker-Lewis Index = 0.934. Apart from the hypotheses about bridging social networks, which appear to have no significant effect, all relationships in the model maintained their significance level. Figure 2 summarizes the results of the final empirical model with all the relationships tested. When comparing the standardised coefficients represented in this Figure, it is clear that the magnitudes of the standardised coefficients differ. Perceived risk as a threat was related to personal attitude and subjective norms , confirming H4a and H4b, respectively. Entrepreneurial experience was related to perceived behavioural control , which partially confirms H3. Cultural difference in entrepreneurship was related to perceived behavioural control , which partially confirms H6. Institutional entrepreneurial support offered by formal institution was linked to perceived behavioural control , which partly confirms H7. --- Discussion on findings of this study In this article, we studied the antecedents of immigrants' entrepreneurial intention by testing a model that combines previous research on entrepreneurship, immigrant entrepreneurship, and psychological factors that form immigrant entrepreneurship intention. More specifically, we studied individual variables and contextual variables as indirect antecedents, as well as attitudes, subjective norms, and perceived behavioural control as direct antecedents of IEI. We expected that individual and contextual variables would show indirect effects via attitudes, subjective norms, and perceived behavioural control. Direct impact on subjective norms was also being expected from attitudes and perceived behavioural control. Regarding the direct antecedents of intention described by the personal attitudes, subjective norms, and perceived behavioural control, only 'perceived behavioural control' was not conclusive in predicting IEI. While this result contradicts previous literature which proposed that individuals' decision to start their own business is influenced by the perceived feasibility judgment particularly among immigrants. This result confirms 'experience' as a source of self-efficacy, in line with Bandura's work . Moreover, as long as the perceived risk does not undermine the perceived feasibility of their business idea, immigrant entrepreneurs can create value for themselves with more or less risk in the host country. This risk mitigation is suggestive of their potential entrepreneurial resilience. Regarding contextual variables, among the three TPB factors, only 'perceived behavioural control' was affected by direct effects of distance in entrepreneurial culture and institutional supports for entrepreneurship, and not by network support. As for cultural distance, any confusion among immigrants is likely to reduce perceived feasibility, which contributes to the feeling of ineffectiveness. Whereas for perceived support, it confirms verbal persuasion as a source of self-efficacy in line with Bandura's work: the dynamic narratives of programs and other people's experience tend to persuade the immigrant audience that they can competently carry out any entrepreneurial activity if they try . The extra-ethnic social network of the immigrants appears not much helpful for their career plan. This emphasizes the lack of integration of immigrants in local networks. Although the reality of an ethnic enclave needs to be nuanced nowadays, this point nevertheless suggests that ethnic resources remain an asset. The strong ties of networks operating within the communities are a determinant factor for an ethnic business start-up serving the communities with the similar tastes and preferences. In a nutshell, our results show that TPB partially accounts for overall indirect effects. Individual factors, indicators of experience and perceived risk all appear to operate within the broader framework of TPB in that they are linked to the IEI. On the other hand, the seemingly unsuccessful indirect effects of entrepreneurial culture, distance and institutional supports for entrepreneurship are probably due to the cognitive nature of both distance and support on feasibility. The result of social networks, which seems counterintuitive, rather calls for doing things differently . While attitudes and perceived behavioural control are understood as the two strongest antecedents of immigrant entrepreneurship intentions , how can we understand the indirect effects of individual and contextual factors' lack of transmission to the final intention? Two explanations seem plausible. First, the possibility of reverse causality has been raised in the previous literature. It has been suggested that an increase in IEI may affect desirability and feasibility . Elfving et al. report that the idea of such reciprocal causality is reasonable. This suggests that the intention formation process would be iterative and therefore evolutionary . Unfortunately, our sample did not allow us to test such a mechanism. Secondly, the result seems to challenge the performance of the entrepreneurial support of which some immigrants are beneficiaries. Discovering the gap between the entrepreneurial culture of their country of origin and that of the host country creates "a constant tension" , a source of dissatisfaction which looks like a double-edged sword. On the one hand, that dissatisfaction pushes them to start their business as individuals who do not conform to the predominant or mainstream direction of the country's cultural dimensions . At the same time, on the other hand, the tension created by cultural differences is likely to limit the effect of perceived behavioural control on intention . Because when an important informal institution is different, the gap which undermines efficient and effective transactions of productive markets can be construed as informal institutional void . This tension can only be mitigated by institutional supports for entrepreneurship. This is the mission that entrepreneurial support structures should fulfill with immigrants in their entrepreneurial emergence process. Otherwise, the potential immigrant entrepreneur procrastinates, even has mental blockages and gives up in the face of obstacles. Therefore, the immigrants should use the opportunity of their mixed embeddedness in institutional context. --- Theoretical implications Theoretically, this study makes several important contributions to immigrant entrepreneurship. First, we connect immigration with entrepreneurship to integrate mixed embeddedness with the TPB, both conceptually and empirically on a cognitive level. Based on our assessment, both TPB and mixed embeddedness logics are important to understand the relevance of the IEI formation process. This indicates new theoretical linkages that have rich potential for theory and research in immigrant entrepreneurship. This study extends the TPB by contributing significantly to the limited literature on factors driving the immigrants' intention process to become entrepreneurs in their host country. In this article, we are concerned with the antecedent drivers of IEI, and whether these are different from the drivers of traditional EI. Since both immigrant and traditional entrepreneurship are desirable for economic growth, global competitiveness and entrepreneurship diversity, it is important to understand how both types of entrepreneurships behaviour emerge. This empirical study confirms the plausibility of TPB in understanding the antecedents of intention to start a business by immigrants. It has clearly shown the importance of several factors that are often overlooked in previous works on IEI. The goodness of fit of the model validates the inclusion of these factors in the TPB when predicting EI of immigrants. Moreover, while the evidence from the literature shows that the TPB variables have been extensively studied in the decisions of individuals to engage with an intention to start a business in various contexts, studies that engage immigrant entrepreneurs' intention formation process are rare. The inclusion of such previously unexplored factors fills important knowledge gaps and enriches the understanding of their effects on the EI of immigrants in host countries, under a holistic decision-making process . Second, it also enriches the theory by comforting the TPB against "the problem of 'inclined abstainers' , individuals who form an intention and subsequently fail to act, that has been a recognized limitation of the TPB" . Third, it improves the understanding of the mixed embeddedness approach, by adding the effects of country of origin , a neglected aspect that recently drew criticism . The approach is a Waldinger et al. 's interactive model refined by adding new elements limited to the host country-specific institutional frameworks . Finally, to the best of our knowledge, entrepreneurial culture distance in entrepreneurship research has not been adequately addressed previously. In doing so, this study advances theoretical conceptualization in the field of immigrant entrepreneurship. Furthermore, the IEI formation process cannot be adequately described without addressing the factors holistically, through learning and cultural sensitivity. This logical argument that underpins this study helped us to identify which factors should be studied, as well as how and why they are inter-linked. --- Empirical implications The operationalization of cultural distance of entrepreneurship concept is intended as an empirical contribution to existing knowledge on immigrant entrepreneurship. This study empirically tests an entrepreneurial model based on the relationship of belief-attitudeintention framework developed by several authors such as Krueger . We present an integrative model integrating individual and contextual dimensions along with psychological factors that jointly form the immigrant entrepreneurship intention formation process. This study differs from the study of Zhu et al. where variables like entrepreneurial cultural differences were absent. --- Practical implications The importance of our research lies, first, in the fact it provides a valuable piece of information to those in charge of entrepreneurial support and decision-makers who seek to further promote the emergence of entrepreneurial activity in immigration context. Immigrants cannot claim to become entrepreneurs merely on the basis of an identity . As entrepreneurship is a learning process , even more so is entrepreneurial intention itself. We argue that EI is also a learning process with regards to the way enterprises are doing business. Second, analysis across the world's entrepreneurial ecosystems displays common challenges posed by an entrepreneurial culture to develop and transmit and how to ensure that individuals who wish to start a business actually take action . The study affords clear implications of theory for problem-solving in immigrant integration situations. Immigrants should 'learn to undertake' for ensuring progress in the process. Rather than developing rigid policy instruments, our results allude to the importance of encouraging the entrepreneurial mindset and network of immigrants. The problem is not just taking action, but rather persisting in action. This requires integral embeddedness. We therefore support and plead for formal experience-based training. Third, if our results show that perceived risk can weaken the passion for entrepreneurship, entrepreneurial behaviour reality and contexts require individuals to get familiar with local entrepreneurial culture. Examining culture at a more granular level than previous research reveals that entrepreneurial culture is a shared liability issue: the liability of foreignness behoves the immigrant to learn the local entrepreneurial culture whereas the liability of the host country consists of cultivating such culture in a way that allows learning it to boost the entrepreneurial mindset. Empowering immigrants' entrepreneurial intention through entrepreneurial culture is the key. Policy makers should take action to help their entrepreneurial ecosystems to thrive by strengthening human capital, addressing local/national inequalities through promoting cohesive, inclusive, and sustainable entrepreneurship. To support integration through entrepreneurship, destination countries should help the immigrants in improving their human and social capital. Consequently, this would lessen the disadvantage they face in their host countries. Finally, in international business literature, several recent studies have begun to focus on the joint effect of formal and informal institutions . The results of our study are consistent with this and call for institutional complementarity in the support to be offered to immigrant entrepreneurs. --- Conclusion Although it is not always easy to work at the intersection of two disciplines, this study could attest to the benefits of combining economic and psychological perspectives in examining IEI. It is challenging to appreciate how the cognitive perspective, in which we have embedded this work, has served as an interface to integrate several theoretical approaches. This has led to a deeper understanding of the process of IEI. The difficulties and obstacles being encountered by immigrants in starting and developing their businesses are often those that they should have paid attention to during the entrepreneurial intention phase. As the saying goes, "Trees with deep roots are those that grow high. " The challenges that are not identified at this stage can persist and jeopardize the career that is chosen out of opportunity or necessity. While perceived risk only affected intentions via the TPB's desirability factors, the formal and informal context only had direct effects on the feasibility factor of the TPB framework. Particularly, future studies could focus more on a longitudinal analysis of these direct effects. By and large, therefore, we conclude that the interaction between individual factors and contextual factors plays an important role in the transition of immigrants from the employability world to that of selfemployment, and that future research should continue to shed light on this interaction, preferably in an interdisciplinary manner and especially, using longitudinal designs. This will contribute to a better understanding of immigrants' EI for engaging in entrepreneurship. Moreover, the use of a structural equation model has confirmed that the distance between the host country's entrepreneurial culture and that of the country of origin acts as a reducing factor in perceived feasibility. In contrast, entrepreneurial support should serve as an amplifier of the latter to maximize EI and, without further delay, move on to real entrepreneurial action. There would be a compromise in the perception of feasibility of a business project between entrepreneurial cognitive mechanisms, particularly between the distance of entrepreneurial culture and institutional entrepreneurial support. This study calls for an adaptation of the ad hoc structures to the actual support needs. It should be noted that this study has several limitations. Although the hypothetical path model is based on well-established theories, unfortunately, the correlational design of our study does not allow for strictly causal interpretations. Another limitation is the fact that our data was collected from a single source: the immigrants. Canadian experience of immigrants was only assessed using the 10. 3389/fpsyg.2023.1153142 Frontiers in Psychology 15 frontiersin.org single-item measure. While it is important to limit the number of items that respondents must complete, future research could also use multiple item instruments for this construct. Finally, IEI is a psychological state of mind and there are many more individual and social variables that could also be integrated into the model. We have also assumed Canada as a given background of space and place in relation to immigrant entrepreneurship except the entrepreneurial cultural difference, institutional supports, and personal network in the host market. Future studies on IEI might consider other individual, and contextual variables related to Canadian space and place that facilitate or create constraints in the IEI formation process. Future study might also consider variables such as the duration of stay in Canada and visa-type of immigrant entrepreneurs for the IEI formation process . --- 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. --- Frontiers in Psychology 12 frontiersin.org and Vozikis, 1994), it, however, corroborates subsequent studies by these same authors who see entrepreneurial self-efficacy as another cognition, also with intentional qualities, as derived from social learning theory . As an alternative to the direct effects of antecedents on entrepreneurial intention, only personal attitudes show an immediate effect on subjective norms, while the impact of 'perceived behavioural control' on subjective norms is not confirmed. This suggests that an immigrant's self-efficacy does not seem to convince his or her reference group. In this study, the effect of the reference group's social norms is difficult to identify due to the sample's cultural diversity. Il can also imply that the need for starting an entrepreneurial venture for survival in a new country was so dire that immigrants entrepreneurs do not put that much important on the effect of subjective norms of their reference group. However, it cannot be excluded that we are dealing with some individuals with low selfefficacy beliefs: pessimistic self-efficacy beliefs are likely to affect behaviour, particularly thinking and decision-making quality . Pertaining to individual variables, the three psychological factors have helped to better understand the effect of these variables on immigrants' intention to engage in entrepreneurship. They add an important perspective to the study on immigrant entrepreneurship by addressing why individual variables might be necessary for immigrants' transition to entrepreneurship. In this vein, our study Final empirical model for predicting immigrant entrepreneurial intentions. --- Ethics statement The studies involving human participants were reviewed and approved by the Research Ethics Committee of Laval University. Written informed consent for participation was not required for 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.

Economic integration of ever-increasing number of immigrants in the host country is a challenge both for the immigrant and their host government. Immigrant entrepreneurship can be one of the solutions to this challenge. However, little is known about how immigrant entrepreneurship intention formation process takes place. Immigrants face various challenging situations that make them psychologically and cognitively distinct. This study models from a holistic perspective, the dimensions of individual and contextual variables as antecedents of Immigrants' entrepreneurial intention (IEI). The study aims to identify the key factors responsible for developing EI of immigrants with an implementation intent. Cross-sectional data from Canada is examined using a sample of 250 immigrants. The analysis adopts a structural equation modelling approach. In addition to risk perception, bridging social network, and experience, we postulate that the perceived distance of entrepreneurial culture (country of origin versus host country) and entrepreneurial support are crucial factors that influence IEI. Empirical analyses based on survey data partially confirmed our hypotheses. The results show the role of psychological and cognitive factors in determining immigrants' intention to start a new business. We extend the Theory of Planned Behaviour (TPB) by identifying certain understudied determinants in the literature and presenting a holistic decision-making process in the context of immigration-entrepreneurship nexus. Examining specific factors that appropriately contextualize immigrant entrepreneurship research and relativize the EI through a learning-based approach advances current literature. It offers insights to policymakers and practitioners to contemplate entrepreneurial culture as a shared liability issue (foreignness, host country), and adapt their entrepreneurship guidance accordingly. Thus, this study opens the way to a better understanding of the business behaviour of immigrants. Their impact matters for the entrepreneurial diversity that resilient ecosystems need.

Introduction Stunting is an ongoing issue in many low-and middle-income countries. UNICEF/WHO and the World Bank [1] indicate that the number of stunted children is approximately 151 million, accounting for 22.2% of the children in the world. Moreover, the proportion of stunted children is concentrated in low-income and lower-middle-income countries compared to upper-middle-income and high-income countries [1]. Approximately 83.8 million stunted children live in Asia, mainly in Southern and southeastern Asia, 58.7 million in Africa and 5.1 million in Latin America and the Caribbean. Indonesia is one of the countries with a high burden of malnutrition, including stunting [1]. Child health outcomes are poor, even though the Indonesian economy is the largest in Southeast Asia and the 17 th largest in the world [2]. Data published by the Ministry of Health show that the incidence of stunting among children aged five years and below remains high at 30.8% [3]. The World Bank [4] noted that Indonesia has underperformed in terms of reducing the level of stunting compared to other upper-middle-income countries and other countries in the region. Given the high prevalence of stunting and its impact on children's cognitive development, the productivity level of Indonesia's next generation is predicted to be half of its potential [4]. Therefore, tackling child stunting remains a major government commitment, as asserted in the Indonesia Medium Development Goals 2015-2019 and 2020-2024 [5,6]. The wider literature on stunting reveals that various child-, parental-, household-and community-level characteristics are associated with stunting [7][8][9][10][11][12][13]. At the parental and household levels, several dietary and socioeconomic factors have been shown to be correlated with the risk of stunting. With regard to risk factors, Beal et al. [7], for example, established that the risk of stunting in Indonesia is higher in households that have no access to safe drinking water. Household wealth status is another significant predictor, as children coming from poor households are more likely to be stunted [11,12]. Meanwhile, at the community level, the prevalence of stunting has been shown to be higher in communities that lack access to health care [7]. In terms of protective factors for stunting, previous studies have shown that the likelihood of stunting is lower in communities where antenatal care services and integrated health and nutrition services are available [8,9,13]. In addition, consumption of diverse food within the household has also been found to lower the likelihood of stunting [14]. Furthermore, parental education has been shown to be significant, with children raised by educated parents having a lower risk of being stunted. Semba et al. [11] explored the channels through which parental education impacts stunting and argued that educated parents provide more care , which would in turn lower the risk of stunting. The prevalence of stunting in Indonesia varies by region, as illustrated in Fig 1 below [3]. It improved across all provinces between 2013 and 2018, except in East Kalimantan . The capital city of Jakarta Province had the lowest prevalence in 2018 at 17.7%, whereas East Nusa Tenggara recorded the highest at 42.6%. Provinces in the eastern part of Indonesia, where many development indicators lag behind other regions, have a higher prevalence of stunting. The World Bank [4] has also highlighted the regional variation in the incidence of stunting in Indonesia and further noted that the risk of stunting was higher in poor and populous districts where access to basic infrastructure of water, sanitation and hygiene was lacking. This paper examines the individual-, household-, subdistrict-and provincial-level determinants of stunting using a multilevel mixed effects model. Methodologically, this is an improvement over most of the previous literature in the field [see, for example, [13][14][15], as earlier studies examined the determinants of stunting in Indonesia using logistic and probit regressions. A multilevel model was appropriate for our analysis because of the hierarchical or clustered structure of our data. Young children living in the same household and community can be expected to have more similar stunting risks compared to those living in different households and communities [11,12,15]. Furthermore, children in the same province are more likely to have the same risk of being stunted because they have similar access to health care services and other infrastructure [8,9,13]. In addition, parental characteristics and household socioeconomic background have an influence on children's eating habits and nutritional status [14,15]. Multilevel modeling enables us to investigate individual heterogeneities and the heterogeneities between clusters and improves the estimation techniques used in previous stunting studies [see, for example, [13][14][15]. In addition, taking into account the clustering in the data generates more reliable standard errors of regression coefficients [16]. This paper addresses two main research questions: Do variations at the province, subdistrict, household and individual levels explain childhood stunting in Indonesia? What are the multilevel determinants of childhood stunting in Indonesia? The remaining parts of the paper are organized as follows. Section 2 discusses the data and methodology used in the paper, including the outcome variables and various control variables included in the estimation. Section 3 presents and discusses the results of our estimation. The last section presents the conclusions and provides policy recommendations based on the findings of the study. --- Data and methods --- Data source An open access and rich dataset from the Indonesian Family Life Survey was used to estimate the multilevel determinants of stunting across households, subdistricts and provinces in Indonesia . The IFLS is a longitudinal survey representing 83% of the Indonesian population in 1993. The survey has five waves of data collected in 1993, 1997, 2000, 2007-2008 and 2014-2015. The survey was conducted by the RAND Institute with the cooperation of local universities and research centers in Indonesia. The first wave of the survey covered only 13 provinces, but the number was broadened to include more than 20 provinces in the last round to capture respondents' mobility to other provinces. Ethical clearances for the surveys were provided by institutional review boards in the United States and Gadjah Mada University for IFLS waves 3, 4 and 5 and by the University of Indonesia for IFLS waves 1 and 2. This particular study focuses on the last two waves of IFLS-wave 4 and wave 5 -analyzed as repeated crosssectional surveys. There were 13,500 households and 43,000 individuals interviewed in the fourth wave of the study. The number of respondents increased in the fifth wave to 15,900 households and more than 50,000 individuals. This study only covers young children aged five years old and below. The dataset includes a total of 8,290 young children, with 4,142 in wave 4 and 4,148 in wave 5. Using child anthropometry information, we excluded children identified as having biologically implausible values based on z-scores of height, following the World Health Organization child growth standard, which reduced the number of children to 8,105. In addition, we removed young children for whom complete information on household and community characteristics was not available . Hence, the number of young children included in our final analysis was 8,045. The proportion of respondents with missing values was insignificant . Four hierarchical levels were considered in our analysis: individual , household, subdistrict and province. Children were nested within households . There were 6,437 households with 8,045 children aged 5 and below in the two waves of the IFLS. Approximately 20% of the total households had more than one child aged 5 and below. Households were nested within subdistricts . There were 1,332 subdistricts recorded in the two waves of the survey. We considered the subdistrict as the third level in our model, as service provision and quality of care in primary health centers or puskesmas are determined at the subdistrict level. The fourth level was the province, within which subdistricts were nested. We considered provinces as the highest level in our analysis; there were 21 provinces in the two waves of the IFLS used in our study. The IFLS provides a wide range of information, including data on birth history, anthropometry of children , clinical and subclinical infection, dietary habits and demographic characteristics. Child health status data include both a self-reported measure of general health status and a biomarker measurement conducted by a nurse. Furthermore, the household data consist of information on parental education and parental anthropometry, antenatal care during pregnancy, consumption and wealth, and household access to WASH. Finally, the IFLS also includes other community-level data, consisting of access to nutrition-specific intervention programs in the PHCs in children's neighborhoods. --- Outcome variable According to the 2005 World Health Organization child growth standard and Indonesian Ministry of Health guidelines [17], stunting is a measure of children's nutritional status based on their height. Nutritional status is determined by comparing the height of children with their peers of the same age. Height was measured during the survey by trained interviewers. Then, the z-score of height was calculated using the height of children and the corresponding median and standard deviation for children of the same age, which were obtained from the anthropometry guidelines. We then further grouped nutritional status into four categories using the calculated zscore values. The first group consists of severely stunted children whose height-for-age zscores are more than three standard deviations below the World Health Organization child growth standards median. The second group consists of stunted children whose height-forage z-scores are more than two standard deviations below the WHO child growth standards median. The third group is considered to have normal nutritional status, and their z-score is within two standard deviations of the WHO child growth standards median. The last group consists of children who are considered to have above normal nutritional status, with z-scores more than two standard deviations above the WHO child growth standards median. As the focus of our analysis in this research is stunted children, for our regression analysis, we categorized children into two groups-stunted and not stunted. The stunted group consisted of children who were severely stunted and was represented by a dummy variable equal to one. The remaining children were categorized as not stunted and were represented by a dummy variable equal to zero. --- Individual-level variables One of this study's particular aims was to assess the impact of children's dietary habits on stunting. The IFLS dataset provides data on dietary diversity and consumption frequency in the one week prior to the survey for each child in the family. Studies have suggested that adequate dietary diversity lowers the odds of stunting, whereas the consumption of unhealthy snacks raises it [14,[18][19][20]. We constructed a binary variable capturing the intensity of unhealthy snacking as a measure of children's dietary habits. Following Wang et al. [21], the dummy variable for unhealthy snacking took the value of 1 for children consuming unhealthy snacks more than 7 times a week and took the value of 0 for those with lower consumption frequency. Snacks in the IFLS survey include instant noodles, fast food, carbonated beverages and sweet snacks that are usually high in salt, fat and sugar and low in micronutrient content. However, unhealthy snack data are only available in IFLS wave 5. Therefore, we conducted two estimations. Our first estimation used both waves of the IFLS and excluded the unhealthy snack variable, whereas our second estimation used only the IFLS wave 5 and included the unhealthy snack variable. Demographic characteristics of children, such as gender, have also been considered predictors of stunting [15,22,23]. A dummy variable was constructed to test whether male children have a higher risk of being stunted, as earlier studies have found [15,22,23]. The study also included neonatal weight as one of the predictors of stunting, as suggested by Tiwari et al. [23] and de Silva and Sumarto [15]. According to the World Health Organization [24], a newborn baby weighing fewer than 2.5 kg is considered a small baby. Our dummy variable assumed a value of 1 if the neonatal weight was fewer than 2.5 kg and 0 otherwise. Infections , such as enteric infections and diarrhea, contribute to stunting [25]. The IFLS dataset has information on children's acute morbidity in the four weeks prior to the survey, including the occurrence of diarrhea . We constructed a dummy variable that assumed a value of 1 for children who had experienced acute diarrhea and 0 otherwise. --- Household-level variables Household-level variables consisted of both parental-and household-level factors that have been found to affect stunting in the wider literature. Previous studies have indicated that maternal education is associated with a lower risk of stunting [7,15,23]. Mothers are primary caregivers in most Indonesian households, and we controlled for maternal education using years of schooling. We also included the mother's height in our model to control for maternal stature, in line with previous literature [11,15,26]. According to Beal et al. [7], a short mother has a higher risk of having stunted children. Therefore, we created a dummy variable equal to 1 for mothers whose height was fewer than 145 cm and 0 otherwise. Previous studies have shown a strong association between stunting and socioeconomic background. De Silva and Sumarto [15] and Mani [27] presented evidence that higher household consumption expenditure per capita and greater wealth lower the prevalence of stunting among children. The IFLS dataset provides detailed information on food and nonfood consumption. Food expenditure consists of spending on staples, vegetables, dried foods, meat and fish, beverages and prepared food. The expenditure on nonfood items includes spending on education, electricity, water, telephone, household items, recreation, entertainment, clothing and medical costs. We used the quartile of total consumption expenditure per capita as a measure of household wealth, categorizing the expenditure data as quartiles labeled Q1 to Q4, with Q1 being the lowest quartile of expenditure. We included three dummy variables that identified poor households in the bottom quartile of the consumption expenditure distribution as a base compared with the higher quartiles of Q2, Q3 and Q4. To account for possible differences in health service delivery between rural and urban areas, we included a dummy variable for place of residence, which equaled 1 for children living in rural areas and 0 for those living in urban areas. Some earlier studies have suggested that childhood stunting is more prevalent in rural areas [15,23,28], and we examined whether this also held true for Indonesia. Finally, this study also examined the contribution of household access to WASH. Previous studies have underlined the importance of sanitation and access to health services in lowering the risk of stunting [12,15,29,30]. This study considered the association between access to clean WASH and the risk of stunting. Three dummy variables were introduced in the empirical model to capture WASH variables. The main source of drinking water in households was coded as 1 if the source of drinking water was either tap water or mineral water and 0 otherwise. The availability of a toilet was coded as 1 if there was a toilet with its own septic tank for sanitation and 0 otherwise. Additionally, the disposal of garbage was coded as 1 if garbage was disposed into a trash can that is collected by a sanitation service and 0 otherwise. --- Community-level variables We examined the effect of nutrition-specific intervention programs in PHCs in young children's neighborhoods. The IFLS dataset provides information on access to three nutrition-specific services provided by PHCs: growth and development monitoring, additional treatment for malnutrition and additional nutrition for the poor. A dummy variable was created to differentiate between young children who have access to all three nutrition-specific services and those who do not . --- Statistical methodology The study examined the individual-, household-, community-and province-level determinants of stunting using a multilevel mixed effects logistic model. Multilevel models allowed us to take into account the hierarchical structure in our data and calculate residual components at each level in the hierarchy. The individual-level variables we controlled for included children's demographic characteristics, birthweight, history of diarrhea and dietary habits. The family-level variables included mother's education, mother's stature and family consumption. We also included contextual variables at the community and district levels in the form of access to clean water, hygiene and sanitation, availability of nutritional services and area of residence . The adjusted odds ratio of the fixed effects reflects the likelihood of stunting in children. The intraclass correlation coefficient measures the degree of homogeneity within clusters in the risk of stunting. The partitioning of the residual components at each level enables us to see the effect of "unobserved" province-and community-level characteristics on stunting. Another advantage of multilevel models is that they allow simultaneous estimation of group effects and the effect of group-level predictors. We started our estimation by running mixed effects logit null models without covariates. The first null model introduced a random intercept term at level 4 . The second null model included an additional random intercept term at level 3 . Additionally, the third null model included an additional random intercept term at level 2 . The null models provided an indication of how much variation in stunting each additional cluster accounts for. Predictors were introduced in a stepwise manner, starting with child-level covariates, and followed by family-or household-and community-level covariates. The table also shows that more than half of the children consumed unhealthy snacks frequently based on Wave 5 data. In terms of gender composition, 52% of the children were boys. Moreover, the proportion of children who suffered from acute diarrhea was 15.46%. However, only 4% had been small at birth, with a weight of less than 2.5 kg. --- Results --- Characteristics of study participants Mothers in our sample had, on average, 8 years of education, which is equivalent to reaching the second year of junior high school in Indonesia. In terms of stature, 45.17% were fewer than 145 cm tall and were, therefore, classified as short following Beal et al. [7]. For householdlevel variables, the data revealed that the monthly average household consumption expenditure per capita increases as we move from the bottom quartile to the top quartile. The average for the bottom quartile was 230,947 Rupiah compared to 2.3 million Rupiah in the top quartile. The proportion of children living in rural areas was 44.16%. From the descriptive statistics for access to WASH facilities, we can see that more than 96% of households had access to clean water, only 68.8% had access to sanitation, and an even lower proportion had access to hygiene. Last, the data show that 27% of families had access to all three nutrition-related services from PHCs. --- Multilevel analyses of stunting determinants We present the results from the estimation of our three null models in Table 2. As noted previously, the first null model includes random effects at the province level, the second null model includes random effects at both the province and the subdistrict levels, and the third null model includes random effects at the province, subdistrict and household levels. We can see from the table that the likelihood ratio test statistic is highly significant for all three null models . This shows that multilevel models are a better fit to the data than a single-level model. Moreover, we also conducted likelihood ratio tests comparing the four-level model with three-or two-level models and found that the four-level model was a better fit for the data. Thus, stunting in Indonesia varies by province, subdistrict and household, and analysis of stunting needs to take into account variations at all these levels. Fig 2 below shows a caterpillar plot of the residuals from all 1,332 subdistricts in the sample with 95 percent confidence intervals. The residual shows the departure of the risk of stunting for subdistricts from the average . The graph reveals that for a substantial number of subdistricts, the 95% confidence interval does not overlap with the horizontal line at zero, indicating that stunting in these subdistricts is significantly above average or below average . Table 2 also presents the intraclass correlation coefficient , which measures the degree of homogeneity in the risk of stunting within clusters . A higher ICC indicates a stronger correlation in the risk of stunting within a cluster. We can see from Model 3 that the level-4 intraclass correlation at the province level is 0.031, whereas the level-3 intraclass correlation at the subdistrict-within-province level is 0.127 and the level-2 intraclass correlation at the household-within-subdistrict level is 0.297. This indicates that within-subdistrict differences are more important in explaining the variation in the risk of stunting in Indonesia than differences between subdistricts and provinces. We can also calculate the variance partition coefficients to see the contribution of unobserved cluster characteristics to the risk of stunting at each level in our model. The VPCs indicate that 3% of the variation in stunting is due to differences between provinces, whereas 10% is due to differences between subdistricts . Differences between households account for 17% of the variation, whereas individual differences between children account for 70% of the variation in stunting. We present our estimation results in Table 3. Our most comprehensive model controls for household-and individual child-level covariates and community-level contextual characteristics . Two main estimates are generated from the stepwise regression in S1 Appendix, as discussed in the methodology section. The first estimation employs two complete waves of the dataset ; these results are presented in Columns 1 and 2 of Table 3. The second estimation relies on the latest wave of data , as information about dietary habits, particularly unhealthy snacking behavior, is only available in wave 5; these results are presented in Table 3 Columns 3 and 4. For the individual variables, our findings indicate that a high frequency of snack consumption is associated with a higher risk of children being stunted. In terms of magnitude, frequent snacking increases the risk of being stunted by 30% , as shown in Table 3 [18,28,[30][31][32]34]. Additionally, our results indicate that boys have a higher risk of being stunted than girls, a finding that is consistent with previous studies. The likelihood of stunting was higher by 17% for boys than girls using two waves of data and by 26% using the Wave 5 dataset [32][33][34][35]. Another individual-level factor that is associated with a higher risk of stunting is neonatal weight. This study found that small babies weighing fewer than 2.5 kg at birth have a 2 times higher risk of being stunted than babies of normal weight. According to our model utilizing both waves of data , the odds of stunting for a small baby were 2.29 . The final individual-level predictor of stunting is infection with diarrhea. The estimations revealed that suffering from acute diarrhea in the four weeks prior to the survey is associated with a higher risk of being stunted, with an odds ratio of 1.27 in the model using Wave 4 data and an odds ratio of 1.30 in the model using Waves 4 and 5 . Our results also indicate that maternal characteristics, such as maternal stature and years of schooling, and household characteristics, such as household wealth quartile, place of residence and access to basic infrastructure , are significantly associated with stunting. Children whose mothers are shorter than 145 cm have a 19% greater risk of being stunted. Moreover, the number of maternal years of schooling lowered the risk of being stunted . Our results also suggest that children from poor households have a higher risk of being stunted. The risk of stunting decreased by 23% for children in the second quartile of the wealth distribution. The risk of stunting was further lowered for children in the fourth quartile by 44% . It is apparent from our results that children living in rural areas have 19% greater odds of being stunted than children living in urban areas. This study also found that having no access to clean water increases the risk of being An odds ratio is statistically significant at either 1 percent , 5 percent or 10 percent of the confidence intervals. https://doi.org/10.1371/journal.pone.0260265.t003 stunted by 36% ]). Similarly, having no access to sanitation was associated with a 27% higher risk of being stunted ]). A higher risk of stunting was also associated with a lack of access to hygiene at 52% ]). The stepwise estimation using the multilevel mixed effects model shows that the risk of stunting is higher if the children have no access to nutrition services programs in PHCs, but this association is not statistically significant ]). Finally, the estimation shows that the odds of being stunted for young children in 2014 was higher than that for young children in 2007 . The data show that the proportions of stunted children in 2007 and 2014 were 24% and 29%, respectively. --- Discussion Our analysis found that stunting is associated with several individual-, family-/household-and community-level variables. Frequent unhealthy snacking, male sex, low birthweight and diarrhea increase the risk of being stunted. Family characteristics that contribute to stunting risk include short maternal stature and having a family with a low socioeconomic status. In terms of community characteristics, this study found that living in rural areas increases the risk of stunting by 19%. The risk of stunting is also higher for children living in a community with a lack of access to clean WASH. The results show that there is a positive association between a high frequency of snack consumption and the risk of children being stunted. Studies have indicated that snacking is becoming more prevalent in Indonesia, both in rural and in urban areas. A study by Sekiyama et al. [19] showed that one-third of food consumed by young children in West Java, Indonesia can be categorized as snack food. High snack consumption has a detrimental effect on children's development because snacks contain mostly fat and energy but have a lower density of protein and micronutrients. Black et al. [31] and Tarwotjo et al. [32] suggested that a lack of micronutrient intake, such as calcium and vitamin A, adversely affects children's linear growth. The World Health Organization has reported that chronic deficiencies in micronutrients are experienced by more than 2 billion people worldwide [29]. Micronutrients are vital for children's development because they have a significant role in bone formation , long bone growth and intrauterine femur length increase [33][34][35]. The importance of micronutrients for children has also been established by other studies measuring the effect of the School Feeding Program on children's development [36][37][38]. A quasi-experimental study by Metwally et al. [36] revealed that feeding children pie made of flour fortified with vitamins and minerals has a positive effect on cognitive development. Nevertheless, the effect of SFP on nutritional status takes a longer time to manifest, so the effect is not statistically significant. Another study of SFP in rural Kenya showed that the intake of minerals, such as zinc and iron, and vitamins may increase children's appetite, muscle growth and physical activity [37]. The importance of micronutritients on children's diet has also been found in the impact evaluation of SFP programs in rural Uganda [38]. It was found that children fed one or two eggs per day gained more height and weight because eggs are a source of 13 essential micronutritients and protein, which are essential for children's development. Our finding that boys have a higher risk of being stunted than girls is consistent with previous studies. Adair and Guilkey [35], Moestue [34] and Wamani et al. [33], for example, found that the height-for-age z-score for girls is higher than that for boys; thus, girls have a lower prevalence of stunting in Sub-Saharan Africa and China. The literature suggests that higher stunting prevalence among boys may be explained by complementary feeding practices. Boys receive premature complementary foods, as parents perceive that breastfeeding is not sufficient to fulfil the greater energy intake they believe is required for baby boys [18]. A study by Tumilowicz et al. [39] showed that among Guatemalan children, more boys than girls aged 2-3 months are fed complementary foods. The IFLS dataset for young Indonesian children also shows that complementary feeding is initiated for boys earlier than for girls. On average, complementary feeding for Indonesian young children in the IFLS data of Waves 4 and 5 started at 19.74 weeks for baby girls and 18.91 weeks for baby boys; the difference was statistically significant in a t-test. In addition, these complementary feeding practices do not benefit boys because they are more likely to be fed more meals than girls. Tumilowicz et al. [39] presented evidence that baby boys are fed two more meals than girls in a 24-hour period. Premature complementary feeding practices have a detrimental effect on young children because they pose a greater risk of catching infectious diseases [40,41]. In addition, early introduction of food before babies reach 6 months of age has no significant effect on children's length or weight development [23]. As presented in the Results section, we found that babies of lower birth weight have a two times higher risk of being stunted than babies of normal birthweight. This finding is consistent with a study by Tiwari et al. [23], which found that average and above average weight newborn babies have lower odds of being stunted than smaller babies. Furthermore, A Saleemi [42] and Varela-Silva et al. [43] also showed that the risk of smaller babies being stunted is three times higher than that for other babies. According to Schmidt et al. [26], neonatal weight and particularly length are good indicators of the status of children's nutrition in the future. Low neonatal weight and short length may be an indication of intrauterine growth restriction , meaning that babies are not growing at a normal rate inside the womb during pregnancy. Lower neonatal weight and height may also be related to maternal malnutrition during pregnancy, which in turn influences the development of the baby [23]. Moreover, small babies may also have been born prematurely, which means they may not have fully developed during pregnancy [23]. In the long run, IUGR may lead to numerous developmental issues, such as growth retardation, lower cognitive ability development and poor neurodevelopmental outcomes. In terms of infection with diarrhea, our findings are consistent with previous studies by Bardosono et al. [44], Beal et al. [7] and Tiwari et al. [23]. These authors also found that diarrhea is associated with stunting. According to Richard et al. [45], diarrhea is a particularly common health issue in developing countries, as households lack access to clean water and sanitation. Drinking from unimproved water sources and drinking untreated water increase the risk of diarrhea due to intestinal infections from a variety of bacteria, parasites and viruses. Richard et al. [45] suggest that the impact of diarrhea on linear growth is particularly strong when young children suffer from multiple episodes of diarrhea in the first 24 months of their lives. Furthermore, diarrhea may lead to growth retardation if the occurrence of diarrhea coincides with a lack of good-quality food and poor access to health care. Diarrhea has a detrimental effect on linear and ponderal growth, as it lowers dietary intake, escalates metabolic demands and lessens nutrient absorption in the gut [45]. Our analysis found a strong association between maternal stature and childhood stunting. Semba et al. [11] similarly established a strong association between maternal stature and stunting, and Schmidt et al. [26] contended that maternal stature and neonatal weight are the strongest predictors of child stunting. Maternal stature is perceived to be a good indicator of intragenerational undernutrition. Prendergast and Humphrey [46] argued that having a stunted mother is relevant in explaining stunting prevalence in children because of the importance of the nutritional status of the mother on children's stunting. Mothers suffering from undernutrition may have a higher risk of having stunted children because of their significant influence, especially in the first 500 days of a child's life. The association between maternal years of schooling and risk of stunting is also supported by previous studies [see, for instance, 8,19,41]. A better educated caregiver is perceived as having appropriate maternal nutritional knowledge [44]. Furthermore, Semba et al. [11] found that better educated parents tend to engage in more protective caregiving; for example, they may do this by ensuring that their children receive vitamin A capsules, are fully immunized, have access to better sanitation and consume iodized salt. The results also provide evidence that children from poor households are at higher risk of being stunted. The strong association we found between family wealth and stunting has been established in the literature [7,11,13,27,[47][48][49][50]. Bardosono, Sastroamidjoo and Lukito [44] argued that poor families lack the resources to consume high-quality nutritional foods and access health care. Our result shows the positive association between living in rural areas and the risk of being stunted. Previous studies support the finding that children living in rural areas have a higher risk of stunting than their peers in urban areas [see, for instance, 15,23,28]. According to Mahendradata et al. [51] and Mulyanto, Kurst and Kringos [52], both the demand and the supply of health care vary between urban and rural areas. People living in urban areas have more access to health care and other related infrastructure, such as roads that reduce the travel time to health care facilities. Meanwhile, access to health services in rural areas is more limited. According to Sparrow and Vothknecht [53], 6.3% of subdistricts in Indonesia have no access to PHCs. These districts are mostly in rural areas outside Java Island. Furthermore, their study reported that 4.2% of PHCs in rural areas have no physician serving in health facilities. Physical health infrastructure, such as working incubators, lab facilities and outpatient polyclinics, is also more limited in rural areas. Another study by Schmidt et al. [26] suggested that a higher prevalence of stunting in rural areas compared with urban areas is related to a greater sensitivity to changes in food prices. Families in rural areas are more sensitive to food price increases because they allocate twofifths of their budget for staple needs. As the price of foods increases, the purchasing power of rural families declines, making it harder to fulfil the essential nutritional requirements of their children. Our results also show that a lack of access to WASH is associated with stunting among young children in Indonesia. Secure access to WASH infrastructure is critical. Young children are more prone to diarrhea, intestinal worm infection and environmental enteropathy when households have poor WASH facilities [9]. These infections may lead to nutritional issues. For example, children may lose their appetites, so they might consume less food than they need. In addition, these types of infections can lead to the malabsorption of nutrition and chronic immune activation. Finally, infections may induce fever, which requires the body to burn more food and exert energy to fight the infection instead of using it for physical development. The insignificant association we found between stunting and access to nutrition services in PHCs may be due to the limited capacity of the Indonesian nutrition program, as shown in a report by UNICEF [54]. In terms of coverage of the nutrition-specific interventions recommended by The Lancet [55], the Indonesian government has only adopted 4 out of 10. Of the remaining six programs, four are partially covered, and two are not included. In terms of health infrastructure, the proportion of nutritionists per head in the population is low in Indonesia and varies across regions. In the larger provinces on Java Island, such as in Central Java, the number of nutritionists to every 1,000 people was as high as 43.14 in 2017. However, the number was much lower in the provinces outside Java Island. For example, in East Nusa Tenggara, one of the provinces with a high prevalence of stunting, the number was only 12.04. Our results also show that the risk of stunting for young children was higher in 2014 than in 2007. Previous studies have revealed that after a significant decline in stunting prevalence in Indonesia in the 1990s and early 2000s [28], the prevalence remained unchanged in the 2000s [56]. Our finding aligns with national data from the Indonesia Socio-Economic Survey and Basic Health Survey, which shows that stunting prevalence was higher in 2013 than in 2007. A World Bank publication acknowledges the important role that nutrition programming and surveillance at the village level in the 1980s played in reducing the prevalence of malnutrition in Indonesia. However, this massive program has experienced setbacks and lost the close attention of the government. Furthermore, Indonesia has undergone decentralization, which has reduced the effectiveness of nutrition programs in improving children's nutritional status due to weak management and poor governance [57]. --- Study limitations and strengths This study highlights the importance of family-and community-level variables in stunting, in addition to individual characteristics. The assessment of the different levels of clusters in this study facilitates understanding of how contextual factors contribute to stunting in children. Hence, our study demonstrates the urgency of addressing not only personal-or individual-level factors but also household-and community-level factors to reduce stunting prevalence. The limitations of this study are listed here. First, regarding the source of the data, the two waves of the IFLS data used in our paper are representative of approximately 83% of the Indonesian population, covering 21 provinces; thus, some areas of eastern Indonesia were excluded from our analysis. Additionally, IFLS Wave 4 data do not capture unhealthy snacking behavior among young children. This variable is considered an important proxy for measuring children's dietary habits; therefore, we used only Wave 5 data to examine this issue. Second, from a methodological perspective, the cross-sectional nature of our analyses limited our ability to infer causation. Moreover, some data were based on self-reported information, for example, the birth weight of the children, and thus may be susceptible to measurement error. In addition, our study did not control for the random slope component in the model. The assessment of nutritional services was conducted from the supply side . However, we adjusted for several important confounders and took into account some unobserved characteristics through multilevel modeling. --- Conclusion Stunting remains a development issue in Indonesia, with approximately 30% of young children being stunted. This study examined the multilevel determinants of stunting among young children in Indonesia. At the contextual level, the ICC showed that there is a correlation in the risk of stunting for children living in the same province. The correlation becomes stronger for children living in the same subdistricts. Finally, the strongest correlation of the risk of stunting was found among children living in the same household. Moreover, the likelihood ratio tests revealed that stunting in Indonesia varies by province, subdistrict and household level, and analysis of stunting needs to consider variations at all these levels. At the child and family levels, our results identified several statistically significant determinants of childhood stunting. In terms of individual characteristics, being a boy, having a low neonatal weight and experiencing acute diarrhea were associated with stunting. In terms of family characteristics, we found that mothers' characteristics, specifically maternal stature and maternal education, were associated with stunting. In contrast, living in a family with a higher socioeconomic status lowered the risk of stunting, and the risk of stunting was much lower for children in the highest quartile of the wealth distribution. Finally, in terms of community characteristics, we found that living in rural areas increased the risk of stunting by 20%. The risk of stunting was also higher for children living in a community with lack of access to clean WASH. From a policy perspective, our findings suggest that tackling stunting in Indonesia requires substantial effort to create spaces that assist policy implementation in establishing supportive multilevel conditions. These include addressing both individual-and household-level factors that support good child nutrition and development. Healthy eating habits, mothers' education and awareness, socioeconomic characteristics and the availability of WASH matter. --- The data are available in a public repository from the https://www.rand. org/well-being/social-and-behavioral-policy/data/ FLS/IFLS/download.html. : Universitas Sebelas Maret Grant Contract number 452/UN27.21/PN/2020 URL: www.uns.ac.id The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Stunting is still a major public health problem in low-and middle-income countries, including Indonesia. Previous studies have reported the complexities associated with understanding the determinants of stunting. This study aimed to examine the household-, subdistrict-and province-level determinants of stunting in Indonesia using a multilevel hierarchical mixed effects model.We analyzed data for 8045 children taken from the 2007 and 2014 waves of the Indonesian Family and Life Surveys (IFLS). We included individual-, family-/household-and community-level variables in the analyses. A multilevel mixed effects model was employed to take into account the hierarchical structure of the data. Moreover, the model captured the effect of unobserved household-, subdistrict-and province-level characteristics on the probability of children being stunted.Our findings showed that the odds of childhood stunting vary significantly not only by individual child-and household-level characteristics but also by province-and subdistrict-level characteristics. Among the child-level covariates included in our model, dietary habits, neonatal weight, a history of infection, and sex significantly affected the risk of stunting. Household wealth status and parental education are significant household-level covariates associated with a higher risk of stunting. Finally, the risk of stunting is higher for children living in communities without access to water, sanitation and hygiene.

Introduction The desire to have a child is based both on psychological and social reasons. Assisted reproduction treatments have made it possible for many individuals/couples to have a family even when sperm and oocytes are reduced or lacking. Large numbers of children are born following donor conception, and there is an increasing demand for donor conception worldwide. Depending on legislation and regulations, treatment with donor sperm, oocytes, and embryos is available to various groups of recipients, including heterosexual couples, lesbian couples, and single women. Donor conception has traditionally been performed with anonymous donors, while it has been less common to use a donor who is 'known' to the recipient, most often a female relative who donated oocytes. There is a global trend towards programmes using donors that are identifiable to the resulting offspring at maturity, commonly labelled 'identity-release' or 'open-identity' donors. The use of identity-release donors implies that the donor is anonymous to the recipients, although they may receive some non-identifying information about the donor. Upon request from a donor-conceived child that has reached mature age, the donor's identity is released to the child. Legislation on identity-release gamete donation was first introduced in 1985 in Sweden and later in other jurisdictions . Donor conception creates families where the genetic linkage between family members is varying and where there are genetic links to individuals outside the family unit. The presence and/or absence of genetic linkage may have psychosocial consequences for all involved parties, i.e. for the donor and his/her family, as well as for the recipient, the donorconceived child, and their larger family. There is a relatively large body of research on the psychosocial aspects of anonymous donor conception, and to a lesser extent on 'known' donation. Systematic reviews in the field show that both oocyte and sperm donors' psychosocial wellbeing was good throughout all donor groups , and families created through the use of donor gametes appeared to be welladjusted . During recent years, the attitude towards disclosure in gamete donation has shifted from secrecy to openness, and disclosure is now strongly encouraged by the Ethics Committee of the American Society of Reproductive Medicine . A recent systematic review focussing on donorconceived offspring showed that genetic ties are perceived as important, especially during adolescence and adulthood, and that many were interested in receiving more information about the donor and for potential contact . In contrast to the relatively large body of research on anonymous and known gamete donation, research on the psychosocial aspects of conception with gametes from identity-release donors is more limited, mostly due to the fact that this type of donor conception has been less common. The purpose of the present review is to summarize the available research on psychosocial aspects of identity-release gamete donation. Furthermore, we want to present an overview of the specific perspectives of donors, recipients, and offspring, including motivations for participating in this type of donor conception, as well as perceptions of disclosure issues and potential contact between donor and offspring/ family. PubMed and PsycInfo databases were used in order to search for relevant empirical studies. Due to the diverse use of terminology for this type of donation it is possible that some studies including relevant groups were missed. This overview covers only studies that specifically noted the inclusion of donors, recipients, or offspring involved in identityrelease donation, but does not include studies on surrogacy, although such arrangements frequently include donor gametes. In several studies, a small subset of participants concerned identity-release donation. Such studies were included provided that they presented results from these groups separately, and were otherwise excluded [e.g. ]. Not surprisingly the largest number of identified studies was performed in Sweden, where identity-release gamete donation has been mandatory since 1985, and the remaining studies were conducted in other European countries and in the USA. --- Perspectives of identity-release donors --- Motives and characteristics By definition, the term donation implies altruism, and both male and female donors who agree that their identity may be released to offspring at maturity have been found to donate primarily or solely based on altruistic reasons, i.e. they want to help involuntarily childless people . However, also other motives such as receiving confirmation of one's own fertility potential, spreading one's good genes, and donating as a way to have a child/children in the future have been reported , with sperm donors more often reporting spreading their genes as a salient motive compared to oocyte donors . Although the dominant motive for donating was altruistic, two small survey studies found that a subgroup of identity-release sperm donors also reported financial motives . A Danish interview study with sperm donors, five of whom had opted for identityrelease status, found that financial compensation was a factor for the decision to allow more information about them to be made available to recipients, but the child's wellbeing was also considered when providing extended information about oneself . Also, in a large Finnish study of oocyte donors, one in four reported that the financial compensation had at least some influence on their decision to donate . In contrast, in a recent interview study including 24 oocyte and sperm donors in the UK, all rejected the idea that they had been financially motivated, and it was particularly important for sperm donors to frame their donation as a purely altruistic 'gift', as a financial motive was perceived to be incompatible with a beneficial potential relationship with offspring from their donation . Oocyte donors, on the other hand, were more comfortable to incorporate the fact that they received financial compensation in the narrative of their donation as a 'gift' to recipients longing for a child. The personalities and characters of gamete donors are of interest for the recipients but also for the resulting offspring. In a Swedish national study, the Temperament and Character Inventory was used to assess both oocyte and sperm donors. The sperm donors were found to all be in the normal range of character, which means that the donors perceived themselves as autonomous individuals with capacity to take responsibility and with the ability to behave in a goal-oriented manner . The sperm donors described themselves as persons well integrated in society and having a capacity for relatively high identification with and acceptance of other people. Concerning the personality and character of the oocyte donors, it was evident that they described themselves as less worried, shy, and fatigued, and as more persistent compared to a comparison group of women in fertile age . These findings are reassuring for all involved, both in the donation and treatment process, and for the future families, and suggest well-functioning screening procedures in a non-commercial donor programme. --- Openness about donating Little is known about donors' view of informing others, such as partners and biological children, about their donation. In two Swedish survey studies, each including 30 sperm donors, almost all had shared information with their partner about their intention to donate or of being a donor . The involvement and support from the partner seemed to be important factors for the decision to donate sperm, particularly among younger men . Many donors in the Ekerhovd et al. study planned to inform their own children of the donation, particularly if the donation did result in a child. Similarly, in a well-designed Finnish study, almost all oocyte donors who were mothers either had or planned to share this information with their children . --- Thoughts about offspring and potential contact For identity-release gamete donors, the number of children conceived with their gametes is of particular interest, since the offspring will be able to obtain the donor's identity and may attempt to contact the donor. However, only one study was found investigating donors' views regarding the number of children a donor may conceive . About half of 235 oocyte and sperm donors 5-8 years after their donation regarded 1-10 children to be an acceptable number of offspring from one donor, with oocyte donors more often supporting an upper limit than sperm donors. Following identity-release donation, a majority of both oocyte and sperm donors would like to be informed if their donation results in pregnancy and birth . In a Swedish follow-up study of gamete donors, sperm donors reported a higher level of emotional involvement with offspring from their donation compared to oocyte donors . This included wanting to know how the child fares in life and feeling responsibility for the child if anything happened to his/her parents. In two Swedish qualitative studies, each including 30 sperm donors, most of them were positive or neutral towards contact with adult offspring from their donation . This finding was confirmed in a large follow-up study of sperm donors and oocyte donors 5-8 years post-donation . Ten percent of donors were negative towards being contacted by an offspring, and some comments indicate that this was based on a desire that the child would feel no need for contact and be 'happy in their real family' . Among oocyte donors in Finland, a majority stated that they were positive or neutral towards future contact with an offspring, but they were more uncertain regarding potential contact between their own children and a donor offspring . Furthermore, in a qualitative study of 11 oocyte donors from the UK, women were happy to be contacted by offspring, but some expressed concerns regarding potential negative impact of such contact on the offspring's parents and on the donor's own family . So far, only one study has reported on identity-release donors' position when adult offspring from their donation seek information about them . In that study, from one sperm bank in the USA, clinic staff contacted sperm donors when information about them was being requested, and 39 out of 43 men responded that they were open for contact with their offspring. --- Satisfaction with the donation and need for counselling The experiences, satisfaction, and consequences of being an identity-release gamete donor, i.e. with respect to the medical care and treatment, have been investigated in a few structured follow-up studies. In a Finnish follow-up study of 428 former oocyte donors, 67 of which were identity-release, almost all were satisfied with their donation . Similarly, in a Swedish study of 300 oocyte and sperm donors, most of them were satisfied with the donation . Those who expressed ambivalence before the donation reported lower satisfaction 2 months after their donation . In a qualitative study from the Netherlands, male donors expressed a need for counselling in order to discuss the emotional consequences of their donation, disclosure to their own children, family, and friends, and potential future contact with an offspring . In a Swedish follow-up study of 210 oocyte and sperm donors several years following donating, one in four donors reported a need for counselling about how to manage potential future contact with offspring from their donation . More than half of these donors wanted to be notified when an offspring requested information about them in order to prepare for potential contact, while one-third were negative to receiving such information, partly to avoid potential disappointment if no contact attempts would follow. In the above-mentioned Finnish study, the oocyte donors indicated a high level of satisfaction with the support offered during the process and a relatively low need for additional support . --- Perspectives of recipients --- Motivation for choosing identity-release donation In general, reasons for choosing treatment with donor gametes include having a biological tie to the child, desiring to experience a pregnancy and to have a child who has a genetic link to at least one parent. The most common reasons for choosing identity-release sperm donation stated by heterosexual-couple, lesbian-couple, and single-woman parents in a US study were that this gave the child the option of getting more information about the donor, including his identity, and the option to be able to meet him . In a US study of 129 lesbian mothers, most of them were satisfied with their choice of an anonymous, known, or identifiable donor . Those who had selected an open-identity donor were most satisfied with their choice, both because they avoided potential custody conflicts and/or involvement from a third person, and because offspring would have access to information about the donor. --- Disclosure Identity-release donation gives the offspring an option to obtain identifying information about the donor. However, offspring can only make use of this option if he/she has been made aware of the donor conception, most often by his/her parents. In a Swedish study of 148 heterosexual couples with children conceived through donor insemination in the years directly after the law was introduced, only 11% had informed the child about the donor conception, 46% planned to disclose later, and one-third were unsure or planned not to disclose . Those who had disclosed did not regret their decision to disclose and thought that being open about the donor conception had been beneficial to the child. In a follow-up interview study including 19 couples from the above study, participants said that healthcare staff had influenced their thinking, and a majority of those who had been encouraged to tell their children about the donation had done so . Another interview study of 31 heterosexual-couple parents with 1-to 7-year-old children conceived with donor sperm during 1997-2003 found that 75% already had or planned to talk with the child about the donation . In a later Swedish study of 111 heterosexual couples with 1-to 4-year-old children following oocyte or sperm donation , 78% planned to disclose to the child about the donation, and 16% had already started the disclosure process. A subset of 30 heterosexual sperm recipients from that study also participated in an interview study when the child had reached 7 years of age . The authors concluded that sharing information about donor conception with offspring was a complex process that involves different levels, and in which parents' beliefs and the child's responses serve as driving or impeding forces. A UK study investigated disclosure to offspring among 31 heterosexual solo mothers and 47 heterosexual-partnered mothers with donor-conceived children aged 4-8 . About half of the solo mothers and one-third of the partnered mothers had already told the child about their conception with donor sperm. Among those who had not yet disclosed, partnered mothers were significantly more reluctant or negative to disclose than solo mothers. In line with this finding, a US study showed that all single women and lesbian couples with adolescent offspring had disclosed their use of donor insemination to their children, while this was the case for 70% of heterosexual couples . Disclosure did not seem to have any negative impact on the families, regardless of the parents' sexual orientation or relationship status. Several studies have found that large groups of recipients had told other persons about their use of gamete conception , with no differences in disclosure behaviour with regard to sex or type of donation . One stated reason to refrain from sharing this information with people outside a close circle of friends and family was that the child should learn about the donation before other people did . Among parents who plan not to share information about the donor conception with their child, disclosure to others increases the risk of accidental disclosure. --- Managing family life When a couple conceives with donor oocytes or sperm, this creates a family where the child has a genetic link to only one of the parents. The presence and/or absence of genetic linkage, as well as the existence of an identifiable donor, may have psychosocial consequences for the couple and the family. Two Swedish interview studies of heterosexual couples following sperm donation concerned family life. Leeb-Lundberg et al. reported that some parents had worried that the lack of a genetic link to the father would create an unequal relationship with the child, but these concerns had disappeared over time. Isaksson et al. found that resemblance between child and parent was an important theme, and parents were reported to navigate between the importance of genetic connectedness and of 'doing parenthood' through social interactions. Non-resemblance between parent and child was described to bring the donor to the front and the donor constituted an 'absent presence', as also described in a qualitative study of single mothers in the UK . In the longitudinal 'Swedish Study of Gamete Donation', recipient couples of donor oocytes and sperm were followed 2-5 years after treatment. Heterosexual couples that had been treated with sperm donation expressed satisfaction with their relationship , and couples using oocyte donation treatment had a balanced and solid view of their relationship , where having children or not after treatment had no effect on the nature of the relationship. Lesbian couples following sperm donation reported stable relationships and a high satisfaction with their relationship, also after unsuccessful treatment . They also reported less parenting stress compared to heterosexual-couple parents following IVF with their own gametes and parents following a spontaneous pregnancy . While a previous study in the USA indicates that, following donor insemination, heterosexual couples, lesbian couples, and single women were positive about their decision and were quite open about the donor conception , lesbian-couple families may face specific challenges related to their non-traditional family formation. Results from interviews with 20 female-partnered mothers of young children indicate that participants had lacked psychological support in the process of planning and becoming a parent . They expressed a desire to be treated as equally valid mothers and as a proper family by professionals at child healthcare services . Also, the results from a web survey with 145 Belgian and Swedish participants, 36 of whom had used identifiable donors, showed that donor-conceived families were challenged by cultural norms and values and responses from friends, healthcare professionals, and teachers . When children conceived with gametes from identityreleased donors grow up, parents need to deal with the question of disclosure to the child. In a study of 111 heterosexual couples following oocyte and sperm donation, onethird were not in agreement about what to disclose to their child about his/her conception, and these couples reported a lower relationship quality than couples who agreed about disclosure . However, incomplete couple agreement about disclosure did not appear to have a negative impact on parental stress . --- Contact with donor and donor-siblings In a Swedish study including 279 heterosexual recipient couples of donor oocytes or donor sperm, about half believed that it was in the best interest of the child to be able to obtain identifying information about the donor, while the remaining were unsure, neutral, or negative . While few believed that contact between the child and the donor could be harmful for the offspring or family, about one-third could not form an opinion about this. In a subsequent qualitative study of 30 heterosexual parents with a 7-year-old child, some parents were curious about the sperm donor and hoped that the child would make contact in the future, while other parents expressed concerns about potential contact between the child and the donor . With openness about donor treatment, both parents and offspring may want to get information and contact others who share the same donor. The Sperm Bank of California has established a service that connects families who share the same donor, and it has been used predominantly by families headed by lesbian couples and single women, most of whom had used identityrelease donation . These groups' motivations for contact with other families who share the same sperm donor included to create a family for the child, obtain support for their children and/or themselves, and to get information about shared traits and medical problems . Femalepartnered women most often described their own and their children's relationship with 'linked' families as a unique type of relationship, a 'special bond', an 'extended family', or merely 'acquaintances' . --- Perspectives of offspring There is a dearth of research including the perspectives of persons conceived with gametes from donors who originally chose to donate within an identity-release programme, and all concern persons conceived with donor sperm. Scheib and co-workers have presented several studies based on donors, recipients, and their offspring from one sperm bank that has offered identity-release donors since 1983. One interview study included 29 adolescents conceived with sperm from open-identity donors, from households led by lesbian couples, single mothers, and heterosexual couples . A majority reported always knowing about their donor conception and were comfortable with their conception origins. Most also planned to request the donor's identity and pursue contact in order to learn more about themselves. These results are in line with two longitudinal studies of families headed by lesbian couples in the Netherlands and the USA, where half of adolescents conceived with sperm from an open-identity donor reported a desire to meet their donor and 67% of adolescents planned to contact the donor at the allowed age of 18 . Only one study was found that reported on the final step of an identity-release donor programme, i.e. requests and provision of identifying donor information to adult offspring. In a follow-up study, Scheib et al. reported on the first 10 years of this practice at one sperm bank. During this period, adult offspring from 256 families were eligible to receive such information, and a total of 85 offspring contacted the clinic for this purpose. Being a female offspring and belonging to a single-parent household increased the probability of requesting donor information, while having heterosexual-couple parents decreased the likelihood of a request. A large majority of offspring contacted the clinic for information within the first three years after turning 18. The most common motivations for requesting the donor's identity were to gain information about who the donor is as a person, his motives for donating, and medical or health information. Many believed that information about the donor would help them learn something about themselves and help to 'fill in the missing links'. While a majority expressed an interest in contacting the donor, most had low or no specific expectations of a potential contact, and very few expressed a desire for a close relationship. Four offspring were informed by the clinic that their donor was not open to contact and were reported to be very disappointed and upset. --- Discussion The aim of this review was to provide an overview of the perspectives of donors, recipients, and offspring involved in identity-release donation. Identifiable donors of oocytes and sperm predominantly reported altruistic motives, in line with motives reported for anonymous and known donors . Still, the prospect of a potential future meeting with donor offspring may influence how donors reflect about and frame their motives for donating. Identity-release oocyte and sperm donors were found to be mature and well-adjusted individuals , which is reassuring and indicates that the screening procedures are well-functioning. The studies that have investigated long-term consequences of donating in an identity-release donor programme indicate that most donors were satisfied with their decision and had positive or neutral attitudes towards being contacted by offspring from their donation . However, subgroups of donors expressed a need for support and counselling, both to handle their own situation and to prepare for a potential situation when an offspring seeks contact . While a recent review concluded that families following gamete donation in general are well-functioning , conception with oocytes or sperm from a donor who will be identifiable to the child at maturity may have specific psychosocial consequences. The present results indicate that recipients of gametes from identity-release donors had stable relationships and were increasingly open about having used donor conception , with female-partnered and single women being most positive towards disclosure to the offspring . Parents were generally satisfied with their choice of an identity-release donor as this gives their child the option to obtain more information about their genetic origin . Some parents had own interest in contact with the donor and/or with families who had used the same donor . Concerning the perspectives of offspring conceived with gametes from identity-release donors, the present review highlighted the very limited knowledge base for this specific group. Only four studies were found , all concerning adolescent and young adult offspring conceived with donor sperm. The results indicate that about half of the offspring who are aware of their donor conception, and have the possibility to obtain the identity of their donor, plan to do so, and many also intend to contact the donor. Their motivations for learning the donor's identity and meeting the donor are in line with those reported by offspring conceived with gametes from anonymous donors . The study by Scheib et al. is the first to report on the percentage of offspring eligible to receive identifying donor information who actually made such a request, which was about onethird of the total sample. Also, it was recently reported that only 5% of eligible adult offspring from heterosexual-couple families in Sweden had requested donor information . At the moment, there is no information available about the large groups that have not requested information about their donor. Are they aware of their donor conception and the possibility to obtain the donor's identity? What is their level of interest in this information? Are there any practical issues, concerns, or considerations that impact their decision not to seek donor information? In view of the relatively low disclosure rates reported by heterosexual couples who conceived with donor gametes in the 1980s and 1990s , is it reasonable to assume that at least some of those offspring are unaware of their origin with donor gametes. The studies covered in the present overview were performed in Europe and the USA and included quantitative and qualitative studies with cross-sectional, retrospective, and longitudinal designs. Studies of individuals involved in gamete donation are frequently based on single clinics and suffer from relatively low response rates, which limits the generality of the findings. Research on donor-conceived offspring is hampered by specific difficulties identifying this population, as it is ethically only possible to approach individuals who are aware of their donor conception. Recruitment of participants through self-selection, e.g. membership in networks for donor conception, is feasible but introduces a selection bias. Thus, there is a lack of knowledge about the perspectives of donors, recipients, and offspring who are not interested in seeking information about genetically related persons. Also, the number of long-term follow-up studies in this field is limited, and attrition is a matter of concern, as in all longitudinal designs. Changes in legislation, DNA-based voluntary contact registers, and direct-to-consumer genetic tests constitute new challenges and may have great influence for the future for assisted reproduction with donor gametes. The possibility of identification of genetically related individuals may have an impact not only on donors, recipients, and offspring, but also on their extended families . The need to ensure that all this information is handled with the best safety and privacy rights has been stressed . However, reflections on the future of genetic testing and/or screening must be distinguished from the long-standing debate about disclosure of donor conception to children . In conclusion, donor conception creates families with varying genetic linkage between family members and where there are genetic links to individuals outside the family unit. In the case of identity-release donation, the offspring has the opportunity to obtain identifying information about his/her donor. Existing research about the perspectives of donors and recipients involved in identity-release donation indicates that both oocyte and sperm donors primarily have altruistic motivations and that recipients are increasingly open about having used donor conception. Furthermore, several studies indicate that the offspring are interested in contact with the donor, and most donors are open to such contacts. Keeping in mind the lifelong consequences of identity-release donor conception, recipient families and donors could benefit from support and counselling to increase their confidence in managing family life. In view of the present findings, as well as the rapid development and increasing use of resources to identify genetic relatives, more high-quality research is warranted on the long-term psychosocial consequences of gamete donation. --- Disclosure statement No potential conflict of interest was reported by the authors. --- Notes on contributors Agneta Skoog Svanberg, registered nurse/midwife. PhD and professor in reproductive health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden. Gunilla Sydsj€ o, certified psychotherapist/MA behavioural scientist. PhD and professor in psychosocial obstetrics and gynaecology, Department of Obstetrics and Gynaecology, Department of Clinical and Experimental Medicine, Link€ oping University, Link€ oping, Sweden. Claudia Lampic, lic psychologist. PhD and associate professor in caring sciences, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.

Donor conception creates families with varying genetic linkage between family members. This may have short-term as well as lifelong psychosocial consequences for all involved. Gamete donors have traditionally been anonymous to recipients and offspring, but there is a growing trend towards identity-release donor programmes that give offspring the right to obtain the donor's identity. This review aims to provide an overview of the perspectives of donors and recipients and offspring involved in identity-release donation. The results show that both oocyte and sperm donors have primarily altruistic motives, and recipients, in particular lesbian and single women, are generally open about the donation to their offspring. The few existing studies on offspring perspectives indicate that those who are aware of their donor conception appear to be interested in contact with the donor, and most donors are open to such contact. Investigations of donors and recipients indicate a need for more counselling and support to manage family life with varying genetic linkage within and outside the family unit. This includes preparing for and managing future contact between the donor and his/her family and donor offspring and their family, as well as between donor siblings and their respective families.

INTRODUCTION Autism Spectrum Disorder is a neurodevelopmental disorder characterized by frequent high-level behaviour problems [1]. It is not clear what the exact cause of autism is. However, it is related to heredity, and there is no known cure for autism, although treatment has been suggested [2]. Caretakers of children with ASD present various forms of stress, including worries and feelings of helplessness to have a child who often portrays tantrums and violent behaviour, leading to a feeling of humiliation and negative labels [3]. Usually, children are https://doi.org/10.58421/gehu.v3i1. 148 2 trained in toileting at two years old, but this may not be the case with children with ASD, who are still aided in nearly all areas of their lives coupled with extra attention from their parents. In Zambia, there are no exact figures for children living with ASD, although roughly, there are indications of about 40,000 cases of ASD [4], [5]. With such estimates, it cannot be ignored that the impact of ASD exerts a significant influence on the individuals with the disorder and those around them. This study explored the influence of ASD on parents and shed light on what helps them cope with it among Zambian Parents. A wealth of literature provides different experiences parents go through in their everyday lives. Conceivably, parents experience much stress when they are told the results after the diagnosis of their ASD child [6]. Literature reveals that negative coping by some parents of children with ASD led to anger, confusion, avoidance, distress, and projection. Further, parents sometimes encounter physical reactions such as fright, trembling, and loss of appetite [6]. Studies show that parents of children with ASD suffer more from depression, anxiety, and stress than parents of normal developing children or those without disorders [7], [8]. Studies by Rafferty et al. [9] and Hastings and Johnson [10] revealed that those parents require a vigorous and comprehensive level of parenting as children with ASD need more time, resources, and management skills. The literature mentioned above established that most marriages of parents of children with ASD experience less sexual satisfaction and end in divorce more than families of typically developing children [8], [11]. Rafferty et al. [9] also investigated the social dynamics of parents when they inform their friends and relatives about the diagnosis. The study found that parents generally experienced different responses; positive and reassuring responses included expressions of love and support, whereas negative responses included regret and an offer to help if needed. It is also the case that parents will have experienced significant stress before the diagnosis because their child would have been displaying stimulating behavioural symptoms, but the parents would not have understood why or how to deal with them [12]. Empirical analysis has also suggested that parental stress is related to the severity of the child's symptoms and behaviours [13], [14]. Behaviors that are too difficult to manage require professional intervention, and, as such, parents continually need to seek appropriate educational and training services [15]. This can require a significant amount of administration by the parents as they spend much time looking after their children at home, which can be a source of stress. Furthermore, parents are expected to experience stress if the information and necessary access to resources are unavailable. Parents with insufficient information about the disorder will lack the understanding necessary to cope, which can affect how they can meet the child's strains. Parents may also be unable to follow their interests or goals, and mothers, usually the primary caregivers, can feel predominantly restricted. Economic circumstances resulting from having a child with a disability can also cause parental stress in different instances, like when significant fees are required for private services [5], [16]. Reviewed literature, therefore, shows the focus was on the stress children with ASD go through, challenges and opportunities experienced in learning and teaching children with ASD, and the psychological functioning of teachers handling children with ASD without necessarily addressing parental stress as they interact with their children with autism. The majority of such studies have involved children with ASD with a focus on educational attainment, instructional strategies, and rehabilitation of such children [4], [17], [18]. Although these studies have been done and significantly have contributed to available knowledge on children with ASD globally, very little attention has been paid to how parents of children with ASD cope with their children's behaviours, which causes them stress. This study was therefore conducted to establish the trials of parents of children with ASD pass through in coping mechanisms in the Lusaka district in Zambia. The study, therefore, sought to answer two main research questions as follows: How do parents get stress when working with their children with ASD? How do parents cope with the experiences of their children with ASD? --- METHODS This study employed a qualitative approach. A phenomenological research design was used. The study purposefully recruited ten parents aged 30 and 50 years old, where six of the participants were mothers and four were fathers, all from Lusaka District. The study used homogeneous sampling, which helped to describe parents' trials with their children with ASD in the Lusaka district in Zambia. The research design was suitable for this study because it helped understand how parents and guardians of children with ASD coped with stressful situations. Through interviews, nonverbal cues were observed and coded while what they said was recorded as verbatim excerpts, evidence of fieldwork. The study involved ten parents and guardians interviewed via face-to-face interactions. Participants were four male and six female. One of the participants was a grandmother who was caring for her daughter with ASD. Participants were tapped from different professions, while others were not working in the formal sector. One of the participants had two children with autism, which gave the study a different experience from those with one child with autism in their family. Face-to-face in-depth interviews were used to collect data from participants. Indepth interviews allowed flexibility in how the questions were asked, with each interview taking an average of 30 minutes. The interviews helped in asking additional questions and observing nonverbal cues. Interview questions covered the participants' family life, challenges, stress, and coping techniques. Data were analyzed via the identification of key themes that were guided by the research questions and emergent themes from discussions with participants, a research practice supported by Barriball and While [19], who contended that qualitative data might be analyzed through common and recurrent themes and that thematic analysis is a way of organizing qualitative data and involves the researcher identifying and making sense of the emerging themes [20]. This study transcribed, coded, and categorized data according to themes. It ensured that themes were consistent and well understood [20]. The School of Humanities of the University of Zambia Ethics Committee approved the study. Participants agreed to take part in the study and signed ethical consent forms. Their identities in this study have been withheld to fulfil the ethical requirements of anonymity and confidentiality. --- RESULTS AND DISCUSSION The findings of this study have been presented and discussed according to the main themes derived from the research questions. --- 3.1 Ways in which parents get stress from their children with ASD This study revealed several stressful situations for parents of children with ASD. More so, the situations are not any different from parents in similar situations, although the degree or severity of the condition also impacts the amount of stress on an individual parent. --- Stressful conditions of Parents' Generally, the findings showed that parents got stress from performing daily routine duties such as child care, financial burdens, communication barriers, stigma, and frequent discussions with professionals who endeavoured to help out. The findings from the study are supported by Pisula and Kossakowska [16], who opined that parents become distressed and family functioning is impacted in numerous ways due to rearing a child with autism. Parents bear most of the emotional burden as caring for the child falls predominately upon them [7]. --- stress from childcare duties Stress also emanates from childcare-related duties. The findings of this study align with Alnemary et al. [5]. According to Alnemary et al. [5], some parents lack knowledge of how to manage problem behaviour exhibited by a child with autism and end up being overly stressed. The failure to know the condition creates pressure, anxiety, and stress to handle emerging behavioural challenges emitted by children with ASD. Childcare duties create high transport costs for parents as they take their children to and from hospitals for treatment and consultations with medical doctors [2]. According to the findings of this study, it is not easy to care for a child with autism. Thus, a gap emerges in this study that parents appear to have knowledge and skills in managing problem behaviour for children with autism [21]. One of the parents says: It is not that easy because you have to do everything for the child, from waking up until he or she sleeps. This wears me out, said participant < A'5>. Children living with autism are usually inconsistent in terms of routines. Parents found caring for their children after school difficult without a helper or other family members. Parent participant < A'9> said it was challenging because I have changed nannies occasionally. After all, they become stressed and quickly relinquish their duties to look for other less demanding nanny duties. This leaves me with many care responsibilities for the child, yet I have to fend for the family. Overall, childcare duties were stressful to parents, as evidenced by the complaints of most parent participants; members who had someone to help reported less stress. For instance, an elder sister would help to take the child to and from school. This was not easy for single parents. --- Financial burden This showed that working parents who could afford financial resources found it easier to take care of their children with autism than those who did not have the resources. This finding relates to Wonani and Muzata [4], who reported that parents complained about the financial burden or costs of having children with ASD compared to those without. Therefore, taking care of a child with autism was highly costly since parents needed to take their children to the hospital for medical checkups, treatment, and professional guidance on how to care for them. In this study, all parents complained that taking care of children with autism was expensive. One of the parent participants < A'2> testified below: I must confess that I find it costly to take care of my son, who has autism, especially since I am not married, which means I have no husband to help me take care of this child. I also have to shoulder all the costs by going to the hospital and performing home chores when he needs attention. I usually take him to be scanned because it is routine according to how we were advised at the hospital, and because it is routine, you must pay consultation fees every time. The other financial-related burden reported by parents was transport. Parents shared that they have to always take and drop their children right at school so that their child is not ridiculed if allowed to walk to school alone or with peers. Parent participant < A'4> explains: When using a public minibus, you always worry about people you sit with because they make silly statements about the child. Additionally, one participant, < A'10>, reported that she was unemployed and her husband could not continue supporting the child. She narrates: when my husband stopped supporting the child, I could not take the child for treatment at the hospital as was a routine previously. I cannot afford school fees at a private school. These findings, therefore, appear to indicate that parents need financial and other forms of support to provide for their children and offset the adverse impact of such a child on the overall family needs. Institutions and organizations that support the vulnerable in society should take a keen interest in identifying persons in such circumstances. Parents of children with autism need financial support, mental health support, and training in skills to manage problem behaviour that comes with the condition. --- Communication barriers Communication is a critical feature that aids child development. Mutual communication aids children's development as they can quickly receive guidance and instructions from parents, and they, too, can make requests and seek various services. However, it is now naturally accepted that children with autism lack communication. For parents, it was so stressful that they could engage in fruitful interaction with their children who had autism. One of the extracted excerpts below speaks to this finding: You know how important it is to communicate. Nevertheless, in this case, I can talk to my child, even if I try. I am not sure he understands me; the worst part is that he cannot communicate back. However, some parents, especially the older ones, believed that communication with children gradually improved with time and patience. Parent participant < A'3> reported his experience as follows: At the beginning, it was rough, but now the child can follow some instructions, and we can also know what he wants at a particular time. Perhaps with time, we will be communicating < A'3>. --- Stigma Families of children with autism are more likely to feel socially isolated and stigmatized than families of children with no disability at all [22]. Studies by Gray [12] and Wonani and Muzata [4] report that parents of children with ASD may feel stigmatized in public places. < A'9> reported that People always stigmatize us as parents and the child in places, but you have to show love to your child. However, in a public place, I have to explain to the person my child is seated next to so that he or she understands when my child behaves in a contrary way. Although parent < A'9> reported this, not all parents had similar experiences. Some parents did not report any form of stigma. One parent reported that people at a church were more supportive of her daughter with autism. We receive positive attention from members of our church. My child is engaged in different entertaining activities when we go to church. However, since I am always worried, I try to check on her or sit with her in church constantly. Varied experiences of parents show the different orientations and attitudes in society. When attitudes are negative, the sources of negative attitudes need to be targeted with educational sensitization talks. When positive attitudes linger, there is a need to strengthen and utilize such societies to help turn other societies in the pursuit of supporting parents and children with autism and other disabilities. --- Coping Strategies Used by Parents --- Acceptance When parents realize their child has ASD, they may accept it, put all other emotions behind them, and focus on ways to better their and their children's lives [5]. However, it does not come that easy. Parents must pass through various stages before they adapt and accept and deserve support through the journey to adaptation and acceptance. The adaptation process may know no age, although experience with children with ASD in this study shows that elder parents tended to accept their condition and move on a little quickly. Parents who finally accept their child's condition would say like the parent < A'5> below: I have to move on. I do not need to keep on complaining. So, I need to find ways of paying attention to my child's needs, and gradually, the child improves until no one notices that the child has a disorder. --- Support groups The study discovered that a family raising children with ASD with other family members needs support and assistance in dealing with their emotions. In this study, most parents received support from family members. Most help came from the grandparents of the child with autism, i.e., the child's mother. One middle-aged parent participant responded that she generally cares for her baby, but her biological mother assists her in every way possible. In this study, participants reported getting support from other family members and their families. However, a few others noted that they did not receive regular assistance from relatives or family members. Participant <A8> specified that her family provided psychological and emotional support: my entire family supports me since I am the first to have an ASD child. Surprisingly, this study reveals that female participants received support from family while no male parent did not report this. This calls for further investigations into the nature of support provided to parents of children with autism and establishes whether females receive more support than male parents yet harbour the same challenges. Generally, the findings restrict support to the family level, meaning that parents may not be aware of the relevance of a broader support system that can be created from the communities in which they live. It is essential to introduce parents to other parents living with similar children so that they can appreciate and exchange knowledge, skills, and understanding of the trials they encounter when children with ASD are raised. Support groups may include professional groups that may train children in social skills, communication, therapeutic activities, and daily living skills. Parents need to be introduced to communities of hope that provide counselling and guidance on where to access financial help. --- Leisure Outings Another finding critical to coping with autism is the adoption and use of technology. Parents with access to information technology tools such as computers, phones, and games easily helped parents engage their children with autism in play and social behaviour regulation. One of the parents <A'4> narrates below: --- I use technology at home to keep my child from throwing tantrums and give me free time to do my things. I use phones and tablets, which keep my child away from problems. Another contribution from participant < A'2>) says: I use television for my child to watch cartoons and showing my child pictures of new persons or places to enhance growth and understanding to know what is happening and if we want to go to a place unfamiliar to him. Although this finding was not prevalent for most parents for various reasons, including lack of access to gadgets, it is essential to explore the use of various technologies in helping regulate social behaviour for children with autism. Various games can entertain children through play, but computer games can help train children in acceptable social behaviour. What needs to be addressed is the issue of access for parents, affordability, and knowledge of the relevant software for behaviour regulation. --- Use of technology Another finding critical to coping with autism is the adoption and use of technology. Parents with access to information technology tools such as computers and phones with games quickly helped parents engage their children with autism in play and social behaviour regulation. One of the parents, < A'4>, narrates below: At home, we use phones and a tablet, so we use games to help the child play and relax. We use some cartoons to teach good behaviour, how to ask for things, say sorry, etc. Occasionally, we would ignore his demands as another way to control his behaviour. We also explain by use of verbal explanations. Another participant < A'2>) recounts: We sometimes use stories and models, and we show the child pictures of new places and people to help him understand what is in the environment. We advise visitors to our home not to introduce aspects that trigger bad or aggressive behaviour in the child. Although this finding was not famous for most parents for various reasons, including lack of access to gadgets, it is essential to explore the use of various technologies in helping regulate social behaviour for children with autism. Various games can entertain children through play, but computer games can help train children in acceptable social behaviour. What needs to be addressed is access for parents, affordability, and knowledge of the relevant software for behaviour regulation. --- Safety and Behavioral Tokens Parents used tokens to reward good behaviour for managing non-compliance and reducing stress. For instance, one parent-participant < A'10> reported that I use the reward system when my child portrays a specific good behaviour; I give him what he likes. For example, my boy loves Pizza. I go with him to buy to encourage the behaviour. Praising is also a coping strategy for my child to see good behaviour. I also continue with routine demands, various strategies, and social stories despite my child's protests, working with some of these strategies. Parents' participant < A'7> submitted that: Our house is near the main road, so we had mounted steel bars, installed alarms, and inserted many locks on doors and squeezed window frames to stop my son from going out and getting lost. I am comforted and at peace; he is in a familiar place. This is another unpopular response that did not receive a higher coding but is relevant in regulating behaviour and reducing stress among caregivers of children with autism-behaviourists such as BF. Skinner, Edward Thorndike, and Ivan Pavlov noted the relevance of rewards in modifying behaviour [11]. Parents need to be helped to become aware of the nature of rewards and how often they can help their children regulate stressful behaviour. In a surprise but real revelation of findings that most parents did not bring out, one parent reported using physical punishment. Below is the attestation by participant< A'5>: I lose it at times. I beat the child when he shows unacceptable behaviour, so I treat him like any other child in the house. I do not give special treatment coming from a family of orders. I beat him, though he does not show any remorse. Another parent who used a yelling and shouting strategy at the child eventually realized it was not working. She says: I fail to tell what strategy to use for my child. As a mother of five children, I screamed, roared, and carried negative distress in return for violence or problem behaviour. My effort to use time out did not work, and the child would shout or leave me alone. Punishment to diminish unwanted behaviour is acknowledged in behavioural psychology but not supported in the current discourse of behaviour modification. Negative reinforcement should be discouraged, especially in the current human rights discourse that children should enjoy daily. --- Supervision and monitoring of Behavior modification schedules The responses from the parent participants adopted the supervision and monitoring model to help modify their children's behaviour and reduce stressful occurrences if the children were left loose. This means parents need to stay alert and ready to intervene always to avoid damage. One parent participant < A'4> said, "My son has no fixed schedule; he can sleep at 14:00 hours and wake up at 22:00 hours. Furthermore, no one is allowed to sleep when he wakes up, and he needs to be given extra attention to have pandemonium in the house. He can sometimes sleep at 18:00 hours and wake up at 02:00 hours. To us, it is to be always ready, and at times, we distract him so that he does not sleep early but after 20:00 hours so that he wakes up in the morning. --- Spiritually and Religious Strategies Like Banja and Muzata [1], this study revealed that parents resorted to God or other religious figures they believed in to help them cope with their child's condition. Thus, religion can mediate in parents' coping trials, an observation made by Spector and Steve [23] in an earlier study. In this study, the following excerpts reveal what parents said: parent participant < A'6> said that. I believe God cannot give me a problem I cannot handle. I accepted that my children have a disorder, and I always pray for strength; that was a vital religious experience. I began reading my Bible, wanting to know why I was given a child with a disorder and where I went wrong. I keep asking myself this question and praying for God's miracle to heal my child. Participant < A'1> A father said it is essential to be patient and accept every child God has given someone because God rewards people in different ways. As a Christian, I have accepted my child using verses in the Bible that one day, God will heal my child in his own time. Religion has a role in helping parents cope with the difficulties they face in life, and this study, therefore, calls on religious leaders and organizations to play a role in helping parents adapt to the disability and manage the stress caused by having a child with ASD. --- CONCLUSION This study explored the coping strategies parents of children with autism spectrum disorder in the Lusaka district use to cope with the stressful behaviours of their children. Through a hermeneutic phenomenology, ten parents participated in the study's sample size. Based on the findings of this study, parents in Lusaka need various services to adapt, accept and support their children with ASD. Parents must be provided with knowledge and skills on various methods to interact and cope with children with ASD. They must be linked to various service providers to access financial support, counselling services, and skills to live with a child with ASD. Linking parents to support groups would help alleviate depressing feelings and improve mental health among parents living with children with autism. The study was qualitative, using ten parents of children with autism, which means it is restricted in generalizability. It would be necessary to upscale this study quantitatively to obtain more parents in the same situation to broaden service provision to all parents of children with ASD in Lusaka and Zambia.

This was a hermeneutical phenomenological qualitative study of the coping strategies parents of children with autism spectrum disorder (ASD) use to cope with the demanding behaviours of their children in the Lusaka districtin Zambia. Parents, as key caregivers of children with disabilities, are likelier to develop unhappiness and worry than parents of classically developing children. Parental stress is usually associated with the severity of the ASD disorder. It was imperative to study how parents in Lusaka District coped with children with ASD daily. Interviews were used to collect data. Ten (10) parents of children with ASD were purposively selected to participate in the study. Data analysis was done in themes that revealed extra worries for parents, caused mainly by a lack of information about ASD, especially before diagnosis. Parents adopted specific strategies to cope with their children's problematic behaviour in areas of social interaction. Further, parents require much assistance developing interaction between them and specialists to acquire support services regarding coping strategies for their children's behaviour.

Introduction Within the United States, a disproportionate number of incident HIV infections and new diagnoses of HIV lie within men who have sex with men . In Los Angeles, for instance, over 75% of all infections are attributable to MSM [1,2,3]. Among MSM in the United States, Latinos accounted for 20% of new infections and African Americans accounted for 37% of new infections [4]. To address the epidemic among at-risk populations, researchers have requested innovative approaches for understanding and preventing sexual risk behaviors. Online technologies have been rapidly growing in use and may play a role in facilitating sexual risk behaviors, especially among at-risk populations [5,6]. Internet use was previously used primarily among upper-middle-class white populations, however, minority groups have increasingly used online technologies [7]. For instance, in the United States, from 2005 to 2006, there was a 121% increase in the number of African American households with high-speed Internet connections and a 46% increase in Latino households with broadband usage, with 56% of Latinos using the Internet on a daily basis [8,9]. In fact, English-speaking Latinos are almost identical to Whites in their use of Internet and home broadband [10], and African Americans and Latinos are more likely than Whites to access the Internet from mobile devices [11]. Social networking technologies, platforms for virtual social communication, have been the predominant factor for the growth in online technology use among minority groups. Social networking sites, such as Facebook, Grindr, and Twitter, are online platforms designed for social communication through sharing of pictures, messages, and other forms of multi-media communication [12]. African Americans and English-speaking Latinos are almost 1.5 times more likely to use online social networking sites compared to the general adult population . This trend is consistent in Twitter usage, online video usage, and usage of location-based devices [13]. In addition, gay, lesbian, and bisexual individuals use social networking technologies more often than heterosexual individuals [9]. Although research has explored the link between Internet use and sexual risk behaviors [14,15,16,17], little work has focused on social networking use and sexual risk. However, it is especially important to study the relationship between social networking and sexual risk behaviors because these technologies were specifically designed for social communication and interaction [12,18]. Research from Internet studies suggest that, compared to people who do not seek sex on the Internet, Internet sex seekers tend to have: more frequent anal sex, more previously diagnosed STIs, more sexual exposure to men, greater numbers of sex partners, and higher numbers of sex partners known to be HIV positive [14]. Social networking users have a potentially increased risk, as social networking technologies allow users to engage in real-time interaction that can be used to initiate rapid sexual encounters. For example, people can use location-based mobile applications such as SexMap and Grindr to search for potential sexual encounters with others in immediate geographic proximity. It is therefore important to evaluate how social networking technologies might affect sexual risk behaviors, especially among social networking users who are at high-risk for HIV, such as MSM. This study seeks to determine the relationship between social networking use and sexual risk behaviors among minority MSM. Specifically, we assess 1) rates of using social networking technologies for sex-seeking, and 2) sexual risk behaviors associated with seeking sex on online social networks. --- Methods This study was conducted according to the principles expressed in the Declaration of Helsinki. The UCLA Office of the Human Research Protection Program approved this study. Methods conform to recommended guidelines for using social networking technologies in HIV prevention research [19]. Participants provided a web-based informed consent. Over a period of 4.5 months , 122 participants were recruited online, from physical venues frequented by African American and Latino MSM , and from direct referrals from study participants. Participants were paid $30 in gift cards to complete a survey. Four participants were found to have completed multiple surveys. Their second response was dropped, leaving 118 participant responses. Six participants completed part of the survey. Their responses are included in this analysis. Participants were recruited online using the following methods: paid, targeted banner ads on social networking sites , and setting up a fan page on Facebook with information describing the study. Participants recruited using online methods were directed to a website where they could receive more information and enroll. Fliers placed in physical venues frequented by African American and Latino MSM described the study and provided a contact email address and a web link for participants to receive more information and enroll. Most fliers were culturally tailored, including a picture of a male Latino or African American, stating that the study was looking for male participants who were 18 years of age or older, African American or Latino, interested in men, and had a Facebook account. Fliers provided a contact email address and link to a Website where participants could receive more information and enroll. Participants were informed that they could refer friends who were interested and fit the inclusion criteria. Participants were not paid additional incentives to refer friends. Potential participants visited the study Website and were screened for eligibility. Eligible participants were males who were: 18 years of age or older, living in Los Angeles, had had sex with a man in past 12 months, and had a Facebook account. Because we attempted to recruit a sample of predominantly minority MSM, we first recruited 70% of the sample from these populations and then opened recruitment to MSM from other populations. Participants were excluded if they did not fit inclusion criteria. A Facebook Connect application was used as a verification tool to ensure that each participant had a registered and unique Facebook account. If the eligible participant consented to the study, he had to provide his Facebook username and password through Facebook Connect. Once this connection method verified his status as a Facebook participant, he was asked to input his email address, phone number, and completed an online survey. The 92-item online survey took approximately 45 minutes and included a collection of items from previous research on sexual risk behaviors, Internet use, as well as a number of novel items related to use of social networking technologies. Items focused on demographics , race/ethnicity, income, and education); Internet and social media usage; and sexual health behaviors . Prior to responding to items related to social media use, participants were given a definition of social networking sites along with a list of examples sites . Internet and social media usage items focused on the amount of time spent using the Internet and social media ; reasons for using these technologies ; and comfort when using these technologies to talk about sexual risk behaviors. For example, after a description of the difference between general Internet sites and social networking sites, participants were asked about their use of social networking sites for seeking sex, ''In the past 3 months, how many sexual partners have you met on the Internet/social networking sites?'' They were not asked to differentiate between general social networking websites and websites that were designed specifically for dating or seeking sex. Sexual risk behavior-related items focused on number and gender of sexual partners , sexual behaviors, and number of times exchanging sex for food, drugs, or a place to stay. For example, participants were asked, ''In the past 3 months, have you exchanged sex for food, drugs, or a place to stay?'' Chi-square tests were used to assess differences in population demographics, Internet and social media usage, and sexual risk behaviors. Analysis of variance tests were used to assess differences in age between groups as well as to confirm Chi-square differences on continuous variables. Multiple regression analysis was used to assess the relationship between number of sex partners met on the social networks and exchanged sex, new sex partners, sex with men, and oral sex, controlling for age, race, education, and total number of sex partners. Total number of sex partners was added to control for the possibility that group differences in social networking sex partners could be accounted for by overall increases in sex partners. Analyses were performed on deidentified data using Stata software [20]. --- Results As Facebook Connect was used to verify Facebook status, 100% of participants were current Facebook users. Slightly less than half of the sample used Myspace and Twitter , with a smaller portion using Grindr and various sex-seeking sites such as Adam4Adam.com and Manhunt.com . Table s1 displays the demographic results between populations and in the overall sample. Participants were predominantly Latino or African American . The majority of participants had at least a high school education, with over 60% of participants from the western United States. Almost all participants reported being either gay or bisexual , and single . The average age of the sample was just under 32 years of age, with White participants on average being older than the rest of the sample. Group differences by population were found on education level, birthplace, and age. The majority of participants had used the Internet and online social networking technologies to meet new sex partners within the past 3 months. On average, participants met over 4 of their most recent sex partners using these technologies. Compared to African Americans, Latinos on average more frequently used Internet/ social networking technologies to meet sex partners . Table s4 presents results of a regression analysis looking at exchanged sex, new sex partners, sex with men, and oral sex as outcomes. Controlling for age, race, education, and total number of sex partners, there was a significant positive relationship between number of sex partners met from online social networking technologies and 1) likelihood of having exchanged sex for food, drugs, or a place to stay, 2) number of new sex partners within the past 3 months, 3) number of male sex partners within the past 3 months, and 4) likelihood of engaging in oral sex. --- Discussion Results from an analysis of MSM social networking users suggest that MSM are using online social networking technologies for sex-seeking, and that meeting sexual partners from social networking sites is associated with increased likelihood of engaging in sexual risk behaviors. Those who met sexual partners from social networking sites were more likely than those who did not to have exchanged sex for food, drugs, or a place to stay; have new sex partners within the past 3 months; have had sex with a greater number of men; and have engaged in oral sex. These effects were not due to the possibility that people who engage in more frequent sexual encounters engage in more sexual risk behaviors , but were unique to sex-seeking on social networking sites. These results are important because they suggests that social networking websites, when used for sex-seeking, may be associated with transmission of HIV and other sexually transmitted infections. The ability to recruit African American and Latino MSM Facebook users for this study provides support that minority groups are actively and increasingly using social media technologies. [10,13] This study builds on those findings by suggesting that minority MSM are actively using social networking technologies for seeking sex. Knowledge of these changing trends is useful for understanding both the locations and behaviors of at-risk groups so that these same technologies that could potentially facilitate HIV transmission could also be used for HIV prevention. Latino MSM appear to be especially likely to use social networking technologies to search for sex partners. This finding could be useful in helping Latino MSM researchers understand how to use social networking technologies for Latino MSM recruitment and for development of culturally-tailored HIV prevention interventions. This study builds on research on the relationship between Internet use and HIV risk [14,16,21,22] by showing that number of sex partners met on social networking sites was associated with increased likelihood of engaging in sexual risk behaviors . However, number of sex partners from social networking sites was also associated with an increased likelihood of having had oral sex. This finding may provide support that the social networking sites do not necessarily lead to increased HIV transmission, as people using the technologies for sex-seeking might be able to meet and have sex with more individuals but might engage in oral sex to mitigate these risks [23]. This study provides new data on the use of social networking technologies among at-risk groups. It is important to begin to understand how use of social networking technologies, by way of promoting both social engagement and anonymity, can affect HIV risk behaviors. Studying how social networking users engage other sex partners will be important in crafting HIV prevention interventions toward at-risk populations. For example, websites that track and integrate geolocation technologies are currently being used to initiate rapid sex-seeking encounters. As technology develops and can be used to facilitate sex-seeking and sexual risk behaviors, it becomes important that researchers and policymakers study and understand how these same technologies can be used to prevent the spread of HIV and other sexually transmitted infections. Policymakers and sexual health organizations have already begun using social media to reach at-risk populations, and as research is furthered in this area it can be used to support models for improvements in sexual health policies and interventions. Study limitations are based primarily on the focused population and enrollment criteria. First, as the sample is based in Los Angeles, it is possible that participants from other locations might not share the same population characteristics. However, high HIV rates in Los Angeles make Los Angeles an important area for HIV prevention research. Second, although sexual risk behaviors presented in this study are associated with HIV transmission, knowing the specific type of sexual behavior would help to more accurately determine the associated risk. For example, while exchanging sex for food and drugs is associated with sexual risk, engaging in unprotected anal intercourse in exchange for drugs would be associated with greater risk than engaging in protected intercourse. This study presents a first look at associations between social networking use and sexual risk behavior, and future studies that identify the specific sexual behaviors may help to provide a more definitive link to HIV transmission. Next, participants were not asked to report how they were recruited to the study. Future research can address this question to provide data on best recruitment methods. Finally, it is possible that the present results might not generalize to groups other than MSM, or early technology adopters. Although social networking use is being studied among broader racial and ethnic populations of people living in the Untied States [10,13], research on the link between social networking and HIV risk has only recently been studied and has focused on populations at high-risk for HIV, such as MSM [19,24]. Future research is encouraged to test whether these findings extend to other at-risk populations. --- Conclusion The present study suggests that African American and Latino MSM are using social networking technologies to search for and meet sex partners, and those who use these technologies are more likely to engage in HIV risk behaviors. Understanding how at-risk populations use social networking technologies is important for crafting and scaling culturally-tailored HIV prevention interventions. --- Supporting Information ---

Online social networking usage is growing rapidly, especially among at-risk populations, such as men who have sex with men (MSM). However, little research has studied the relationship between online social networking usage and sexual risk behaviors among at-risk populations. One hundred and eighteen Facebook-registered MSM (60.1% Latino, 28% African American; 11.9% other) were recruited from online (social networking websites and banner advertisements) and offline (local clinics, restaurants and organizations) venues frequented by minority MSM. Inclusion criteria required participants to be men who were 18 years of age or older, had had sex with a man in the past 12 months, were living in Los Angeles, and had a Facebook account. Participants completed an online survey on their social media usage and sexual risk behaviors. Results from a multivariable regression suggest that number of sexual partners met from online social networking technologies is associated with increased: 1) likelihood of having exchanged sex for food, drugs, or a place to stay within the past 3 months; 2) number of new partners within the past 3 months; 3) number of male sex partners within the past 3 months; and 4) frequency of engaging in oral sex within the past 3 months, controlling for age, race, education, and total number of sexual partners. Understanding the relationship between social media sex-seeking and sexual risk behaviors among at-risk populations will help inform population-focused HIV prevention and treatment interventions.

Historical Process of Women's Rights Women's rights and the role of women in society have emerged in different ways from the first human communities to the present day. In the early ages of humanity, before human beings settled down, the family structure was matriarchal, but with the transition to settled life, it is thought that the patriarchal structure, that is, the maledominated social structure, began to form instead of the matriarchal structure. Another view is that even matriarchal societies have a patriarchal structure and there are no situations where women are dominant 1 . There are many documents showing the existence of these women's problems, even in ancient documents. These documents reveal the inequality between men and women in the societies of that period. Most researchers agree that genderbased discrimination is a deeply rooted form of discrimination 2 . The role assigned to women throughout history has often been that of "ruler". This situation tells us that the inequality between men and women has continued to exist since antiquity, varying according to time and place 3 . One of the reasons why women started to be seen as less valuable than men is the developments in the field of production. The fact that the tools used in production were invented by men caused the material power to be in the hands of men, and the fact that the material power was in the hands of men put women in a lower position against men 4 . When we look at the documents found from the earliest times of humanity, it is not common for women to participate in social life, to be educated and to work, but it is possible to see examples. Narratives about prominent women physicians, architects, philosophers and women sages from Ancient Egypt, Ancient Greek Civilization or the Roman Empire have survived to the present day 5 . Although ancient Egyptian society was patriarchal, it is known that women had some special rights. They had the right to buy property and to be tried equally with men in court. However, although it is known that there were female pharaohs, it is understood from the documents that have survived to the present day that women were not brought to important places in the administration 6 . The marginalization of women increased during the Ancient Greek period. Women were left at home and excluded from society. They were seen as a commodity that could be traded. However, it was considered important for men in high positions to marry the daughters of well-known families in order to give birth to a noble man. The value of a woman's social status remained dependent on giving birth to a noble child 7 . According to the beliefs of the Sumerians, it was not the gods who created everything and owned everything, but the goddesses, that is, women. According to the surviving documents about the Sumerians, monogamy was practiced and it is understood that women and men had equal rights. In a poem written during the Sumerian period; "My mother is a light shining on the horizon, a mountain deer, a shining morning star." An example of the value given to women appears in the line 8,9 . The clay tablets written by the Assyrians who lived in the borders of today's Kayseri province show that Anatolian women were free at that time. During this period, there were city states in Anatolia. Women who took an active role in the administration of these states are described in these tablets. It is known that women were also active in trade life. [8] In the Hittites, who lived in the same region after the collapse of the Assyrian trade colonies, it is known that the powers of the Queen and the King were equal 10 . However, since there are very few documents related to the family in this period, there is not much information about the status of women in social life 11 . Nevertheless, it is known from some documents that Hittite laws did not discriminate between men and women in punishments and the same punishment was given for the same crime. In the Roman Empire, where the patriarchal structure was dominant, the justice system worked in favor of men. A serious pressure was created in social life by using concepts such as privacy and honor against women 12 . In such an environment where women were pushed out of society, Christianity, which promised equality and freedom, was born. In Christian teachings, it is accepted that all people are equal. The place of women has been moved to a different position with the concept of family 13 . However, as seen in most religions, religious teachings have been shaped according to the habits of the community in which they are found. Christianity fused with the social mindset and became a patriarchal faith. The churches, which were the enforcers of the law, judged women more strictly than men 14 .In the environment of the Middle Ages, where fiefdoms ruled, educational institutions gradually began to conform to the wishes of the church. Women's basic education became possible centuries later, provided that their families made donations to the churches 5 . The teachings of Judaism are similar to the effects of Christianity's degeneration over time on relations between men and women. Beliefs such as the idea that a woman was created from a man's rib, the belief that the human race was expelled from paradise as a result of Eve, the first woman in most religious teachings, eating the forbidden fruit, have led to a deep prejudice against women in society. As a result of all these, women have been marginalized in society and made dependent on men 15 . Looking at the status of Turkish women in Asia in history, it is known that women played important roles and had equal rights with men. In addition to the signatures of khans, the signatures of their wives, hatuns, also appear in state documents. One of the important findings of the equality of men and women in Turks is the word "marriage". The expression "they got married" is used instead of "the man took the woman" which is frequently encountered in old documents 16 . Regarding women in the ancient Turks: "An order was not considered acceptable if it started with 'the khan says so'. It would be acceptable if it started with the words "the khan and the khan are ordering". The khan could not receive ambassadors of foreign states alone. Ambassadors could appear in front of both of them, the khan on the right and the khatun on the left. It is understood from this that the role of women in public services was as great as the khan. The right of guardianship in the family belonged not only to the father but also to both parents. There was no harem, veil or age in the ancient Turks. Women could enter any assembly." 17 . Ancient Turkish women could ride horses, shoot arrows and fight when necessary 16 . Monogamy was the law in Ancient Turks. In the light of all this information, it can be said that the Ancient Turks had a democratic and feminine mindset 18 . When we look at the historical development of women's rights; Turkish women were free and had equal rights with men in the pre-Islamic period according to the conditions of the period. Religious beliefs of the period considered women sacred 18 . The Turks entered Anatolia during the Seljuk period. The Seljuks were under the influence of Iran, where they had lived before, under the influence of the Arabs since they accepted Islam, and under the influence of the Byzantines living in the Anatolian lands they came from. During this period, Turks in Anatolia had to act according to Islamic rules while acting according to their own habits 8 . With the teachings of Islam, women have gained importance. They had rights over family life. According to Islamic teachings, a married woman was given valuable goods called "mahr". This practice was done so that the woman could manage herself in case her husband died or the woman was left alone, such as divorces. However, before Islam, the gifts given for the wedding were given to the woman's family and the father would marry or sell his daughter to whomever he wanted. In Islam, a woman's refusal to marry meant that the marriage was void. In pre-Islamic Arab society, women began to receive their share of inheritance, which they had not received in the past, with the teachings of Islam 19 . However, Islam, like other religions, has changed by being mixed with the values of the society in which it was formed. In Islamic belief, the differences in the creation of men and women have been determinant in social relations and this situation has caused inequality 20 . For these reasons, the social position of women changed radically after the adoption of Islam. The provisions of Islamic law and its implementation in society limited women's space in public life. Women were trapped in family and home life. Obedience and submission were expected of women in Islamic societies 21 . In order to evaluate the relations between men and women of the period, the position of women in pre-Islamic society should be taken into consideration 22 . When we look at the Ottoman Empire, we see three statuses: palace women, mansion women and public women. Palace and mansion women had to live within the framework of Islamic rules. Although some of the palace women had some works built, the majority of them were women of other nationalities. In general, palace women lived a life similar to prison life. Public women, on the other hand, were almost all productive women. They shouldered the burden of the Ottoman Empire; they sent their husbands and children to military service, worked in agriculture, raised animals, and produced food and clothing. They gave some of their earnings to the state as taxes. As a result, although the economy of the state was almost entirely in the hands of women, it is seen that girls in the Ottoman Empire were taken out of school when they were 8-9 years old and were confined to the house. Women were also restricted from going out on the streets in various ways during this period. In some regions, they were not allowed to walk or ride in cars or trams, and actions such as walking around the Grand Bazaar, sitting in a shop, or talking in a group were also forbidden to women 8 . During the War of Independence, our women worked with all their strength, produced food and clothing, and even took part in the front line for the liberation of our homeland from the enemy. Despite all these contributions, the text of the law prepared by the parliamentarians who tried to enact a law on family law in 1923 included articles such as "Since the woman is mentally and religiously weak, she must be under the protection of the man, the man can take many women and divorce them as he wishes, women's working outside disrupts social life, and science destroys women's morals." The text was not accepted in this form. However, months before the proclamation of the Republic, Mustafa Kemal, in a speech, spoke of "freedom for women, equal educational opportunities and a social position for women no different from that of men" and said in Konya: "The fact that our women, who were under much less favorable conditions, have become equal to men, and in some cases even surpassed them, is a proof of their extraordinary abilities and equality." 23 . With the adoption of the Civil Code and the abolition of Islamic provisions and the granting of the right to vote and then to be elected , Turks began to return to their past in Central Asia and the seeds of the idea of equality between men and women were sown. In the Republican era, thanks to Atatürk, women were able to step into the world of science for the first time. Before the Republic, it was impossible for women to go to university. Most of our first women scientists in the Republican years were women who had received their education abroad. After the establishment of the Republic of Turkey, with the adoption of the Law on Unified Education , our education system changed and women and men were offered equal conditions in education. With the Dress Code and the Turkish Civil Code , the place of women in society changed and women were granted equal rights with men 23 . With the factorization brought about by the Industrial Revolution in Europe, women started to play a more frequent role in business life. This situation played an important role in revealing the situation of women and the violence they were exposed to. Concepts such as equality, justice and peace, which began to be expressed with the French Revolution, also came to the agenda for women. With the beginning of the Age of Enlightenment, the idea of compulsory education covering the whole population began to spread. Whether or not girls should receive this compulsory education soon became a matter of debate 24 . The right to citizenship was demanded for women, and it was argued that women should also be able to receive vocational education that was only available to men. For a century, however, women were not allowed to study at universities. The reason for this situation was that women were considered physically weaker than men and that they were not suitable for such an education in terms of intellectual ability 5,24 . By 1840, the first female students in Europe began their education at the University of Zurich. Despite all these developments, many scientists living in those years, who adopted the conventional perception of women, argued that the idea of "equality between men and women '' was unnecessary 25 . Today, even in developed countries, women are still not equal to men in social life and human rights. In developed countries, gender discrimination and the obstacles placed in front of women at every stage of their working life, from admission to employment to promotion, are the most common forms of this inequality. In addition to the problems in developed countries, problems in basic life situations such as being subjected to violence and being deprived of education are more common in developing countries. --- Violence Against Women For centuries, violence against women, as a violation of human rights and a form of discrimination, continues to exist all over the world, regardless of ethnicity, class, religion, social status, cultural, economic and geographical boundaries. According to the patriarchal mentality, even if a woman is a victim of violence, she is the one who harbors the cause of the crime. Considering that every woman victim of violence may have provoked the perpetrator, her "criminal" behavior is questioned. Violence is defined by the UN as all individual or collective acts that cause physical or mental harm to people by applying force and pressure 26 . Violence against women is defined by the World Health Organization as any behavior that results or is likely to result in physical, sexual, psychological, economic harm to women, including the prevention of freedom through coercion, whether in public or private life 27 . --- Violence against Women in the Historical Process Archaeological studies trace the origin of women's experiences of physical violence back to 3000 years ago in ancient times. While 9-20% of the bones of male mummies found in these studies were fractured, this rate was 30-50% in female mummies. During the Roman Empire, it is known that men could beat their wives and had the right to kill them for reasons such as adultery and drunkenness. In England, the law allowed men to beat their wives until 1887. In ancient Indian traditions, it is known that women whose husbands died were burned together with their husbands. In pre-Islamic Arab geography, girls were often buried alive because they were seen as a disgrace to society. When the dates show March 8, 1857, the incident in which 129 women workers died as a result of the police intervention against striking workers in a textile factory in New York, the workers were locked in the factory, and then the workers could not escape in the fire that broke out, is one of the biggest examples of violence against women in our recent history. March 8 was first celebrated as Women's Day in Denmark in 1910, and is now commemorated annually as International Women's Day following a decision taken by the United Nations General Council in 1977. On November 25, 1960, three sisters, Patria Mercedes, Minerva Argentina and Maria Terasa , were taken out of their car, raped and murdered as they went to visit their husbands in prison. With the resolution adopted by the UN General Assembly in 1999, November 25th of each year is celebrated as the "International Day for the Elimination of Violence against Women and International Solidarity". --- Causes of Violence against Women Sexist approach that does not believe in equality , family conflicts and disharmony, low income level, personality disorders, exposure to violence in childhood, substance abuse , traditional assumptions , low level of education, honor and ritual excuses are the most common causes of violence against women. The most fundamental cause of violence against women is gender discrimination and asymmetrical power relations stemming from the patriarchal social structure. In the UN action plan on combating violence against women , the concept of gender is defined as the socially constructed roles, behaviors, masculinities and attitudes that a given society deems appropriate for women and men. We are one of the countries with the highest gender inequality and the deepest "gender gap". In this study conducted by the World Economic Forum in 2021, we ranked 133rd out of 156 countries. In the same study, we are the 1st country in the world in the rate of dismissal of women during the Covid-19 pandemic 28 . --- The Most Common Types of Violence against Women Physical violence, psychological violence, sexual violence, economic violence, stalking, forced or child marriage, trafficking in women and forced prostitution, genital mutilation of women are the most common forms of violence against women. According to the World Health Organization, one in every three women is subjected to physical or sexual violence by an intimate partner. Two out of every five women are known to have experienced psychological violence by their current or former partner/life partner. Worldwide, 38% of femicides are committed by the victim's partner or intimate partner. Twice as many women die in domestic violence as in wars and global conflicts. Women aged 15-44 are more likely to die from rape and domestic violence than from cancer, traffic accidents or infectious diseases 27 . --- Femicides In general terms, it is the killing of women or girls, regardless of who commits it, because they are women. It is evaluated separately from male homicides due to its purpose, i.e. gender discrimination. In 2019, in the Global Homicide Report published by the United Nations Office on Drugs and Crime, which investigates the rates of women being killed because they are women, it was reported that approximately 87000 women were victims of homicide in 2017 all over the world. Approximately 3/5 of these women were murdered by their lover, spouse or family member. Asian countries lead the list of countries where femicides are most common, followed by African and American countries. --- The Effects of Violence Against Women on Human Health Violence deprives women of their right to health, which is their most fundamental right. Women victims of violence face physical and psychological consequences. Violence can lead to negative health behaviors such as smoking, alcohol and substance abuse, decreased physical activity, overeating and obesity. Negative effects on mental health such as low self-perception, post-traumatic stress disorder, depression, anxiety, phobias, panic attacks and social exclusion can be observed. Unwanted pregnancies, sexually transmitted diseases, gynecological diseases such as pelvic inflammatory disease, pregnancy complications, unsafe abortion may occur, which may negatively affect women's reproductive health. It has been reported that women who experience violence during pregnancy are negatively affected in terms of reproductive health, and newborns and fetuses are also affected by this situation 31 . Violence can result in homicide or suicide and have fatal consequences. --- Where Can Women Victims of Violence Apply? 89% of women who are subjected to violence do not apply to any institution. 8% apply to law enforcement agencies, 5% to family courts, 4% to health institutions, 3% to prosecutor's offices, 1% to bar associations. In our country, women who have been subjected to violence can apply to administrative law enforcement bodies , judicial law enforcement bodies , public prosecutor's offices, family court judgeships, health institutions, the Ministry of Family and Social Services and its affiliated units, local governments, bar associations and non-governmental organizations 32 . --- Preventing Violence against Women The "Universal Declaration of Human Rights" drafted by the UN after World War II. Although the "Universal Declaration of Human Rights" prepared by the UN after World War II is a comprehensive international convention, it is not legally binding. Published in 1979 to combat all forms of discrimination against women, the "CEDAW" convention is legally important. It has been accepted by 165 countries, including Turkey 33 . CEDAW was prepared based on the basic principles and principles in the Universal Declaration of Human Rights, and it has put the fundamental rights and freedoms for all human beings on a legal basis for women. One of the internationally recognized and binding conventions on violence against women is the Istanbul Convention. It was adopted on April 7, 2011. With this convention, physical violence against women, domestic violence, sexual violence including rape, psychological violence, stalking, forced marriages, forced abortion, forced sterilization and sexual harassment are defined as violence against women. The Istanbul Convention aims to prevent violence against women, protect victims, punish perpetrators of violence, and develop holistic state policies on the issue 34 . It was repealed in our country with the Presidential Decree published in the Official Gazette No. 31429 on March 20, 2021 35 . The most important piece of legislation on violence against women in Turkey is the "Law No. 6284 on the Protection of the Family and Prevention of Violence against Women", which was drafted in light of the provisions of the Istanbul Convention and entered into force in 2012. Another important piece of legislation, the "Regulation on the opening and operation of women's guesthouses" entered into force in January 2013. The "Regulation on Violence Prevention and Monitoring Centers " on Violence Prevention and Monitoring Centers to which women victims of violence can apply entered into force in 2016. There are ŞÖNİM in 73 provinces and 144 guest houses in 81 provinces 36 . --- Conclusion and Recommendations Enacting laws to eliminate gender discrimination, making arrangements to ensure equal opportunities in education, increasing women's employment in business life, providing women with the same economic freedom as men, strengthening and supporting women's social and economic status, ensuring women's equal representation in politics and decision-making mechanisms and their effective participation in these areas, ensuring that the media conveys the negativity of violence in an appropriate language and raising awareness in society. It is important for us to prevent violence against women and gender discrimination, to make programs based on gender equality on state radio and television, to include courses on women's human rights and gender equality in the curriculum, to make preventive and deterrent regulations on early and forced marriages , to change the socio-cultural structure dominated by patriarchal structure, to develop decisive state policies to prevent gender inequality and to improve women's rights. --- Compliance with Ethical Standards We confirm that no funding was received for the conduct of this study and the preparation of this manuscript. The costs of the study were paid by us.

In history, the greatest aspiration of people is that all humanity has equal rights regardless of race, language, religion or gender. Gender inequality seen in communities where patriarchal structure prevails has caused women to be deprived of their rights. The exclusion of women who have been deprived of their rights due to their gender and even exposure to violence is a global problem that continues from past to present. Violence against women, which is as old as the history of humanity, is a phenomenon that affects all societies deeply and negatively. As a fundamental human rights and freedom problem, it continues to exist all over the World as a universal public health problem, regardless of ethnic origin, class, religion, social status, culture, economic and geographical boundaries. Domestic violence is the most common form of violence against women. In this study, the historical process of women and their rights, the place of women in society today, the historical process of violence against women, the causes and types of violence against women, femicides, the end point of violence against women, the effects of violence on public health, violence in our country will be discussed. Furthermore, institutions and organizations that women victims of violence can apply to, and suggestions against violence towards women are mentioned.

As a chronic psychiatric disorder, schizophrenia is accompanied by disruptions in perception, cognition, emotions, behaviours and life functioning. 1,2 The onset of schizophrenia typically starts in late adolescence or early adulthood, and the symptoms appear gradually. 3,4 Frequent relapse and readmission to hospitals often afflict persons with schizophrenia and their families. 1 Schizophrenia poses long-term challenges not only to the patient but also to his or her family, particularly the primary caregiver. Previous research showed that caregiving burden remained significantly high among primary caregivers of PwSs with a deterioration in social functioning, 5,6 worse self-care abilities 7 and more care demands. 8 The theory of transactional stress and coping can be applied to conceptualise the relationships between different patterns of stressors and caregiving burden. 9,10 According to this theory, caregiving burden is defined as a transaction between a caregiver and the surroundings that is perceived by a caregiver as surpassing his or her available resources and being a threat to personal well-being. 11,12 Family caregivers' perceived burden is affected by factors from their internal world and external surroundings, such as the care recipients' more severe symptoms and impaired social functioning. 2,13 Prospective studies examining the associations between clinical characteristics and caregiving burden have documented inconsistent results. Specifically, some studies have found that increased severity of psychopathology and reduced social functioning predicted a heavier burden. 14,15 Nevertheless, a recent longitudinal study reported that clinical changes in schizophrenic symptoms were not significantly related to long-term experiences of the caregiving burden. 13 Although previous studies suggested the psychological consequences of impaired social functioning on caregivers, 2,16 most of them were cross-sectional. Little is known about the effects of changes in patients' social functioning over time on the caregiving burden throughout the illness trajectory. The caregiving burden for PwSs is a complicated aspect of mental healthcare. 14 In many societies, the original family is deemed the most significant social contact for a person. 17 A high level of caregiving burden is prevalent among family caregivers of PwSs. For instance, a substantial number of studies have reported a high risk of psychological distress experienced by parent caregivers. [18][19][20] Marriage or partnership was also greatly influenced by the illness, especially among cases in which the spouse caregivers resided with and cared for the PwSs for many years. 17 Recent studies found that the psychological well-being of sibling caregivers was affected by a significant caregiving burden. 21,22 Family structure and caregiving-related arrangements may change over time. Parents are usually expected to take a caregiver role throughout their child's long-term illness trajectory, particularly when the ill child does not have a partner. [23][24][25] As parents get older, siblings might take over the caregiving responsibilities for their ill sister or brother from their parents. 22,26 When transitioning to being the primary caregiver of a PwS, the new caregiver may be confronted with great challenges and need to adapt to the caregiving role. 27 However, there has been limited research exploring the determinants of caregiving burden when caregiver transition occurs in a family of PwSs. In this study, caregiver transition was defined as a change of a PwS's primary caregiver from one type of family caregiver at baseline to another type at follow-up. Caregiving burden may vary across different caregiving roles. For example, a recent empirical study reported that parent caregivers experience a significantly higher subjective burden than their spouse counterparts. 28 Parent and spouse caregivers of PwSs may perceive the psychological burden differently. 29,30 Nevertheless, few studies have been conducted to evaluate the longitudinal predictors of caregiving burden in families with and without caregiver transition. The objective of this study was to evaluate the effects of changes in social functioning on the caregiving burden for PwS with and without caregiver transition over a period of 21 years . We hypothesised that among families of PwSs in rural Chinese communities: the caregiving burden might be predicted by sociodemographic characteristics of PwSs differently in families with and without caregiver transition; the caregiving burden might be predicted by the severity of symptoms of PwSs differently in families with and without caregiver transition; and the caregiving burden might be predicted by changes in social functioning of PwSs differently in families with and without caregiver transition over 21 years. --- Method --- Data and procedure This study employed panel data from the Chengdu Mental Health Project , which has been conducted in Xinjin County, Chengdu, China since 1994. 4,31,32 Six townships were randomly sampled from all 12 townships of Xinjin County. 33 This study analysed data from two epidemiological surveys conducted in 1994 and 2015. 34 The same research methods were used for the two epidemiological surveys, including the sampling method, screening procedures and diagnostic criteria for psychosis. 32 Details of the procedures used for the longitudinal surveys, including sampling methods, have been described in our previous studies. 32,34 Initially, to identify potential cases of PwSs, trained investigators used the Psychoses Screening Schedule to interview the heads of all households in the six townships. 2 If the head of household could not attend the interview, another household resident was invited. 2 Afterwards, the trained psychiatrists carried out a comprehensive general psychiatric interview for the potential patients via face-to-face interviews in hospitals. With the purpose of maintaining diagnostic reliability, a diagnosis of schizophrenia was determined by psychiatrists with over 5 years of clinical experience, and they used the same diagnostic criteria from the ICD-10 33 in 1994 and 2015. After identifying PwSs, the family caregivers were invited to attend investigations to report caregiving-related information. The care recipients in this study met the following inclusion criteria: diagnosed with schizophrenia in both waves ; and completed both waves of the surveys . The exclusion criteria were as follows: PwSs died before 2015; and family caregivers had a diagnosis of mental disorders. The eligible caregivers had kinship with PwSs, which could include being the PwS's spouse, parent, child, sibling, child-in-law or other collateral relatives; were aged 15 years or above; and had been caring for the patient for more than 6 months in the past year. 35 Family caregivers who were also mentally disabled or unable to communicate well were excluded. 32,35 Among the 510 PwSs identified in 1994, 250 were investigated 21 years later in 2015. Excluding those who did not have family caregivers , the analytic sample in this study included 225 dyads of PwSs and primary caregivers who had completed the questionnaires in both 1994 and 2015. Ethical approval for conducting the investigations was provided by the University Human Research Ethics Committee of the West China University of Medical Sciences in 1994 and by the University of Hong Kong in 2015. Informed consent with signatures was collected from all respondents at each stage of the surveys. --- Measurements --- Clinical characteristics Severity of symptoms . The Positive and Negative Syndrome Scale 36 was used to measure the severity of symptoms in PwSs. The 30-item PANSS is a seven-point Likert scale , in which all items are divided into three dimensions: positive, negative and general psychopathology. A higher score on the PANSS represents a more severe degree of symptoms of schizophrenia. 36 The PANSS has been validated in the Chinese population. 37,38 In our study, the Cronbach's alpha coefficient of the PANSS was 0.90. --- Social functioning . The social functioning of PwSs was measured using the Chinese version of the Social Disability Screening Schedule 39 in both 1994 and 2015. The SDSS is a ten-item scale used to assess the overall severity of dysfunction of PwSs, with a higher score indicating a poorer level of social functioning. 39,40 The scale has been validated in Chinese populations. 41 The Cronbach's alpha coefficient of the SDSS was 0.95, and the total score ranged from 0 to 20. --- Caregiving burden Caregiving burden . The Burden Scale for Family Caregiversshort 42 was used as a self-report instrument to evaluate the subjective burden of the family caregivers. This scale examined the following ten aspects of the caregiving burden: reduced life satisfaction, physical exhaustion, wish to run away, depersonalisation, decreased standard of living, health affected by caregiving, caregiving reducing strength, conflicting demands, worry about the future and relationships with others affected. 42 The responses to each question were rated on a fourpoint Likert scale, coded as 0 = strongly disagree, 1 = disagree, 2 = agree and 3 = strongly agree. 42,43 A higher total BSFC-s score represents a greater degree of subjective burden in informal caregivers. 42 The three-level classification system was used to interpret the BSFC-s score, with 0 to 4 points ranked as none to a mild degree of subjective burden, 5 to 14 points as a moderate level, and 15 to 20 points as a severe to very severe level. 44 In this study, the internal consistency reliability of the Chinese BSFC-s was verified, with a Cronbach's alpha coefficient of 0.94. --- Sociodemographic characteristics Sociodemographic characteristics in this study included patients' age, gender, marital status and education; and caregivers' relationship to the patient, age, gender, family size and self-reported annual income. --- Statistical analysis Prior to replacing missing values with imputation techniques, Little's missing completely at random test was performed. The results of the MCAR test were not statistically significant , indicating that the data were probably missing at random. Therefore, missing values were replaced by an expectation maximisation technique as appropriate for MCAR data. Descriptive and frequency analyses were carried out to compare the differences between groups with and without caregiver transition. The paired-samples t-test was used to compare clinical characteristics between 1994 and 2015. Analysis of variance was used to estimate the mean differences in caregiving burden within the groups with different clinical characteristics. The generalised linear model approach was used with time-varying clinical characteristics as independent variables and the follow-up caregiving burden as a dependent variable. In the regression analysis models, the hypothetical predictors included baseline demographic variables, total duration of illness, follow-up severity of symptoms and time-varying clinical characteristics . Together with the duration of schizophrenia and the PANSS, the sociodemographic variables were included as covariates in the regression analysis to estimate the associations of changes in clinical characteristics with caregiving burden. After adjusting for the aforementioned variables, illness-related predictors were entered into the regression models, where the 'stable status' subtypes served as the reference groups. The outcome variable was the follow-up caregiving burden. SPSS version 24.0 was used for statistical analysis. --- Results --- Demographic characteristics and caregiving-related information Table 1 presents a comparison of demographic characteristics between baseline and follow-up. In the analytic sample, the PwSs consisted of 82 males and 124 females, with average ages of 39.7 years at baseline and 60.8 years at follow-up. More than half of the PwSs were married at baseline; 21 years later, over half of them were married and 15.5% were widowed . The mean durations of schizophrenia were 10.5 years in 1994 and 29.9 years in 2015. At baseline, there were 133 male caregivers and 73 female caregivers, with an average age of 45.7 years . At follow-up, there were 162 male caregivers and 44 female caregivers, with an average age of 57.2 years . In 1994, 59.7% of the PwSs were cared for primarily by their spouses and 19.4% by their parents. In 2015, 63.1% were cared for primarily by their spouses, 22.8% by their adult children and 12.1% by their parents . Based on the three-level classification system suggested by Pendergrass et al, 44 in 2015, most of the families experienced the caregiving burden at a severe to very severe level, and 25.2% of the families perceived the caregiving burden to be at a moderate level. The median scores for family income per year were RMB 1000 yuan in 1994 and RMB 23666.7 yuan in 2015. The median numbers of family members were 3.5 and 3.0 in 1994 and 2015, respectively. --- Severity of symptoms and caregiving burden across the groups by caregiver transition Table 2 shows the characteristics of the two groups by caregiver transition and gender. In the whole sample, most of the PwSs were cared for by their husband in both waves, and 9.7% were cared for by their wife in both waves; 14.1% transitioned to adult-child caregiving from other types, whereas 14.1% transitioned to spousal caregiving. Mean BSFC-s scores ranged from 15.3 to 20.4 among different types of families, indicating that the families experienced the caregiving burden at a severe to very severe level on average. 44 Significant differences across the groups were observed in terms of the caregiving burden . Specifically, the results of the least significance difference test showed that mean BSFC-s scores were significantly higher in the 'parental caregiving in both waves' group compared with the 'spousal caregiving in both waves' group . --- Predictors of family caregiving burden over 21 years Table 3 presents the potential predictors of caregiving burden between families with versus without caregiver transition. Among families without caregiver transition, a heavier caregiving burden was significantly related to a larger family size and more severe symptoms in PwSs . The results also indicated that a lower level of caregiving burden was significantly associated with deteriorated functioning in 'social activities outside the household' and improved functioning in 'activity in the household' . Among families with caregiver transition, a higher degree of caregiving burden was found to be significantly associated with younger age of PwSs , improved 'marital functioning' , deteriorated self-care functioning of PwSs and improved functioning in 'social interest or concern' of PwSs . --- Discussion To the best of our knowledge, this is the first study to measure the predictive effects of changes in sociodemographic and clinical factors on the caregiving burden in family caregivers with versus without caregiver transition. This study contributes to the literature by emphasising the importance of caregiver transition and changes in the social functioning of PwSs over time when exploring the longitudinal determinants of caregiving burden in rural Chinese communities. --- Predictors of caregiving burden in families without caregiver transition In this study, compared with the families with PwSs having spouses as primary caregivers in both waves, the caregiving burden was significantly higher in families with PwSs having parents as primary caregivers in both waves. This result is consistent with a recent cross-sectional study reporting that parent caregivers experience a significantly higher degree of subjective burden than spouse caregivers in rural China. 30 This result shows that additional social support is particularly warranted to assist parent caregivers in accessing appropriate services and available resources in communities. 20,45 A larger family size predicted a heavier caregiving burden among the families of PwSs without caregiver transition, consistent with previous studies. 46,47 The results of this study indicate that larger families or those with parents as primary caregivers providing care to PwSs for a long period of time in rural Chinese communities are potentially more vulnerable and need more support. In accordance with previous findings, 2,[48][49][50] the results of this study add evidence to the linkage between the severity of symptoms and caregiving burden among families without caregiver transition during long-term home care. Evidence shows that caring for a PwS with greater severity of illness may exacerbate the strain in families over time in rural Chinese communities. For instance, based on previous studies, families might experience a decline in economic status because of the higher expenditure on medication and lower labour capacity of both patients and their family caregivers due to the illness. 34,47,51 The results of this study showed that deteriorated functioning of 'social activities outside the household' predicted a lower degree of caregiving burden among families without caregiver transition. This result is in contrast to previous research indicating that a lower level of social interest or social interaction was linked to a greater degree of caregiving burden. 52,53 Given the cultural influence and social stigma in rural areas of China, this finding may be related to the possibilities that PwSs with decreased social interest may lessen caregivers' long-term distress in terms of worrying about the trouble that a PwS may cause outside the household or the fear of being stigmatised by non-family members. [54][55][56][57] These possibilities warrant further investigation. In our study, the improvement of PwSs with respect to 'activity in the household' was found to be a protective factor against a heavy caregiving burden. This could be PwS, person with schizophrenia. a. To compare the variables between 1994 and 2015, paired-sample t-tests were used for between-group differences of continuous variables; χ 2 -tests were used for between-group differences of categorical variables. b. Others = other relatives, no caregiver, or unknown. c. Data regarding caregiving burden were not collected in 1994. explained by the possibility that these patients might be able to interact with other family members or even assist them with housework and farm work, which could to some extent release caregivers from a heavy workload and improve family relationships, thereby alleviating caregivers' psychological burden. 55,58 Predictors of caregiving burden in families with caregiver transition Building on previous cross-sectional studies, 47,55,57,59 the present study further examined the association between patient age and caregiving burden, demonstrating that taking care of a younger PwS might predict a higher degree of caregiving burden in families with caregiver transition. This may be related to the psychological distress of caregivers resulting from a higher prevalence of disruptive behaviours 60,61 and poor medication adherence 62 among younger adults with schizophrenia. Among families with caregiver transition from 1994 to 2015, improved marital functioning of the PwSs was found to predict a higher degree of caregiving burden in rural Chinese communities. It is plausible that after the PwSs married, in families where the primary caregiver of PwSs changed from other family members to their spouse, the new spouse caregivers were confronted with a high degree of psychological distress in terms of adopting the caregiving role. 27 In addition, in contrast to the aforementioned result in families without caregiver transition, improved 'social interest or concern' functioning in the PwSs was found to be a risk factor for a heavier burden among families with caregiver transition, consistent with prior studies. 52,53 This finding may be related to family caregivers' concerns about PwSs' safety 20 or caregivers' fear of being discriminated against by neighbours owing to stigma about schizophrenia 54,55 when PwSs frequently interact with non-family members in the rural Chinese context. The results of this study also indicated that deterioration in the self-care functioning of PwSs predicted a heavier caregiving burden. This finding is congruent with previous studies showing that family caregivers of PwSs are more likely to perceive psychosocial burden when taking care of PwSs with more care needs or a lower level of independence. 52,53 This finding might be related to the possibilities that when primary caregivers change over time, the new caregivers might be more stressed if they are not familiar with the long-term illness status of a PwS without basic self-care abilities; as PwSs and their caregivers get older, issues regarding who will continue to take care of these patients and where the patients will stay after the caregivers pass away may become important concerns among the majority of family caregivers. 63 Thus, the current findings suggest the importance of having family intervention programmes to help patients learn how to take care of themselves and to support new caregivers in learning how to familiarise themselves with patient self-care needs. --- Limitations Several limitations of the present study are worth noting. First, given the main focus on the change in social functioning and predictors of the later caregiving burden, we did not repeatedly examine the caregiving burden at baseline and follow-up. Baseline symptom information was not collected. Thus, the current findings were limited to interpreting the covariation of associations between changes in the caregiving burden and changes in clinical correlates. 64 Future studies are warranted to further assess the differences in family caregiving burden and its clinical correlates at different stages throughout the trajectory of the illness. Second, when measuring caregiver transition, this study only compared the differences between caregiving statuses in 1994 and 2015. We acknowledged that fluctuations regrading detailed arrangements of primary family caregivers were not observed in the present study. Third, the small sample sizes of several subgroups, including the 'adult-child caregiving in both waves', 'transition into parental caregiving', and 'transition into sibling caregiving' subgroups, limited the transferability of the findings of this study. In addition, the risk of sample bias should be noted, given the high percentage of female patients in this study, which was somewhat inconsistent with a nationwide population-based study reporting that schizophrenia is more prevalent among males than females. 65 In addition, the unusual number of married patients probably reflects the high proportion of female patients. Fourth, the mental status of PwSs was measured using a single item by professionals. Comprehensive measures should be considered in future longitudinal studies to provide more items to uncover patients' ever-changing illness status. Fifth, the generalisability of these findings was limited by the rural sample and the drop-out patient sample during the long time interval in the study. Therefore, the findings might not be applicable to those residing in urban areas or during a long hospital stay. A sample combining both rural and urban residents is suggested for future investigations. --- Policy and practical implications Despite the limitations, this study provides empirical evidence that the effects of changes in sociodemographic and clinical correlates on the caregiving burden were significantly different from those of transition in primary caregivers over 21 years in rural Chinese communities. These findings could inform future culture-specific interventions to work with different types of households with persons suffering from schizophrenia for long periods of time. Identifying determinants associated with the caregiving burden is essential in developing more appropriate strategies for family interventions and home-based services in families of PwSs. 66 Based on the social context of rural China, primary health professionals , social workers or family therapists should provide culture-specific suggestions to the primary caregivers of PwSs based on kinship types and the actual situation of caregiver transition, along with detailed guidance for improving the quality of family caregiving. For instance, based on our findings, effective interventions are particularly needed to improve patients' interest, skills and functioning in daily household tasks and to help family caregivers arrange these tasks to facilitate patient participation. Moreover, for social policy-making and public service provision in mental health, more targeted policies and mental health services could be designed to serve families who are experiencing a great burden of care in underdeveloped areas in China. 32,66,67 For instance, medical expense waivers, anti-stigma interventions, ongoing expert consultation, or stress management training could be provided by the local government to serve the families of PwSs. The findings of this study highlighted the needs of more vulnerable groups, such as larger-sized families, patients with more severe symptoms, younger patients and patients with poor self-care functioning. Regular self-management training and rehabilitation programmes could be tailored to PwSs cared for at home for long periods of time to assist them in reintegrating into their communities. --- Data availability The data are not publicly available because they contain information that could compromise the privacy of research participants. --- --- Declaration of interest None.

Little is known about how sociodemographic and clinical factors affect the caregiving burden of persons with schizophrenia (PwSs) with transition in primary caregivers.This study aimed to examine the predictive effects of sociodemographic and clinical factors on the caregiving burden of PwSs with and without caregiver transition from 1994 to 2015 in rural China.Using panel data, 206 dyads of PwSs and their primary caregivers were investigated in both 1994 and 2015. The generalised linear model approach was used to examine the predictive effects of sociodemographic factors, severity of symptoms and changes in social functioning on the caregiving burden with and without caregiver transition.The percentages of families with and without caregiver transition were 38.8% and 61.2%, respectively. Among families without caregiver transition, a heavier burden was significantly related to a larger family size and more severe symptoms in PwSs. Deteriorated functioning of 'social activities outside the household' and improved functioning of 'activity in the household' were protective factors against a heavy caregiving burden. Among families with caregiver transition, younger age, improved marital functioning, deteriorated self-care functioning, and better functioning of 'social interest or concern' were significant risk factors for caregiving burden.The effects of sociodemographic and clinical correlates on the caregiving burden were different among families with and without caregiver transition. It is crucial to explore the caregiver arrangement of PwSs and the risk factors for burden over time, which will facilitate culture-specific family interventions, community-based mental health services and recovery.

INTRODUCTION Depression is a common mental disease, which can cause serious harm to physical and mental health if long-term relief from symptoms is not achieved. The widespread impact of depression is not only reflected in the extremely high health lost and numerous complications, such as type 2 diabetes and cardiovascular diseases , but also in its promotion of suicide. Depression has evolved into a serious social problem and has accordingly attracted wide research and clinical attention. According to the latest estimates, more than 300 million people currently experience depression , and the prevalence increased by 18.4% between 2005 and 2015. Among different age groups, prevalence peaks in middle and old age . With the development of an aging population, depression among middleaged and older people would become relatively more prevalent. China, as the largest developing country, is also experiencing a trend of rapid population aging. It is estimated that between 2012 and 2050, China's elderly population will increase from 194 million to 483 million, and the aging level will increase from 14.3 to 34.1%; at that time, China would be one of the countries with the fastest population aging rate . A study indicated that there were 56.36 million people living with depression in China in 2017, accounting for 21.3% of cases worldwide . The prevalence rate of depression increases with age and becomes more serious in persons over 60 years. Thus, for China, it is important to adopt measures to promote mental health among high-risk groups, such as middle-aged and older people, to avoid the adverse outcomes of depression. This would also provide the benefit of globally improving mental health. Currently, conventional interventions against depression, such as cognitive behavioral therapy and medication, are considered effective approaches. However, it is difficult to meet the needs of low-and middle-income countries for current depression treatments, given resource limitations ; the cost for depression treatment is notably high. It has been estimated that an annual global cost of US$1.15 trillion is attributable to depression . In China, a study calculated that total economic expenditure per capita for depression was 21,650 CNY, with direct economic expenditure of 6,806 CNY and indirect economic expenditure of 14,844 CNY . This heavy economic burden on developing countries is not affordable. Thus, it is important to seek other effective and feasible low-cost approaches and pay particular attention to preventive interventions. Since the concept of SP was introduced to the field of aging research at the beginning of the 20th century , increasing attention has been paid to the relationship between SP and depression. Activity theory posits that SP by older persons helps them to maintain self-esteem, obtain psychological satisfaction, and live a long and healthy life. Maintaining intellectual, physical, and certain social activities are necessary in later life, not only to promote physical health but also to foster mental health . Prior studies also indicated the relationship between SP and depression among the elderly group. A study found that SP plays a protective role against depressive symptoms , and continuous SP may have strong association with fewer depressive symptoms . Moreover, a few studies further explored the effect of different types of SP on depression. Formal voluntary activities reduce the risk of depression in older persons, but informal help has no such effect . Social activities, group activities, fitness exercise, and intellectual participation can all reduce the risk of depression in older persons, but helping and dedication activities have no significant effect . Voluntary participation has positive effects but obligatory participation has harmful influences . In addition, some studies suggested that SP could relieve depression among certain older adults . However, most studies were conducted using ordinary least squares regression, and a few of them use propensity score matching, which could reduce bias and improve internal validity of the statistical analysis. In addition, few studies have explored the correlation between depression and SP in China while considering frequency, type, and quantity of SP. This study made the following assumptions: first, SP was associated with a lower depression score. The higher the frequency of SP, the larger the quantity of SP, and the more diverse the types of SP, the lower the depression score. Our study explored the impact of SP on depression among middle-aged and older Chinese persons using a PSM method and explored the relationships with respect to the frequency, type, and quantity of SP. Effects were further compared among different age groups, genders, and places of residence. The findings could provide evidence for the targeted social participation measures for specific groups of middle-aged and older people. --- METHODS --- Sample and Data Collection The datasets were obtained from 2018 wave of the China Health and Retirement Longitudinal Study, a national representative survey adopting a four-stage, stratified, cluster sampling method to collect Chinese residents aged 45 years and above, covering 450 villages and 150 counties in 28 provinces in China, and the detailed sampling methods can be retrieved from the study of Zhao et al. . The baseline survey started in 2011 and conducted follow-up surveys every 2-3 years, and the 2018 wave is the latest wave data. In the 2018 CHARLS database, 19,816 observations were admitted from the 2018 CHARLS database. After screening and excluding invalid samples, a total of 9,312 respondents were included in the study, Supplementary Figure S1 shows the process of sample screening. --- Variables --- Outcome Variable Depression is the outcome variable in this study, which is estimated by the CES-D10 scale. The respondents were asked the frequency of their feeling or behavior during the last week, and each answer of positively oriented questions was coded from 0 to 3 according to the frequent value; the answers of the negatively oriented questions were reverse-coded. The total score of the scale ranges from 0 to 30, with higher scores indicating more serious depression. Our study used the score of 12 as the cutoff point to describe the prevalence of depression . In the previous related studies, CES-D 10 showed a good internal reliability . --- Explanatory Variable The explanatory variable in this study is SP, which was estimated by their participation in 11 social activities in the past month. If respondents participated in any of the social activities, they were considered to have SP, otherwise, they were considered not to have SP. --- Confounding Variables The following variables were selected as possible confounding variables according to previous studies . Confounding variables include three aspects: demographic characteristics, including gender, age, marital status, education, retirement, residency, individual income, medical insurance, number of family member, and living near child/children; lifestyle characteristics, including smoking, physical activity, and alcohol consumption; and health status, including types of NCDs, selfrated health changes. Detail codes, and definitions are shown in Table 1. --- Statistical Analysis A chi-square test was used on categorical variables to test the differences in social participation and its diversity and frequency. In addition, an independent sample t-test was used for continuous variables to assess social participation differences, an analysis of variance was performed to evaluate the differences in social participation's diversity and frequency. PSM was used to estimate the effect of SP on depression. As the data we used were observational, there existed the risk of bias caused by study design, unbalanced distribution or grouping, nonrandom sampling, subjective tendency of the measurer, and so on, as well as confounding variables, all of which can lead to biased estimation . PSM can address covariate imbalances between treatment and control groups in observational studies by matching respondents with similar characteristics in the two groups. This can reduce the influence of data bias and confounding variables and facilitate a more reasonable comparison between the exposure and control groups. Observational data are thereby rendered more akin to random trial data, and robust estimation results may be obtained . Thus, this study used the PSM method to estimate the average treatment effect of SP on depression of the middle-aged and older people. The PSM method was first proposed by Rosenbaum and Rubin , and it has become one of the important empirical methods to deal with nonrandom data. The process of the PSM method is as follows: first, calculating propensity scores by logit regression model to predict the probability of SP, which was matched by confounding variables. We then calculated the average treatment effect for the treated , and the formula is as follows: ATT = E[] -E[] where E[] represents the depression scores of respondents participating in social activities, and E[] is the reference outcome. Next, the matching effect was assessed by testing the absolute standard bias between the treatment and control groups after matching. Previous studies showed that the smaller the ASB of confounding variables after matching, the better is the matching effect . According to Rosenbaum and Rubin's definition, if ASB is <20, the matching effect can be considered reliable . We used three matching methods including Knearest neighbor matching , radius matching, and kernel matching to ensured the robustness of our results. In the radius matching, a 0.2 SD caliper was employed, and in the kernel matching, a bandwidth of 0.06 was set with an epan kernel. In addition, we also applied ordinary least squares regression models to estimate the impact of SP on depression, and we used robust standard errors to alleviate the potential effect of heteroscedasticity. All statistical analyses were conducted by STATA version MP17.0 software. A p-value <0.05 was considered as statistically significant. --- RESULTS --- Characteristics of Respondents The characteristics of respondents are shown in Table 2. These include the characteristics of social participation and its diversity and frequency among the respondents. Most respondents were women , partnered , rural residents , and with a median age of 64 years old. Of the respondents, the education level was illiterate, primary school, middle school, and ≥high school, which accounted for 17.72, 44.50, 23.38, and 14.40%, respectively. The median of the depression score was 8, the value for the SP and no SP groups were 7 and 9, respectively, and the prevalence of depression symptoms among middle-aged and older Chinese people was 42.92%. Whether middle-aged and older people engaged in social participation differed with respect to most characteristics: social participation was associated with younger respondents, those who were not of single marital status, with better economic status, living in an urban area, having at least a high school education, and living far from child/children. The frequency and variety of social participation differed with respect to most of the characteristics. --- Social Participation Rate of Respondents With Different Characteristics Figure 1 shows the social participation rate of respondents with different types , numbers , and frequencies and social participation rate by different ages, genders, and residencies . The proportion of social participation among middle-aged and older people account for 56.49%, 30.28% of the respondents participated in one activity, and 26.20% participated in at least two activities, 42.04% of the respondents participated in activities more than one time a week. We also obtained that among all types of social participation, the top two types with the highest participation rate are interpersonal activities with 36.08% and entertainment with 29.33%; significant differences were shown among different types, numbers, and frequencies of social participation. The social participants' rate had no significant difference between men and women, while respondents aged <60 years, or those in urban regions, had a higher participation rate than the reference group. The Probability of Social Participation Among Middle-Aged and Older People The estimation results of the probability having SP among middle-aged and older people by logit model are depicted in Supplementary Table S1 . Through the logit model, the PSM score was estimated, and the matching of treatment group and control group was completed. The finding showed that pseudo-R2 is 0.0540, indicating that the model fits well, and the association between possible confounding variables and social participation was revealed, for example, those younger and those with better self-rated health changes were more likely to have social participation. --- Effect Test on Depression Using Unmatched and Matched Data After data matching, we conducted a series of tests to check the matching effect. First, we compared the density function of propensity scores of the treated group and control group. Figure 2 shows that the distribution of the two groups is closer than before matching. Next, the covariates' balancing test was conducted. The results are depicted in Figure 3. All the standard bias of the covariates are reduced substantially after matching . The covariates showed no significant difference among the two groups in Supplementary Tables S2-S4 , and all the ASB are <20%, which indicates that the matching has a good quality. We constructed a histogram of the propensity score in the treated and control group , as Figure 3B shows no essential difference in the distribution of propensity score of the treatment group and the control group after matching. It was clear that no matter which matching method we used, the propensity score distribution became symmetrical. Most of the observations are in the expected range, thus, satisfying the common support hypothesis. Median 0 0 0 0 0 0 0 0 0 that SP had a positive effect on decreasing depression scores by 0.875-0.898 points, namely, SP was associated with lower depression scores. Taking the result of the radius matching method as an example, the depression scores of the respondents with SP were 0.881 points lower, on average, than those of persons without SP. --- Propensity Score Matching Estimation of the Effect of Social Participation on Depression Scores Physical All types of SP had a significantly positive effect on decreasing depression scores ; of the different types of SP, participating in community activities had the largest effect . PSM estimation also showed that compared with no SP, taking part in one or two types of social activity had significant negative effects on depression scores, while the more activities participants engaged in, the lower their depression scores. PSM estimation suggested that a higher frequency of participation promoted lower depression scores. --- Estimation Results for the Effect of Social Participation on Depression Scores Using Ordinary Least Squares The results estimated using OLS are shown in Supplementary Table S5 . In model 1, SP had a significant negative effect on depression scores . Control variables related to demographic characteristic variables were added in Model 2, further lifestyle characteristics were added in Model 3, and health status characteristics were added in Model 4; the coefficient of SP increased to -0.892, -0.868, and -0.774, respectively, while the regression significance level remained at the 1% level. The regression results imply that compared with middle-aged and older adults who did not engage in SP, those who participated in social activities exhibited a depression score that was reduced by 0.63, on average, after adjusting for the control variables. --- Heterogeneity Analysis of the Effect of Social Participation on Depression We further conducted a heterogeneity analysis by age, gender, and residency . The results showed that SP had a significant negative effect on depression scores among different ages, genders, and residencies: being female woman, aged ≥75, and living in an urban area were all associated with more negative effects on depression scores. --- DISCUSSION This study applied a PSM method to explore the effect of SP on depression scores, including examining the effect with respect to the type, number, and frequency of SP, and further conducted a heterogeneity analysis. In addition, we also applied OLS regression models to estimate the impact of SP on depression. Our main findings indicated that SP was associated with significantly reduced depression scores: participating in community activities, higher frequency of SP, and engaging in more types of SP promoted a lower depression score. In the subgroup analysis, SP had a greater effect among older persons, women, and urban residents. The results using OLS also revealed a negative impact of SP on depression scores. --- Prevalence of Depression Symptoms in Middle-Aged and Older Chinese People Through this large-scale investigation, we found that the prevalence of depression among middle-aged and older Chinese people was 42.92%. Although the CESD-10 scale was widely used in depression investigation, it was just the estimation of depression symptom, not obsoletely equal to the real diagnosis and, thus, highly far from the monitoring data. In domestic studies using the CESD-10 scale to measure depression, a study showed that the prevalence of depression of the middle-aged and older in 2015 was 32.62% . Zhou found that depression prevalence was 35.19% in 2018 , which can be seen that the trend of prevalence is rising and the recent finding was close to us. An explanation was that physical pain caused by chronic diseases often leads to mental disorder, which may lead to depressive symptoms. Domestic studies showed that middle-aged and older people are not only the main patients with chronic diseases but also the high-risk groups of depression . Nevertheless, the result in our research was also higher than other previous studies that used an estimated scale; the incidence of depression is not only higher than in earlier reports , but also exceeds that of other developed countries , and even some developing countries . The high prevalence is a reminder that depression in Chinese middle-aged and older persons is an urgent concern. China will face greater challenges in terms of the increasing burden of depression; accordingly, attention must be paid to this issue, and feasible preventive measures are urgently needed. --- Social Participation Could Benefit Older Middle-Aged and Older Adults' Mental Health Our study verified that SP promotes mental health. We found that respondents who engaged in SP had lower depression scores, consistent with previous studies . This could be explained by social participation incentivizing mutual support, providing a sense of belonging, and largely reducing social isolation , which, therefore, result in better mental health . Due to aging, retirement, and declining health quality, among other factors, middle-aged and older people may experience a considerable psychological burden, social isolation, changed social roles, and the need to adapt to aging; these factors may promote depression. Against a background of population aging trends worldwide, mental health has attracted substantial research attention. The WHO noted out that SP is a key factor in healthy aging . Therefore, effective measures should be developed to promote SP. Policy makers should provide support for middle-aged and older people, first, by constructing service facilities suitable for this population, and second, forming related organizations with a community or village committee as a unit and encouraging middle-aged and older people to actively participate in social activities. Participating in Community Activities, Higher Frequency of Social Participation, and More Types of Social Participation Promoted Lower Depression Scores We proceed to explore the associations between depression and different types of social engagement. We observed that taking part in community activities was the best way to promote mental health among all types of activities considered. Community activities are carried out by a mutually beneficial organization formed by people with certain common characteristics; we speculate that such organizations are associated with promoting a sense of belonging. However, the participation rate of community activities was only 2.77%. In China, development of leagues for older persons is incomplete and informal; most leagues are selforganized and lack legal status. Consequently, there is no legal basis for the construction and operation of associations for older persons and, hence, a lack of guarantee in terms of policies, organizations, and funds. This results in many contradictions, difficulties, and problems in the construction of associations for older persons . In addition, we observed that engaging in more diverse social activities and engaging in SP more than once a week were relatively conducive to mental health, consistent with prior studies . Therefore, governments should make effective use of the community as a platform to promote the development of diverse activities, such as by providing financial support. Furthermore, incentive mechanisms could be used to promote the participation of middle-aged and older people in various activities. --- Social Participation Had a Greater Effect on Older Persons, Women, and Urban Residents Through further comparing the effect of subgroups of age, gender, and residency, we determined that SP had a greater effect on women, and urban residents. We also found that the older the age, the greater the impact. People over 75 years of age had the largest effect among the age groups. The percentage of social participants had no significant difference between men and women, while respondents aged <75 years, or those in urban regions, had a higher value than the reference group. The above results emphasize that SP appears to be a more effective measure to prevent depression for women, older persons, and urban residents. Older women are more likely to lack social interaction than older men; furthermore, influenced by the traditional Chinese concept of "men dominate the outside, women dominate the interior" , older men often enter the labor market to earn income and have frequent contact with the outside world, while older women generally engage in housework or take care of children or older relatives at home, compared with men. This part of communication with the outside world is insufficient for women. Activities in which women participated were the primary source of relief for their depressive symptoms and, thus, had a more considerable effect on them. As age grows, the mental health status and social adaptability of the elderly generally decreased, and the possibility of social isolation become higher . Our study also showed that as age increased, social participation decreased; thus, social participation plays a greater role among the venerable age group. Residents of urban regions received more benefit than did rural residents, as the former had a more convenient environment for participation, due to greater availability of diverse social activities in a city. Targeted measures should consider women, elderly, and rural residents, such as middle-aged and older women, and elderly persons with limited mobility. For example, accessibility of participation should be improved by installing elevators in buildings or introducing social workers to conduct activities in the homes of elderly people with disabilities. For rural elderly persons, the social activities currently available have limited effects on improving health. Activities, such as "guangchangwu" and other community activities that are widespread in cities have beneficial effects on health, are rarely available in rural areas . Therefore, it is necessary to improve the provision of various organized activities for elderly persons in rural areas and to guide such persons to participate in these activities on a consistent basis. --- Comparison of Effects Between Propensity Score Matching and Ordinary Least Squares Analysis Strategies A significant negative association between SP and depression scores was found in both PSM and OLS analysis, although the estimated effect was larger in the OLS method than the PSM method, that is, not balancing covariates led to overestimation of the treatment effect. The primary strength of our study is that the PSM method enabled a reasonable comparison to be made between groups with and without SP, reducing estimation bias. There are also some limitations to our study. First, as a cross-sectional study, causal relationships between SP and depression could not be determined; future studies should use longitudinal designs to address this limitation. Second, PSM cannot solve endogenous problems, such as self-selection and omission of variables, which may affect the accuracy of the results. Third, we obtained the result from scale responses, thus, it reflects a degree of mental status, namely, depressive symptoms. However, it does not equate to depression clinically diagnosed by a physician. Fourth, the sample size of persons who took part in several types of SP, such as voluntary activities, community organizations, or using the Internet, was small; using a larger sample of such persons would provide more reliable results, future studies are needed for such further exploration. --- CONCLUSION This study highlighted the crucial role of SP in preventing depression and promoting the mental health of middle-aged and older Chinese people. Community activities were the most effective of all activities. Participation in more diverse activities and participation with the frequencies of once a week or more is beneficial to mental health. SP had a greater effect on older persons, women, and urban residents. The results suggest that as the population of China ages, the government should provide support for middle-aged and older person's social participation, such as by providing venues, funds, and channels for social participation. Organized and diverse activities should be provided and measures should be taken to encourage middle aged and older persons participated in such social engagement. In particular, attention should be paid to women, rural residents, and older persons, who would benefit from targeted measures provided according to their needs. --- DATA AVAILABILITY STATEMENT The dataset are available from the CHARLS repository, http:// charls.pku.edu.cn. --- ETHICS STATEMENT This study was approved by the Ethical Committees of Peking University. During the investigation, all participants provided written informed consent. CHARLS is publicly available and de-identified. The patients/participants provided their written informed consent to participate in this study. --- --- SUPPLEMENTARY MATERIAL The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt. 2022.825460/full#supplementary-material --- 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. Copyright © 2022 Wang, Xu, Nie, Pan, Zhang, Li, Liu, Liang, Gao, Wu, Hao and Shah. This is an open-access article distributed under the terms of the Creative Commons Attribution License . The use, distribution or reproduction in other forums is permitted, provided the original author and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Background: Depression is one of the greatest public health problems worldwide. The potential benefit of social participation (SP) on mental health has been widely acknowledged. Nevertheless, a few studies have used propensity score matching (PSM) to reduce the influence of data bias and confounding variables. This study explored the effect of social participation on depression among middle-aged and older Chinese persons through a PSM method, considering the frequency, type, and quantity of SP. Effects were compared among different age groups, genders, and places of residence.The datasets were obtained from the 2018 wave of the China Health and Retirement Longitudinal Study. A total of 9,404 respondents aged 45 and above were included in the study. PSM and ordinary least squares methods were used to estimate the effect of social participation on depression. Results: PSM estimation results showed that SP had a significantly positive effect on decreasing depression scores (p < 0.001) by 0.875-0.898 compared with persons without SP. All types of SP had a significantly positive effect (p < 0.001), and participating in community activities had the largest effect (β = -1.549 to -1.788, p < 0.001). Higher frequency of participation and more types of SP promoted lower depression scores; subgroup analyses revealed that the promotion effect was significantly greater among women, those aged ≥75 years, and those living in urban areas. Conclusion: PSM indicated that SP could alleviate the depression of middle-aged and older Chinese persons. Targeted measures should be adopted to promote SP and thereby improve mental health and promote healthy and active aging.

their relationship in daily life among older adults. Even less is known about what social factors may help attenuate the affect-pain connection. We examined whether social interactions and reported enjoyment in daily life were associated with an attenuated link between negative affect and two important pain outcomes . This was examined among a socioeconomically and racially diverse sample of 317 older adults aged 70+ who were recruited from the Bronx, NY as part of the Einstein Aging Study and who completed ecological momentary assessments five times daily for 14 days. Three-level multilevel models were estimated, controlling for mild cognitive impairment status, gender, age, education, body mass index, and average level positive affect for models that did not include enjoyment. In given moments, higher negative affect and lower enjoyment were associated with higher pain intensity and pain interference . Moment-level negative affect and enjoyment significantly interacted to predict both higher pain intensity and pain interference , with patterns suggesting a buffering effect of enjoyment. In addition, a three-way interaction emerged such that during moments when no interactions occurred and negative affect was lower than a person's average, there was a buffering effect of momentary enjoyment on pain intensity. Findings extend understanding of the affect-pain connection and the potential mitigating impact of social interactions and moments of enjoyment. Abstract citation ID: igad104.3286 --- DO OLDER ADULTS BELIEVE THEY ARE AGING SUCCESSFULLY IN THE CIRCUMPOLAR NORTH? Britteny Howell 1 , Amber Worthington 1 , Dale Golden 1 , and Leslie Redmond 2 , 1. University of Alaska Anchorage, Anchorage, Alaska, United States, 2. University of Manitoba, Winnipeg, Manitoba, Canada People's perspectives on successful aging may impact their own aging outcomes. To gain more insight, we surveyed a convenience sample of 58 adults aged 55+ years in urban Alaska about their perceptions of their own aging using Fowler's successful aging scale. Overall, older adults rated their aging in the middle of the 1-7 scale across all three questions: how well they are aging, how "successfully" they have aged up to now, and how they rate their lives these days . Correlational analyses indicated that as perceptions of successful aging increase, self-reported good general health increases, r=.499, p<.001, and self-reported disability decreases, r=-.27, p<.05. Despite a small sample size, these findings that perceptions of successful aging increased as general heath increased and self-reported disability decreased, suggest that participants may perceive successful aging and good general health to be positively correlated. Perceptions of successful aging were not related to age in this sample , r=.125, p=.349. This is promising, as it may indicate that older adults recognize good health and absence of disability as integral components for successful aging regardless of chronological age providing opportunities for targeted messaging in future interventions. Future work will

strong hesitancy-lack of trust/conspiracy (11.9%). White (RRR=1.659, p<.01), higher income (RRR=1.005, p<.05) and higher education (RRR=1.078, p<.001) were positively associated with no hesitancy. Respondents with higher education (RRR=0.573, p<.05) were less likely to be in the group of mild hesitancy with uncertainty. Hispanics (RRR=0.583, p<.05) and higher education (RRR=0.332, p<.001) were negatively associated with strong hesitancy with personal concerns. African Americans (RRR=2.426, p<.001) and those with lower education (RRR=1.324, p<.001) were more likely to be in the group of strong hesitancy with lack of trust/conspiracy. Our findings show that vaccine hesitancy is not random, which is closely related to social stratification impacting health disparities in this society.

INTRODUCTION Calls for solidarity have been an ubiquitous feature of policymaking since the onset of the COVID-19 pandemic. In many countries, and even at a transnational level, solidarity has been used in appeals to the public to adhere to measures to contain the spread of the virus, as well as a rhetorical device to underline the message that "we are all in this together" . WHO has embraced the notion of solidarity to underline the need for international cooperation and for knowledge sharing. Solidarity has also been employed as an anchor point to underline the importance of specific policy measures , such as steps to increase vaccine uptake to combat vaccine hesitancy . However, we know little about how people have thought of, and practised, solidarity in their everyday lives since the beginning of the pandemic. What role does solidarity play in pandemic times and how does it relate to public health and other measures introduced since the onset of the pandemic? We build on a practice-based approach to solidarity to answer these questions. We present insights from a large-scale, international, qualitative study that signals a societal longing for institutional transformation-in the form of what we call institutionalised or tier 3 solidarity-to address the many social injustices brought to light and exacerbated by the pandemic, and to show how these insights are relevant for policymaking in pandemic times. Our analysis leads us to reflect on the role of medical humanities in pandemic times: What lessons can we draw for policymaking, healthcare practice and the potential for medical humanities to guide insights into future health crises? These are important questions to address, especially for a large and multidisciplinary field such as the medical humanities 2012). The analysis of solidarity-related practices can help in exploring some salient social justice issues that the pandemic has brought to the forefront of scholarly, public health, political and societal attention, and thereby contribute to one of the longstanding aims of the medical humanities to uncover contexts and meanings of social justice in medical practice and healthcare systems. While the disciplinary, conceptual or methodological focus of the medical humanities can vary depending on how inclusive an approach is taken towards the humanities and social sciences, the patient's experience is at the centre of most of the work in the field. The medical humanities have thus been crucial in influencing and shaping the idea that patients, and their experiences, should be the core concern of the medical practice and research community. More widely, the humanities and social sciences have long --- Original research highlighted the fact that societies are built on social relationships at different levels, and that we need to understand these relationships in order to inform policy and healthcare practice . In our research, we build on the idea that one cannot aim to resolve complex problems or improve healthcare practice without understanding what patients and individual members of society experience. Sadly, a pandemic means that most people will either become a patient, have been a patient or know someone who is or has been a patient. Everyone is affected by a pandemic in one way or another. Drawing on 643 in-depth, qualitative interviews conducted during two phases in nine European countries, this article explores solidaristic practices and how these changed between the two periods of the longitudinal study. In line with Prainsack and Buyx , we understand solidarity as practices by which people support others with whom they see themselves as connected in some relevant waymay it be a common goal, a shared identity or the joint fight for a common cause or a social good. In the interviews, we found that appeals to solidarity resonated with people at the beginning of the pandemic, who largely followed public health advice and stayed home during the first lockdowns. We distinguish solidaristic practices from more rhetorical expressions of solidarity and show how an approach that focuses on concrete actions, inaction or motivations of people to engage in ways that foster or hinder solidarity draws a nuanced picture. It demonstrates where, how different forms of solidarity take place, and where solidarity is seen as lacking. The approach also allows us to make sense of a crucial change that we identified between the two interview phases of the study: whereas acts and expressions of personto-person solidarity were strong in the first interview phase in April and May 2020, in October 2020 they were marked by a longing for more institutionalised forms of solidarity. This may be a common trajectory in times of crisis where a strong sense of solidarity and the need for mutual support decrease over time as the circumstances of the crisis are more normalised and a certain crisis fatigue sets in . Beyond this, however, we see it also a result of injustices and inequalities exacerbated, or brought on, by pandemic policies. A practice-based understanding of solidarity allows us to go beyond interpretations of the waning of solidarity as 'pandemic fatigue', and instead to underline the need for solidaristic practices to be fostered by public institutions in order to sustain them throughout and beyond crises. --- Background: solidarity in European healthcare, public health and the medical humanities Solidarity plays a role in healthcare and public health in at least three important ways. First, solidarity is often labelled a core value on which publicly funded healthcare systems in Europe are built. This applies to both tax-funded health systems as well as systems funded through social health insurance contributions. In the case of the former, Saltman argues that the notion of equity as a guiding principle for how resources are distributed fairly between patients is the 'conceptual near-equivalent' of solidarity in social health insurance systems. The underlying idea is that healthcare should be provided and accessible to all as needed, when needed, without negative financial repercussions and in a reciprocal fashion. Over time, through the institutionalisation of public healthcare, this has led to people accepting the costs of paying into collective pots of healthcare even if they are healthy, knowing that one day when they might need healthcare, they can access it without this having negative consequences for their personal financial situation. This institutionalised form of solidarity hinges on the assumption that all members of society share a vulnerability to ill health, which can be mitigated by a system of mutual support. Against this background, it is easy to see how a health crisis such as the COVID-19 pandemic has the potential to threaten the very foundation on which public healthcare systems rest as practitioners are faced with morally intractable decisions of having to prioritise some patients over others even though the value of mutual support and equal treatment enshrined in the system would suggest otherwise. Second, solidarity is one of several principles that health practitioners and policymakers might draw on when developing public health guidance in pandemic and non-pandemic times. In the literature on public health ethics and bioethics, solidarity is often juxtaposed or compared with other, more individualised principles that justify public health action, such as autonomy or personal responsibility. The latter notions tend to take centre stage in public health discussions, leading Dawson and Jennings to argue that solidarity has been an overlooked concept in public health ethics and pandemic ethics frameworks. They conclude that solidarity can and should be applied in a much more explicit way when justifying public health interventions. At the heart of their argument lies an understanding of solidarity as a collective concept, one that transcends many of the other elements of public health ethics such as beneficence, non-maleficence, justice and autonomy . For public health interventions to be successful, an understanding is needed that safeguarding values and rights at the individual level, for example the value of autonomy, is not possible without first securing values at the collective level, for example through increasing vaccination uptake. From this point of view, the encouragement of populations to get vaccinated is more than a rhetorical frame, it is a policy instrument deeply rooted in notions of solidarity and humanism. Third, despite its fundamental importance in healthcare and public health, solidarity remains an opaque concept that is often used but rarely defined . This article highlights the value of understanding solidarity through a prism of a practicebased approach that allows us to identify multiple and varied forms of solidarity at different stages of the pandemic, hence circumventing some of the operational problems that might otherwise arise from discussing an often poorly defined concept. We do this by adopting the definition of solidarity by Prainsack and Buyx that encompasses practice-based understandings, which has proved to be a fruitful lens for researching enactments of solidarity in healthcare . Prainsack and Buyx argue that the recognition of similarity with another person that in turn gives rise to a solidaristic action is a key element in explaining solidaristic practices: 'Solidarity is an enacted commitment to carry "costs" to assist others with whom a person or persons recognise similarity in a relevant respect'. One of the key elements of this definition of solidarity is that it has to be enacted, that is to say a concrete action has to emerge from which we can extrapolate that solidarity is being practised. This working definition of solidarity allows us to analyse interview data from several angles when investigating which actions and practices might be identified as solidaristic practices. In addition to the motivations that people describe as factors for following public health advice or in supporting others during the pandemic, we can reflect on the types of costs people are --- Original research willing to incur to support others or the way in which they describe groups with whom they feel connected in some relevant way. Importantly for the findings presented in this paper, solidarity can manifest itself at various levels : the interpersonal level, group level and at the level of institutions and norms. Solidarity at the interpersonal tier refers to practices by which people support others based on shared experiences at the person-to-person level. At this tier, we observe and identify many different forms of solidarity and acts of support between individuals, especially in the first phase of the pandemic. The second tier refers to manifestations of a shared commitment at a group level, for example, within a self-help group. In our interviews, this emerged in terms of supporting initiatives implemented by new and pre-existing groups . The third tier refers to institutions, policies and other formalised processes that are organised according to the principle of solidarity or that help to realise it . The understanding of mutuality and equity in access that underlines many European healthcare systems is probably the most prominent example of such institutionalised forms of solidarity in healthcare. As our findings show, however, that such institutionalisations cannot be taken for granted. Many respondents expressed their frustrations with governments not doing more to institutionalise and support the solidaristic practices that were seen in great abundance at the interpersonal level of solidarity. The concept of solidarity is particularly useful in thinking about some of the normative and applied ambitions within the medical humanities as a broad field that draws on methods, concepts and content from different humanities and social sciences disciplines . First, it supports the field's ambition of uncovering, providing and understanding contexts and experiences in medicine and healthcare ). In investigating the experiences of respondents during the pandemic, we found that the practicebased understanding of solidarity provides a useful lens for interpreting what respondents told us about their motivations, hopes, expectations and fears regarding public health measures. Second, the concept can offer insights for the medical community generally, and medical students specifically. By investigating concrete practices of solidarity, we gained insight into instances related to public health or the management of the pandemic in which respondents felt that solidarity was lacking, thereby creating opportunities for formulating recommendations for practitioners and policymakers alike. Incidentally, this ties in with a third ambition found in some of the medical humanities literature: the call for more empirical and policy-oriented work . Last but not least, the concept of solidarity plays an increasingly important role in scholarly thinking in the humanities, the social sciences and increasingly in public health ethics and bioethics . --- METHODS This publication has been made possible by the joint work of the Solidarity in Times of a Pandemic research commons, a large, multidisciplinary research consortium set up at the beginning of the pandemic to explore people's experiences . SolPan is a large-scale qualitative comparative research study comprising interviews with residents from nine European countries . Participants were recruited through online advertisement via university websites, social media networks, convenience sampling, snowballing and purposive sampling , aiming to cover a range of demographics. Age, gender, income, employment status, education, household situation and rural or urban living area were assessed . All participants received a study information leaflet prior to the interview. Formal consent to participate was obtained orally directly before the interview. Both the consent and the subsequent interview were recorded on a digital recorder or using a video chat recorder compliant with the countries' data protection regulations. Even though interviews were held in the participating countries' official languages, all country teams used the same qualitative interview guide developed by the SolPan research commons . Interviews were conducted with the same participants in April and May 2020 and October 2020 . Participants were asked about their practices and lived experiences during the COVID-19 pandemic with the aim to assess the reasons behind those practices. Even though solidarity served as the theoretical framework for the study, we did not use this term in the interview guide to avoid socially expected answers. Instead, we asked about how participants protected themselves and others against COVID-19, how they supported others, how they accessed information they trusted, their perceptions on COVID-19-related policies and regulations and future expectations. Participants were encouraged to talk freely about their lived experiences even if answers diverged from the interview topics. Only audio, and no video material, was stored for transcription and transcripts were pseudonymised. Interviews lasted between 25 and 90 min. For data analysis, the SolPan research commons inductively developed a coding scheme that was applied to all interviews using Atlas. ti or NVivo . Interview data coded with the codes 'supporting practices', 'solidarity', and 'protecting others' was analysed in-depth by each country team in the interviews' original language. Using the concept of solidarity proposed by Prainsack and Buyx , country-specific analytic reports in English language were written, including descriptions of solidaristic practices as described in the interviews, the motivations behind those practices, perceived costs, what tier of solidarity practices accounted for as well as references to similarities and differences with individuals or groups people were solidaristic with. Moreover, attention was paid to whether and how these practices changed from April to October 2020. Those reports were then used as a basis to structure and compare findings between countries, which was done first through exploratory meetings among all coauthors and then in small analytic groups including two to three researchers from each country. Findings were then reassessed by each country team for consistency with their data. Interview excerpts were chosen in collaboration between the country teams. The consortium devised an interview key that ensures pseudonymity but allows readers to identify the country and interview phase from which the excerpt stems, which is used throughout this article. The interview identifier is provided in brackets at the end of every quotation and includes the interview phase , the country code , the initials of the researcher who conducted the interview and the interview number. --- Original research --- Patient and public involvement Patients and the public were not involved in the design phase of this study because the research project was set up at the onset of the pandemic in which co-production of research projects was difficult due to lockdowns as well as the speed in which the project needed to be set up from scratch . The interview guide for the first phase of the interviews was conceptualised by members of the SolPan consortium based on the available literature on solidarity, and based on the public discourse on solidarity in different countries. The interview guide for the second phase of interviews was informed in part by the findings of the first phase, and by priorities raised by respondents. The study findings continue to be disseminated to the participants, and to the public, in the form of blog posts, media communications and academic publications. The precondition for this dissemination was that interviewees gave their consent to being informed about the outcome of the study findings at the end of the interview. --- Findings --- Person-to-person and group-based solidarity Interviews carried out across Europe at the start of the pandemic suggest the emergence of novel forms of interpersonal and groupbased solidarity. We found that the practices composing this kind of solidarity were similar in different European countries. Most prominently they included provision of material and emotional support, which takes the form, typically, of financial aid, provision of food and basic items to those most in need , home delivery of food and other basic items and 'social' support in the form of organising telephone rotas to ensure that people who live alone are not abandoned, setting up neighbourhood WhatsApp groups to organise socially distanced on-street get-together or creating solidaristic hampers where people leave what they want and people in need can take without asking. Moreover, many interview participants described doing the groceries for elderly neighbours or contacting friends and family who live alone more frequently. This type of solidarity is often expressed through a heightened level of attention to the needs of others and the desire to do something for the community. Across the spectrum of solidaristic practices, several interesting commonalities can be traced. We noticed in data across all countries that many participants talked about their motivations for complying with public health measures to contain the pandemic as rooted in understandings of solidarity. Even if the term 'solidarity' was not always used, solidaristic reasonings were displayed in terms of making sacrifices and helping each other as a way out of the crisis. In the words of our interviewees: Following guidelines is at a cost to your own, it could be at a cost to your own business, it could be at a cost of your ability to interact with your family, with your friends, your social interactions, you know upholding the guidelines comes at a cost, but we all seem to be quite happy to do it, given that we know that the value it has to each other. Everyone dutifully does what is required of them. I notice that there is a lot of discipline, much more than you might have thought of beforehand. Of course, there is also a kind of underlying solidarity, a bit of looking out for each other. We see here not just an abstract sense of solidarity or sense of duty, but a concrete desire to protect others, especially those who are perceived to be at greater risk than our respondents considered themselves to be. This translates into a willingness to accept the costs and sacrifices to personal freedoms that go hand-in-hand with complying with containment policies. In singling out vulnerable people when sharing thoughts about why measures are adhered to, our data give empirical support to theories about the need to identify people or groups with whom one feels solidaristic in order to give substance to solidarity. Groups that were mentioned in the interviews included frontline healthcare workers, people who are not able to work from home, small business owners and those in precarious working and living conditions such as the unemployed or people with refugee status: Hopefully this crisis requires a lot of solidarity with older people, with the healthcare workers, with other workers who are most affected by that. It is like this, yes [upon being asked if the interviewee adheres to the measures]. But less out of a concern that I could become sick myself, but merely, if one does not follow it [the measures], yes, it would especially affect the generation above me that would perhaps become infected through me and, yes, it [the older generation] is clearly more in danger than I am at the moment. So, I am not scared that they [clients of the interviewee] carry something [contagious] for me that could harm me. […] it is really important to me that I don't give it to anyone who is a risk patient. And that's why one has to be careful. One never knows with whom one would have contact, if one were infected, before even knowing that one is infected. On the other hand, many respondents saw instances of other people's non-compliance to public health measures as unsolidaristic: So, we have neighbours, they party with friends every day. Which I don't find great because I then think, yes, then, firstly we will perhaps still be stuck in these lockdowns for longer when everything [the virus] breaks out again. And it could also be […] that people die, this I find so…it gets on my nerves if people do not at least try to get through this together as much as possible. […] And one day my sister, who no longer works as a nurse […] but she has now been called up to work as a nurse again through a compulsory measure and she had to sign a document to say she will be available up to 60 hours a week. And as she told me this, some friends arrived at my neighbours' house with bottles of wine and started making noise. And in that moment I was so angry […] because I thought why does my sister maybe then have to care for such idiots, I don't accept this. But yes, I don't know, such unsolidaristic behaviour really annoys me. At the same time, some of our interviewees justified certain infringements of pandemic measures on the basis of solidarity. Some participants broke the rules to support others in need of help socially or psychologically, especially during lockdowns. I went to visit him [an elderly friend living alone]. One morning I defied the law, because we were in full lockdown, but I was worried because I had not heard from him, he was not replying to the texts on our chat anymore. I knew where he lived, so like a thief in the night, slipping from corner to corner in the street, I reached the neighbourhood where he lived and I saw him in his house. 1 The neighbours' son had gone missing, they were completely panicked, and then we took care of their younger child. It is actually not allowed, but you do it anyway, because that panic is more important than […] a guideline […]. What you also do more often because of that Covid is that you take walks in your own village. It's actually very strange, you never do that otherwise and we do that now. And on such a walk we came across a man who had fallen with his walker, but we helped him up and brought him home. I sometimes make exceptions in that sense. I see that more as a kind of priority rule, you have to do things like that. […] So for me these are not measures that are taboo, but they are measures to limit risks as much as pos- --- Original research sible. Every now and then you have to do something and make an exception, I think. But not in the sense that we secretly have parties or anything, we don't. These quotations illustrate the types of reasoning that were employed in instances in which helping others in an emergency situation or during tough times were viewed as more important than the strict adherence to the lockdown rules. People were aware that, strictly speaking, they were not allowed to engage in such practices but they were willing to accept the possible consequences in order to assist others: We are staying in a student residency and a close friend of ours feels lonely. […] He's seeing a psychologist as well. And I don't know, normally we're not allowed to see him or visit him but we do invite him to dinner every day, just to give him some structure in his day. And yes, to carry his mental pressure or burden a little bit […]. Yes, to me that matters more than leaving him alone in his room, knowing that he has a hard time mentally. In other words, in several situations the willingness to act in a supportive manner manifested itself in actions with potentially significant costs for the individual, in the form of fines or other reprimands, if one were caught breaking the rules. Such instances illustrate the nuances of solidaristic actions brought to light through a practice-based definition of solidarity. These forms of support occurred primarily during the first lockdown phases of the pandemic, in which rules and guidelines provided little room for exception or justified infringements. By the time of our second round of interviews, in October 2020, many participants expressed fatigue with the pandemic situation, which corresponded with the public debate in many countries about lower social cohesion and less person-to-person solidarity. Participants also explicitly mentioned that they had not maintained some solidaristic practices that they had engaged in or observed in April 2020 because it was too difficult-for financial, social or psychological reasons. Some related the disappearance of organised solidarity initiatives to the mere fact that they were not as greatly needed as before. Many were confident that supporting initiatives and groups would swing back into action if needed. Yes, well, that's decreased now, but for the reason that the older people are now going out again themselves. Not in the old people's home, someone still does the shopping for my father, but for example for my former bosses, for whom they also did the shopping, they now go out themselves, so they no longer have so much to worry about. When the situation gets tragic again, [these practices] will appear again. To sum up, solidarity was seen as one of several motivating factors to comply with measures and to engage in practices to support others. Interestingly, regarding instances where rules and measures were seen as inefficient or unfair, not sticking to the rules was sometimes also seen as solidaristic. Non-adherence to rules that were seen as useful, however-such as wearing face masks, or keeping a physical distance to others in crowded places-was explicitly labelled unsolidaristic. Especially in the second phase of the interviews, we saw that fatigue and frustration with government action can affect people's willingness, ability and endurance to act in solidarity. This suggests that acts of solidarity also depend on opportunities and circumstances in which solidarity can flourish; the longer a difficult situation lasts, and the more people lose confidence in collective forms of solidarity, the more likely it is that solidarity at the interpersonal level will also be difficult to sustain, and the more likely it will be that people long for a transition to more collective forms of solidarity. --- The longing for collective and institutionalised solidarity Many participants engaged in reflections about how their personal practices can contribute to safeguarding the healthcare system. Van Hoyweghen and Lievevrouw show that such reflections were a key motivating factor for compliance with public health measures in Belgium. Interviewees in France also expressed gratitude for what they perceived as the continuation of institutionalised solidarity in healthcare, for example when medical care continued even in the absence of a prescription for a particular intervention: There's a lot of mutual aid stuff and also shopping for people who can't. That's good. I need injections, the nurse came, I don't even have a prescription, but she comes anyway. As they've closed the practice. It's small stuff, but it's good. In many countries, reflections of one's role in the collective realm of solidarity, and of the importance of this realm, led to concrete actions, or rather to the refraining from risky actions that might lead to injuries as an example of practice-based forms of solidarity: […] More than usual I pay attention to a healthy lifestyle […] so that I do not get ill. I would also not do any risky things right now because, I think to myself, I do not want to have to get treatment in a hospital unnecessarily. Something somebody else perhaps needs, so the space [in the hospital]. These reflections may be interpreted as signalling an understanding of the healthcare system as deeply solidaristic in nature, something that needs to be supported by individuals and government action alike. We will return to this argument in our discussion. In both rounds of interviews, participants also expressed concern and disappointment that there was not more solidarity at regional, national and international level. Many participants in all nine countries were unhappy about the support provided by their governments: for those who had lost work as a result of the pandemic, support was often seen as inadequate. During the first phase, participants were unclear how the supporting process would work: would they hear from someone about their case? When would the payments arrive? How would they make ends meet or pay bills in the meantime? Also, participants complained that support measures were implemented unequally, as some categories like irregular or even independent workers were left out from governmental support initiatives: In Switzerland, there were [political] debates concerning [supporting] the self-employed, but I'd find it also important to talk about rents, for example. Because those running costs remain, they could have been pushed out or eliminated. I am not earning anything at the moment. It is true that from a state perspective I was not earning anything before either, but they should also care for those who were not working [prior to --- Original research We often say in Ireland it is because of the lack of services, we grew out of the lack of services you see that weren't being provided for people. Unfortunately, sometimes the Government depends on us but at the same time I think it is very nice that all these people who try, you know what I mean, to do something for their neighbour or their town or their you know some little things where you are living to make your environment good. Participants criticised some expressions of solidarity that were encouraged at the institutional level as merely symbolic, tokenistic and even hypocritical, while they longed for more concrete forms of support. For example, many interviewees across the nine countries reflected on acts of clapping for carers such as frontline healthcare workers in the first weeks of the pandemic-something which was put forward by different media sources as a prime example of the upsurge of solidarity in times of a crisis. Our respondents, however, were rather critical of such expressions of support as 'acts of solidarity'. It was something that was cited by respondents as creating a sort of 'community' feeling or togetherness in a difficult time, but even respondents who participated in these national clapping initiatives did not always perceive them as being a form of solidarity, because of the low to no costs involved in showing this support, and because, in most countries, it did not translate into concrete support at the institutional-political level such as an increase in funding for hospitals and other healthcare facilities. […] To stand at the window at 7 or 8 pm and to clap […], well, you can do that. But I think this is not an expression of solidarity necessarily for the people working in the hospitals or in care homes. It is a way, an attempt, that people stay optimistic, so showing optimism. I think this is okay, it makes sense. But I would not say that it is a very strong, solidaristic measure. No, of course I think that's a nice sense of solidarity at 8pm. But when I hear it, I think 'wow they still keep it up'. Even my mother, she's a nurse, but she doesn't really think that this attention is necessary either and there was also talk of a pay rise and that's not really happening in the healthcare sector. She doesn't think that's necessary either. It's mainly the young freelancers, someone who has just started a business and has invested heavily and then suddenly can't open his store. They have more need for it. She's more like, 'We're just doing our job'. So, I hope that this [clapping] is something that is going to be longlasting and I hope that it is something that has a positive consequence for those people [e.g., care professionals] as well. If only in a pay rise or extra leave this year. All of that will cost some money too but […] I'm just very scared of how quickly we're going to be forgetting about this after the pandemic. How quickly people forget. How quickly are we going to want to go back to wanting to travel […]. The worry about forgetting what emerged as important or relevant for society in the pandemic is a concern that respondents reflected on more deeply, especially in the second round of interviews we conducted. [In the beginning] there were these efforts, we go shopping for you etc., there were many incentives from the civilian population. Where one felt that this is an act of moving closer together-there was focus on the at-risk groups […]. And then, when the first restrictions were eased, it [the sense of togetherness] was, at least in my perception […] gone quite quickly. The comfort was back in focus, this idea of everyone for themselves, […] I think that nothing will change in a sustainable way, because one is spoilt with consumerism and with luxuries, and simply every person…one doesn't want to give up the things that are comfortable. These concerns about the sustainability of the lessons learnt from the lockdowns exposed a set of nuanced understandings of institutional solidarity, sometimes expressed explicitly and sometimes implicitly. Explicit perceptions of, and expectations for, institutional solidarity included respondents discussing that individual acts of solidarity typically have relatively small impact compared with more institutionalised forms, such as an universal basic income or other forms of state social protection: Maybe the neighbours will get a little closer, at least in my small environment, but in Spain this unconditional basic income has already been introduced, which would be good, of course, if several countries could get involved in trying it out, which I would find very good in the current situation. But I think that this applause for the doctors and nurses, that is, I'm afraid it won't last long. Some interviewees expressed gratitude for state measures that provided safety nets to individuals and businesses at the beginning of the pandemic, and expected that this would lead to less societal disruption in the long-term. I know people, especially in the restaurant industry, who have benefited from them [the government measures]. Either they are partially unemployed, so they can continue to pay their rent. On the other hand, I know other businesses that are not considered to be of primary importance, like this student who had an event-organising business that didn't get anything, but, on the whole, I think people are being helped, there's a net, there's a safety net. If only by the fact that we have social security, we have health care. Solidarity, all this will mean that compared to other more liberal countries, there will be less breakage. The above excerpt underlines the perceived importance of institutionalised solidarity in the form of safety nets provided by the state in times of crisis and beyond. This was often accompanied by a strong sense of worry that an easing of restrictive measures and the gradual return to prepandemic life would open up a vacuum where solidaristic practices had been prominent during the pandemic. People want to generate even more sales and accumulate even more. [They want] to have even more luxury goods for themselves, so that they really have something in bad times. I don't think that solidarity will survive. What every individual can do, yes, okay, like me now in our house: we have a lot of elderly people here. But I was in touch with them before and I'm the kind of person who likes to approach people. I've baked, we've cooked for the people here. We've offered to shop for people. But the thing with the corporates or the rich, that is going to get worse. Much, much worse. They're going to have more turnover, they're going to have more Euros, they're going to have more Bitcoins, they're going to have more money in the banks, they're going to do more sleazy deals so they can get more money. This concern about the unsustainability of the kinds of solidarity seen during the pandemic was visible in both rounds of interviews, and in all countries. In some countries, such as Austria and Germany, respondents were explicit about what they thought was needed to hold on to some of the positive examples of societal cohesion during the pandemic, that is, more institutionalised policies of solidarity such as universal basic incomes. Respondents in other countries were less explicit about such policies, but reflected on the fact that collective solidarity would not last if big corporations, for example, are not held to higher standards and made to contribute to a more equal distribution of economic benefits and burdens in society. Institutionalised solidarity was seen as a crucial factor in mitigating against the multiple negative effects of the pandemic. Beyond the crisis, it was seen on May 9, 2024 by guest. Protected by copyright. http://mh.bmj.com/ --- Original research as an instrument to learn from and to develop policies that contribute to a stronger sense of solidarity in society while preventing a return to the prepandemic states of affairs. --- DISCUSSION A practice-focused understanding of solidarity allowed us to explore how solidarity was enacted-or not-at the individual and interpersonal level. Overall, there was a striking resonance across countries of a great deal of varied solidaristic practices in T1 with a demonstrable onset of 'solidaristic fatigue' in T2 . Our findings show that adhering to measures was seen as a matter of solidarity as long as measures were viewed as effective and fair; when people felt that solidarity was needed but did not yet exist, they enacted it in different ways at a person-to-person level. The abundance and variety of interpersonal and group-based examples of solidarity that emerged in the early weeks of the pandemic was striking. Our data show that the beginning of the pandemic provided space for extraordinary acts of solidarity, which in turn became moments in which people experienced solidarity and support in deep and sometimes challenging ways . In some cases, these experiences translated into a longing for solidaristic practices to last beyond the pandemic, with some respondents believing that this is only possible if governments step in to institutionalise policies that aid solidarity. The solidaristic practices at the person-to-person and groupbased level filled an important institutional void in a situation where formal support systems such as pandemic social security payments or support for local shops to set up an online shopping and delivery presence were yet to be devised. Our respondents seemed to have a shared understanding that individual solidaristic acts matter. In fact, when asked about their reasons for engaging in solidaristic practices, many offered deep reflections about what it means to be a member of society who is aware of the consequences of her actions or inactions, and who cares about the people around her. Such a tacit shared understanding may at least partly be due to the fact that the countries included in this study all have solidaristic healthcare and social security systems, which may have fostered an implicit sense of solidarity. As mentioned in the beginning, frequent appeals on the part of politicians and other public figures to citizens' solidarity were more overt reminders of the indispensability of solidaristic action in a crisis. Forms of assistance such as emotional and mental health support to people suffering from isolation, financial aid, donation and/or delivery of primary goods to those in need, are practices that emerged on individual or smaller organisations' initiative, rather than as response to institutional calls. These practices often emerged to respond to a lack of institutional support practices , which were sometimes explicitly criticised as insufficient or inadequate. In this sense, the findings contribute to the medical humanities' long-standing concern with '[…] influencing […] practitioners to refine and complexify their judgements […] in clinical situations, based on a deep and complex understanding […] of illness, suffering, personhood, and related issues' by providing insights into human experiences of the pandemic, and how people view themselves in relationship to others, the healthcare system and the state. Our research illustrates that individual notions of solidarity can contextually and contingently lead to action, inaction or feelings of discontent, especially when other people's actions are perceived as unsolidaristic. This nuanced picture of solidarity can provide a useful starting point for future research, transitions and teachings in the medical humanities and beyond. If we acknowledge that solidarity is needed for resilience in a public health crisis, then we can say that for it to endure it requires institutional support. As West-Oram argues, '[e]ffective public health programmes cannot rely solely on private individuals always engaging in interpersonal solidarity in an optimal fashion', they also need institutionalised solidarityin the sense of strong healthcare systems and other institutions and policies that satisfy people's basic needs and support the well-being of people and communities. Placing emphasis-and focusing financial and other resources-on institutions and practices of support for people who are disadvantaged would help to reduce inequalities and thus support social cohesion. It would also, we argue, bolster people's ability and willingness to enact solidarity with others. Importantly, it would help to reverse some of the loss of trust that governments in many countries have caused by demanding solidarity of citizens while engaging in unsolidaristic actions themselves, such as vaccine nationalism, or protecting industry interests over the needs of workers. According to West-Oram , a 'government which fails to engage in solidarity with its constituents, makes an implicit statement about the nature of the relationship between itself and the rest of society'. In light of this, we strongly encourage public health and government officials to institutionalise practices of solidarity more systematically. Such manifestations and policies of solidarity might include, but are not limited to, policies introducing a universal basic income, strategies to award and recognise the hard work of healthcare workers in the pandemic either in monetary or structural terms or sharing resources such as vaccines with countries with less access . The opportunities for solidifying new forms of solidarity at the institutional level are numerous, but, as the definition of solidarity by Prainsack and Buyx suggests, solidarity comes at a cost; whether or not new inroads in the pursuit of institutionalised solidarity will be made therefore depends on policymakers' willingness to accept the costs, for example, the costs associated with sharing healthcare resources with other countries, and to explain the need for such costs to society at large. Certainly, the data presented in this article suggest that many of the people we interviewed are willing to act in solidarity and that they are ready and even eager to see more political and social transformation as a result of the COVID-19 crisis. Based on the interview data, we contend that there are several risks of not taking seriously the longing for more institutionalised forms of solidarity. For one, there is a risk that solidarity becomes tokenistic; if encouraged by officials, individuals may consider tokenistic practices such as clapping as an 'easy' or a less tiresome and costly substitute to other and arguably more impactful acts of solidarity. Collectively, these may also be seen as a tokenistic substitute for more decisive government action, for instance, paying healthcare workers more. A second risk is that people's sense of community may erode over time; we saw this in our data to a certain extent in the second phase of our interviews where the former sense of 'being in this together' was partly replaced by a recognition of societal divisions, for instance, between 'masked' and 'unmasked' individuals . Such divisions may especially affect those individuals who were particularly solidaristic in their practices and/or who carried greater costs of the pandemic. It is also vital at those stages of pandemic --- Original research management where public health measures are being relaxed; institutionalised community-level solidarity scaffolds may in those cases be a bridge between state-level measures and an individualistic rhetoric of personal responsibility. For instance, community-level outdoor sports programmes or subsidised online grocery shopping may just be two such measures that would allow people to continue to adhere to safety measures once public health ones are relaxed. We offer a number of observations from our research on why the medical humanities play a crucial role in addressing complex problems in health crises, and how their methodological approaches may be adapted in light of specific challenges of pandemics such as lockdowns. One of the core ambitions of the medical humanities is to shed light on the often overlooked lived experience of health and illness. The very nature of a pandemic means that the number of people affected by the experience of disease and crisis increases exponentially as anyone, and anywhere, can or will be affected. Methodological approaches need to be adjusted accordingly. We accounted for this specific feature of a pandemic health crisis by pursuing a large-scale, comparative, qualitative approach that embedded the study in transnational contexts. Additionally, our study provides ground for calls to offer a more integrated disciplinary approach that links the humanities and social sciences . The study illustrates what such an integrated disciplinary approach can look like and underlines the fruits that transdisciplinary and transboundary research collaboration can carry . Last but not least, we argue that the medical humanities have much to gain from directing their attention to individual health issues, and to health or illness situations that are experienced at a collective level, thus harnessing the previously mentioned emphasis on societal relationships in the humanities and social sciences . The analysis of patient experiences through a collective lens such as the solidarity approach offers unique insights to understandings of the individual self and the collective community in a way that sheds light on health and social inequalities. By focusing on solidarity and solidarity practice, we have shown how the medical humanities might adapt to address poignant social justice issues without losing the ambition of uncovering the individual experience of disease, crisis and vulnerability. We propose three advances which, in our view, are essential for research endeavours in the medical humanities that aim to map out existing social justice issues, and help uncover collective experiences of diseases and health crises: a strong position for empirical and practice-based research alongside more normative approaches; the confidence to make recommendations for practice and policymaking alike and the pursuit of cross-national and multidisciplinary research collaborations in order to provide context to empirical findings and conceptual understandings of the situated nuances of social justice issues. Given the size of the SolPan research consortium, we cannot emphasise this last point enough: the challenge of analysing data from nine countries was fruitfully addressed by a continuous, open and trustworthy exchange between team members, leaders and the whole consortium. With 40+ participating academics at different stages of their careers, we were able to draw on a vast array of skills, knowledge and training in different disciplines of the humanities and social sciences , thus making it possible to probe our data from different angles. --- Limitations While our cross-national, in-depth and longitudinal research bears crucial academic and policy insights, it also exhibits limitations. Although considerable at close to 700 interviews spread across a range of sociodemographics and 9 different countries, our research cannot be considered representative of the citizens of any particular nation or group of nations. Likewise, because of its non-random sample design it cannot be generalised. The qualitative design afforded us the opportunity to probe into people's less obvious views and less overt practices more so than broader survey designs were able to. A second limitation is that while authors had on-the-ground exposure to public health messages and media discourses as they lived in the countries in which they did the research, for the purposes of this paper and due to the lens adopted we did not conduct a full public discourse analysis, which may have given further insights into tier 3 solidarity. A final limitation of the current article is that while we were sensitive to variations in our findings across countries, we did not engage in a systematic cross-country comparison. --- CONCLUSION This article demonstrates that a practice-based understanding of solidarity can help shed light on a frequently used, but often poorly defined, concept. Practices of solidarity during the COVID-19 pandemic were abundant in our sample from nine European countries. Many respondents across all investigated countries told us that they felt the pandemic had exacerbated previously existing health and social inequalities and that governments were not doing enough to mitigate these developments. Specific societal groups were highlighted as being particularly vulnerable to the negative knock-on effects of isolation and stay-at-home measures, namely people who live alone, children who cannot go to childcare or schools, healthcare workers who have to put themselves and their families at risk without adequate remuneration or recognition, the unemployed or selfemployed and people who cannot work from home due to the nature of their work, to name but a few. The interview guide and the conceptual lens of solidarity provided a useful means for us to map out these social justice issues, and they brought to light a longing for more institutionalised forms of solidarity. The study suggests that the medical humanities continue to play an important role, and that they can take on a more prominent role in uncovering collective experiences of disease or health crises. The pandemic reminded people, policymakers and scientists alike that crises of large societal relevance can only be addressed when everybody contributes their partat least in democratic countries. Investigating people's lived experiences through the concept of solidarity sheds a light on the motivations and limits of this endeavour. We offer three take-away messages for public health practitioners and policymakers: solidarity can be an important motivating factor for compliance as well as non-compliance to public health measures, that is, to say that a nuanced picture about compliance emerges in which people sometimes disregard public health measures in order to act solidaristically towards particularly vulnerable groups. Compliance and solidarity are thus not equivalent ; different forms of solidarity, at different tiers, emerge during a public health crisis; it is important that public health officials and policymakers recognise and, where possible, support these forms of solidarity rather than leave them unrecognised or, even worse, act against them by, for example, pursuing policies that are overly focused on personal rather --- Original research than collective responsibility; the longing for institutionalised solidarity needs to be taken seriously and transformed into concrete institutional manifestations of solidarity. Our respondents expressed a strong wish not to return to life as it was pre-COVID-19, but rather think more sensibly and sustainably about the activities, actions and futures of societies. Contributors All authors were involved in the planning, conception and design of the manuscript. The first author led the writing and the review process. All coauthors were involved in data acquisition and contributed to data analysis. All authors contributed to the original draft of the manuscript. All coauthors read and approved the final version of the manuscript. KK accepts full responsibility for the finished work, had access to the data, and controlled the decision to publish. Competing interests None declared. --- Patient and public involvement Patients and the public were not involved in the design phase of this study because the research project was set up at the onset of the pandemic in which co-production of research projects was difficult due to lockdowns. The interview guide for the first phase of the interviews was conceptualised by members of the SolPan consortium based on the available literature on solidarity, and based on the public discourse on solidarity in different countries. The interview guide for the second phase of interviews was informed in part by the findings of the first phase, and by priorities raised by respondents. The study findings continue to be disseminated to the participants, and to the public, in the form of blog posts, media communications, and academic publications. The precondition for this dissemination was that interviewees gave their consent to being informed about the outcome of the study findings at the end of the interview. --- Patient consent for publication Not applicable. Ethics approval Several institutional ethics committees approved this study, including the University of Vienna , the Technical University of Munich , KU Leuven and UCD . Participants gave informed consent to participate in the study before taking part. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available on reasonable request. Data are stored in a secure location. All members of the consortium have access to the data. Access to the data is restricted to the members of the consortium to ensure the confidentiality and anonymity of the research participants. --- Supplemental material This content has been supplied by the author. It has not been vetted by BMJ Publishing Group Limited and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations , and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise. This article is made freely available for personal use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may download and print the article for any lawful, non-commercial purpose provided that all copyright notices and trade marks are retained.

Calls for solidarity have been an ubiquitous feature in the response to the COVID-19 pandemic. However, we know little about how people have thought of and practised solidarity in their everyday lives since the beginning of the pandemic. What role does solidarity play in people's lives, how does it relate to COVID-19 public health measures and how has it changed in different phases of the pandemic? Situated within the medical humanities at the intersection of philosophy, bioethics, social sciences and policy studies, this article explores how the practice-based understanding of solidarity formulated by Prainsack and Buyx helps shed light on these questions. Drawing on 643 qualitative interviews carried out in two phases (April-May 2020 and October 2020) in nine European countries (Austria,

Introduction Everybody will die-death matters to everyone. Hong Kong is experiencing rapid population aging [1]. In 2016, 30% of the total population was aged 55 or above, and this figure is expected to reach over 40% by 2050 [2,3]. There has been active discussion in recent years about the concept of advance care planning. Advance care planning is a process that enables patients to express their preferences regarding end-of-life care, and it enables family members and healthcare workers to understand patients' preferences and to make decisions on the behalf of patients when they are unable to do so [4]. Advance care planning preferences can be indicated in advance in the form of an advance directive [5]. An advance directive is a written statement that allows a person to indicate the form of health care he or she would like to receive in the future when he or she is no longer competent [6]. Many Western countries have already passed laws for AD. For example, the United Kingdom passed the Mental Capacity Act in 2005, which provides a legal framework for introducing advance decisions to refuse treatment [7]. In 1991, the United States passed the Patient Self-Determination Act, which requires all state-funded hospitals to have a policy on living wills and advise patients of their right to execute an advance directive [8]. Death is still a taboo subject that is difficult to openly discuss in Asian cultures. In traditional Chinese culture, mentioning death is sensitive and should be avoided [9,10]. Advance directives have not been legislated in Hong Kong presently. Advance care plans and advance directives were seldom discussed among healthcare professionals or the public in Hong Kong until 2006, when the Law Reform Commission recommended promoting the concept of advance directive through non-legislative means [11]. While there is no specific legislation for advance care plans or advance directives in Hong Kong, it does not mean that people cannot make an advance directive. Under the common law framework, people can establish their end-of-life care wishes in advance. A valid and applicable advance directive has legal status, and family members cannot override it [12]. Although there is a growing interest in advance care planning in Hong Kong, the studies of advance care planning in Hong Kong are limited. Many studies were conducted among elders in a nursing home or hospital setting by medical practitioners in Hong Kong [13][14][15]. For example, Chu et al. conducted a survey in 140 nursing homes in Hong Kong and found that despite the fact that many of them did not understand the idea of an advance care plan or advance directive, 88% of them would prefer to have an advance care plan or advance directive after they had been explained to them [13]. However, one of the major problems of conducting studies in a nursing home or hospital setting is that the respondents or the target samples will be ill or older people [14,15]. Chung et al. and Pang et al. have tried to conduct telephone surveys in Hong Kong [11,16]. Both studies found that respondents were mostly unaware of advance care planning and advance directives. Two studies also reported differences in the preference for using advance care planning. The study by Pang et al. found that 78% of people would use advance care planning after researchers explained the terms to them, and younger people and those with secondary education or above had a greater chance of adopting advance care planning [16]. The study by Chung et al. found that only 60% of people would use advance care planning after having it explained to them during the interviews, and they found that age and education level were not related to the preference for using advance care planning [11]. Telephone surveys, although less expensive than face-to-face surveys, have limitations, especially in Hong Kong. Time constraints are one of the disadvantages of telephone interview surveys. Some potential interviewees might be reluctant to participate in the survey because they fear it would take a long time. Therefore, the questions used in telephone surveys are generally short and simple. Furthermore, the quality of the collected answers is questionable because when researchers reach out to people at home, they are often engaging in other activities, such as eating dinner or watching television. There are also some unique issues to the telephone surveys in Hong Kong. For example, the sampling lists of telephone surveys are often fixed-line telephone numbers; however, in the 21st century, when mobile phones are popular, many households do not have a fixed-line telephone number. It is also not feasible to use mobile phone numbers as a sampling list-as mobile phone numbers in Hong Kong are not registered with real names, many people in Hong Kong have more than one mobile phone number, and the number of mobile phone numbers in use will not be proportionate to Hong Kong's population. While telephone surveys are convenient and inexpensive, the limitations of telephone surveys have become increasingly apparent as landline telephones have fallen out of fashion. Although the cost will be higher, community-based sample surveys are preferable to telephone surveys for many social researchers because the questions in community-based sample surveys can be more detailed and the investigators can be on-site to ensure that respondents answer the questions seriously. However, because discussing death is taboo in Chinese society, studying death in a community setting in Hong Kong is difficult. Such research is unlikely to be popular with communities, such as conservative town councilors or homeowners. The concept of a 'good death' has emerged in Hong Kong over the past decade. Luk et al. have defined that a 'good death' means people have choice and control over where death occurs and who is present with them at the end [17]. Therefore, having the option of dying in place or in a familiar environment and of having the company of family members is important. In Japan, the government has promoted dying in place and terminal home care over the past decade, especially in rural areas [18][19][20][21][22][23]. However, in Hong Kong, death at home or dying in place is basically impossible due to high residential and population density. The majority of Hong Kong's population die in hospital. According to Luk et al., this is because 'people may fear depreciation of property value if the elderly die at home' [17]. Furthermore, inappropriate admissions to hospital are common in Hong Kong. Almost all older patients with terminal diseases or irreversible chronic illnesses die in hospitals, as they are rarely referred to palliative care services [17]. As for the willingness to die at home, Chung et al. found that 68% of people would still be unwilling to die at home if they could get medical assistance at home. More than 90% are unwilling to die at home without medical assistance at home [11]. As most of Hong Kong's residents will eventually die in hospital, people need to have a plan for a 'good death'-deciding how to die , where to die , and who to share the final journey with . Having an awareness of advance care planning is a good start to having a 'good death'. Given that advance care planning is a new concept that was only recently introduced in Hong Kong and that most of the previous studies in Hong Kong were conducted in hospital or elderly home settings, it is necessary to conduct a study asking for community-dwelling older adults' views on advance care planning. While not all the older people in the community are patients, results from community settings can provide a different angle to results collected from a nursing home or hospital setting. By asking older adults' views on advance care planning in the community, we can better understand what medical concerns affect advance care planning, how to promote advance care planning, and what the older adults are concerned about when they decide whether to use advance care planning. The purpose of this study was to investigate the factors that influence the advance care planning opinions of community-dwelling older adults. Three research questions were formed: 1. What are the demographic factors that influence the preference of using advance care planning? 2. What are the important medical treatment factors that influence the preference of using advance care planning? 3. What are the important decision-making factors that influence the preference of using advance care planning? --- Materials and Methods --- Selection of Area Kwun Tong town center was purposely selected to carry out this study as Kwun Tong has the most extensive aging population in Hong Kong. Furthermore, Kwun Tong is one of the post-war new towns developed in the 1970s under the governorship of Murray MacLehose [24]. According to the latest census in 2016, 210,145 older people were aged 55 or above in Kwun Tong. In the residential area selected for this study, 8501 people were aged 55 or above [3]. --- Sampling The targeted respondents were Chinese people living in the Kwun Tong town center aged 55 or above. With the assistance of town councilors, 2446 households were randomly selected within the sampling frame. All of the households with someone aged 55 or above were counted as targeted households and the inhabitant was asked if they would like to be interviewed. If there were no responses at the first visit, two more visits at different times and dates would be arranged; if there was still no answer, the household would be listed as a non-contact. If there was more than one eligible older adult in one household, the 'next birthday method' was used to sample one respondent. Of the 2446 households, 1089 households were able to be contacted after three attempts . Of the 1089 households who were able to be contacted, 683 were identified as having eligible residents , and 282 of the 683 were willing to participate, yielding a response rate 41.3% for the eligible households in this research. --- Measurements Basic demographic information was obtained from each respondent, including age, religious belief, and place of birth. They were also asked about their basic health status . This study did not ask for either personal or household income due to privacy concerns. Then, respondents were asked whether they would use advance care planning, whether they would prepare for death, and whether they had received any death education. An explanation of advance care planning was provided in case the respondents were unaware of it. Four statements related to medical treatments and four statements on decision-making were also given: 1. I will insist on receiving treatment even it is painful 2. I will terminate treatment to maintain life quality 3. I want to use drugs and other means to alleviate physical pain 4. I want to receive mental support 5. I want to discuss my situation with the medical staff 6. I want to discuss my death decision with my family beforehand 7. If the decision made by my family contradicts my wishes, I will insist on my wishes 8. If I cannot decide, I will trust family rather than the doctor All questions were dichotomous questions in order to make the questions more manageable for older adults and to avoid triggering any negative feelings about death from the respondents. Since death is a taboo subject in Hong Kong's society, this study avoided asking too many specific questions so as not to trigger any bad feelings from the respondents. These questions were carefully selected according to different literature. A pilot test was also conducted on 20 older people to ensure the questions were easy to understand. --- Analysis This was a cross-sectional descriptive study. The data was then analyzed using statistical software SPSS 25. Demographic data were combined for ease of analysis. For example, health status was recoded into yes and no. Hong Kong has freedom of religion; different religions exist in Hong Kong. If we break them down, the data will not be enough for analysis. Therefore, it was decided to recode them as 'has religious beliefs' and 'no religious beliefs'. The education level was also recoded as 'received secondary or above' and 'did not receive secondary or above'. Using secondary school as the boundary was based on work from Pang et al., who found that people who did not receive secondary education were less likely to use advance care planning [16]. Pang et al. also found that, because of the previous education system implemented in China and Hong Kong, there was only a small number of tertiary education recipients, the compulsory education in Hong Kong in the 1960s was only six years, and many people could not attend secondary school [24]. Not all of the respondents answered all the questions. Missing data would not be replaced or edited as all variables were nominal data after recording. Basic descriptive statistics, including the mean and standard deviation, were then obtained by using SPSS. To examine the different factors influencing advance care planning use, the Chi-square test was used for independent samples. After that, a multivariable logistic regression was used to find out which characteristics remain significant after controlling for covariates. All characteristics with significant p value in the chi-square test were included as a full model. The enter method would be used. Then, non-significant variables would be removed from the model one by one, starting from the highest p value, until all variables remained significant. The final model would be reported. The Hosmer-Lemeshow goodness of fit test was used to check the model fit. If the p value of the Hosmer-Lemeshow goodness of fit test is smaller than 0.05, the model should be rejected. While stepwise regression is a popular data-mining tool that uses statistical significance to select the explanatory variables to be used in a multiple-regression model, the stepwise method would not be used in this study because the fundamental problem with stepwise regression is that some real explanatory variables that have causal effects on the dependent variable may happen to not be statistically significant, whereas nuisance variables may be coincidentally significant [25]. Instead of using software to eliminate data, using substantive knowledge to guide variable selection is more important and reliable [25]. --- Ethics All participants gave their informed consent for inclusion before they participated in the study. The research was approved by the Research Ethics Committee of the authors' institution and was conducted according to the guidelines of the Declaration of Helsinki. --- Results --- Basic Information about the Respondents A total of 138 males and 144 females were enrolled. The ethnicity of all respondents was Chinese. Their mean age was 72.7 years old and their ages ranged from 55 to 93 years old. A total of 156 respondents had a long-term illness and 26 were disabled. In this study, 55.3% of the respondents had a religious belief; only 21.2% of respondents were born in Hong Kong. Only 13.5% of respondents had heard of advance care planning before the survey . For those that had heard of advance care planning before the survey, 63.2% of them had discovered it through the Internet. Among all respondents, only 48 respondents would consider setting up an advance care planning, after it had been explained to them . This study found that while respondents had prepared for death, only 20 respondents had attended a life and death course or talk . --- Demographic Characteristics and Advance Care Planning The study showed no association between advance care planning and gender . The study showed no association between advance care planning and religious belief . For education level, the study showed no association with advance care planning . With an aging population in Hong Kong, people generally have a longer life expectancy. This study divided respondents into two groups according to age: '55-69 and '70 or above'. The reason for using 70 as a cut-off was because the mean age in this study was 72.7. There was a significant correlation between the age and advance care planning , suggesting that people in the younger group had a higher chance of using advance care planning than those in the older group . Using an independent sample t-test also obtained a similar result, as the mean age of advance care planning favorers was 69.8 , and 73.4 for advance care planning nonfavorers . In terms of place of birth, the study showed a significant correlation between the place of birth and advance care planning , suggesting people born in Hong Kong were more likely to use an advance care planning . --- Health Status and Advance Care Planning While the study showed no association between advance care planning and disability , there was a significant correlation between long-term illness and advance care planning , suggesting that almost 86.5% of respondents with long-term illness had no plan to use advance care planning . --- Life and Death Education and Advance Care Planning Death education is not popular in Hong Kong as death is sensitive subject to talk about. In this study, only 20 respondents had attended a life and death course. However, this study reported that there was a significant correlation between life and death courses and advance care planning , suggesting that people who had received life and death education were more likely to report a preference for using an advance care planning than those who had not attended life and death course or talk . The study also reported a significant correlation between death preparation and advance care planning . --- Medical Treatment, Decision Making and Advance Care Planning In order to understand how to promote advance care planning in Hong Kong, this study also looked at what medical considerations are associated with advance care planning . In terms of treatment, the study found that those who wanted to use advance care planning in the future would have less desire to receive treatment if it would be painful . The reason needs to be studied in the future as the study found that terminating treatment to maintain life quality was not associated with the use of advance care planning . There was also no significant correlation between 'use of drugs and other means to alleviate physical pain' and advance care planning . The study reported a significant correlation between mental support and advance care planning . For decision making, the study reported that there was no significant correlation between 'discussing the situation with medical staff' and advance care planning . However, the study found that respondents who would like to use advance care planning would be more likely to discuss their death decision with their family beforehand . Respondents who prefer advance care planning would also be more likely to insist on having wills . The role of doctors was also important as the study reported a significant correlation between 'trusting a family rather than the doctor' and advance care planning . --- Multivariable Logistic Regression Multivariable logistic regression was used to understand which characteristics remain significant after controlling for covariates. All characteristics with a significant p value in the chi-square test were included as a full model. The enter method was used. Then, non-significant variables would be removed from the model one by one, starting from the highest p value, until all variables remained significant. One of the reasons behind the unfit full model was the small sample size of advance care planning favorers . The sample is not large enough to include 10 variables in the model simultaneously. Furthermore, gradually eliminating variables from the regression model would make it possible to find a reduced model that best explains the data. The final model reported that five out of 10 variables that were significant in the chi square test remained significant in the regression test. They were 'illness', 'prepared for death', 'want to receive mental support', 'if the decision contradicts mine, I will insist on your own' and if I cannot decide, I will trust family rather than the doctor'. This model was fit as the Hosmer-Lemeshow test was not significant , the model therefore should be accepted. --- Discussion This study was one of the first to ask questions about the advance care planning preferences of community-dwelling older adults in Hong Kong, using a residential sampling method. While only dichotomous questions were asked to avoid triggering any negative feelings about death from the respondents-a taboo and ominous topic in the Chinese cultural context. The results provided valuable insights to help promote advance care planning in Hong Kong. This study showed that only 17% of the respondents would like to use advance care planning, even after being given an explanation of the meaning of advance care planning. Previous studies conducted by Luk et al. and Pang et al. reported that 88% and 76% of the respondents were in favor of having an advance care planning respectively [15,16], the result of this study was far lower. Community-dwelling older people may not have considered end-of-life arrangements yet due to their age and health. A telephone survey study by Chung et al. also suggested this point, as their study found that only 14.3% of the sample had heard of advance care planning before the interviews, and just 60.9% of the sample expressed that they would be willing to make an advance care plan after being given an explanation of what advance care planning was during the interviews [11]. The study by Chung et al. was slightly different from this study because the sample of their study was made up of people that were over 30 years old. However, the results of their study were still lower than the data obtained in hospitals or nursing homes. In terms of age, this study found that a greater percentage of the younger people in the sample would like to use advance care planning . Older adults without chronic illnesses were also more likely to use advance care planning . The result from the multivariable logistic regression also reported the same, as it found that the likelihood of using advance care planning in the 'without illness group' was 28% lower than in the 'illness group' . The results of this study echoed the study by Pang et al. [16]. Given that the mean age of advance care planning favorers was significantly younger than advance care planning non-favorers, it is natural to think that the younger generation without illness or disability is likely to choose advance care planning in order to have their own will realized. In the sample of this study, 66.7% of respondents aged 70 or older had long-term illnesses, which was significantly higher than the group of 55-69-year-olds . If we exclude the group of 55-69 year-olds and only analyze the group of people that are 70 years old or older, the data indicate that only 6.3% of advance care planning favorers had long-term illnesses; for advance care planning non-favorers, up to 93.8% had long-term illnesses . The results of this study are very different from previous studies. Previous studies have shown that older adults strongly favor advance care planning, but these studies were conducted in hospitals or nursing homes, and many of the interviewees were dying patients. For instance, the studies of Luk et al. and Pang et al. were conducted in the hospital and nursing home settings; this might be the reason for the completely different results [15,16]. Older adults receiving treatment in hospitals or nursing homes may be advised on or informed about advance care planning by medical professionals. Older adults facing terminal illnesses must also consider end-of-life arrangements, and they might take advance care planning as an option based on the advice of medical professionals. Therefore, the results obtained in hospitals and nursing homes will differ from the research done in a residential setting. While the results of this study are distinct from previous studies conducted in noncommunity-dwelling settings, the results reflect two factors that affect the understanding and awareness of advance care planning. The first is the promotion of death education, and the second is the openness and information acceptance of the respondents. The results of this study implied that death education should be promoted in Hong Kong, as the results suggested that most older adults living in non-hospital or nursing home settings were not ready for death or had never attended any life and death education. A Chinese saying goes, 'death and life have their determined appointments; riches and honors depend upon heaven'. Older adults with chronic illnesses may feel that life and death are determined by destiny, so they might not pay much attention to death preparation. Since it is taboo to talk about death publicly in Chinese society, if there is a lack of promotion or public education by medical professionals, the community-dwelling older adults may naturally not understand advance care planning or even consider using it. This is one of the reasons why older-aged respondents with chronic illnesses surprisingly tended to be advance care planning non-favorers in this research, compared to previous studies that were conducted in hospitals or nursing homes, where patients would have chances to receive information about advance care planning. Therefore, this study recommends that more death education should be promoted, so that people will have the appropriate knowledge and emotional preparedness to face their illnesses, as well as illnesses of family members and friends that may be expected or unexpected. The results also indicated that death education could promote advance care planning, as the results showed that the percentage of willingness to use advance care planning in those who had attended a life and death course or talk was higher than the willingness of those that had not . Those who had prepared for death were also more willing to use advance care planning . The result from the multivariable logistic regression also reported that the odds of using advance care planning in the 'prepared for death' group was 4.94 times higher than those were not . For the openness and information acceptance of the respondents, young and healthy older adults may have more time to and channels through which they can receive information, such as newspapers and the Internet. Given that public discussion of death is taboo in Hong Kong, and advance care planning and advance directives, as the introduction of this article points out, are not separately enacted as a law in Hong Kong, patients need to use advance care planning and advance directives through other common law frameworks [11]. Therefore, the government rarely promotes advance care planning in public broadcasts, such as television and radio. At present, most discussions on advance care planning rely on the public promotion carried out by patient organizations and social welfare agencies or presentations given to dying patients in medical institutions by medical staff, such as hospitals. For community-dwelling older people, this study asked the advance care planning favorers where they first had heard of advance care planning; 63.2% had discovered it through the Internet, 15.8% from traditional press, another 15.8% from medical professionals, and 5.3% from family members and friends . As a result, the Internet plays a vital role in spreading this new end-of-life planning concept. The role of the Internet may explain why the group of those aged 70 years old or above was less willing to use advance care planning. Unlike other countries, the Internet penetration rate of the elderly in Hong Kong is relatively low. According to the Census and Statistics Department, the Internet penetration rate for persons aged between 10 and 54 was close to 100% in 2016, but for persons aged between 55 and 64 years it was 87.7%; for persons aged 65 or above the penetration rate was only 44% [26]. As the Internet is not popular among the elderly, this will reduce their exposure to information. If we compare the study of Chung et al., this conjecture may be true, because the study of Chung et al., which included young people over 30 years old, reported that more people were willing to use advance care planning. Furthermore, since the government has not publicly promoted advance care planning using traditional media, older people seem to have less accessibility to advance care planning information; this might make them advance care planning non-favorers due to a lack of understanding or misunderstanding. This study also found that the difference in birthplace also has a great effect on the results. For the group who would use advance care planning, the proportion of Hong Kongborn was higher than the group that would not use advance care planning. This is probably related to Hong Kong's social and political history. After the Second World War, a civil war broke out in China; many mainland Chinese inhabitants fled to Hong Kong. Many of them gave birth to the next generation in Hong Kong. This study found that the place of birth and age were associated at the significant level , with only 26.7% of the group of those aged 70 years old or older having been born in Hong Kong. For the group aged 55 to 69, 73.3% were born in Hong Kong. As Hong Kong was a British colony at that time, the education system was the British system, and most of the schools were run by either Anglican or Catholic churches. These baby boomers were born in Hong Kong and received education locally, they were therefore relatively open-minded, and many of them even accepted the Christian faith. In other words, with the influence of Western education and civilization, the baby boomers in Hong Kong not only have more channels through which to learn about health information but also have less Chinese cultural identity than the pre-war generation [26][27][28]. Previous studies have shown that people born in Hong Kong generally have a more Western and open way of thinking than people from China [28][29][30]. It may be possible that they are less likely to treat death as taboo and more likely to accept advance care planning. Moreover, the previous studies found that social-economic backgrounds such as sex, religion, or education level are not related to the use of advance care planning in Hong Kong [11,15]. Therefore, it is suggested that future research should focus on the relationship between advance care planning and social status or cultural backgrounds. Apart from age, birthplace, and life and death education, the results also found that medical care and social support were related to the use of advance care planning. The results suggested that the medical care and social support for end-of-life patients should be improved, as when the respondents were asked the medical questions which related to advance care planning, 27.5% of the respondents who were willing to make advance care planning expressed that they would not want to receive treatment if the treatment would be painful. However, the exact reason for this needs to be studied in the future as this study reported that neither 'terminate treatment to maintain life quality' or 'use drugs and other means to alleviate physical pain' results were statistically significant. The logistic regression also reported that the results for 'insist on receiving treatment even it is painful' were not significant after controlling for covariates. The study also reported that 20.2% of the respondents willing to make advance care planning expressed that they would like to receive mental support, which was higher than those who said no to advance care planning . The result from the multivariable logistic regression also reported that mental support was important in explaining the use of advance care planning as it remained significant after controlling for covariates. Those who would like to receive mental support were 8.1 times more likely to use advance care planning than those who would not want to receive mental support . Based on the results, we can see that medical care and social support for end-of-life patients are important. Therefore, the government should consider improving the medical care and support services for patients. Without them, there could be difficulties in achieving some of the patients' expressed preferences and wishes [31]. The current study also reported that respondents willing to make an advance care plan were more likely to want to discuss their death decision with family in advance. However, the results also showed that 25% of the advance care planning favorers would insist on their own death decision if the decision contradicted with the wish of their family members. Furthermore, 28.8% of the advance care planning favorers said they would trust their doctor rather than family members if the respondents could not make a decision, regardless of whether this was due to mental or physical health reasons or just disagreements with family members. The percentage was higher than the percentage of people that would trust their family members . The multivariable logistic regression also found that these two were the most important for the respondents, as the results reported that the group of people that would insist on their decision being carried out rather than the decision of the family members was 5.33 times more likely to use advance care planning than the group that would trust their family members' decision . The results also reported that the group that would trust the doctor's decision was 75% less likely to use advance care planning than the group that would trust their family members' decision . The regression results imply two important issues. Firstly, older adults' empowerment is a critical part of the decision to use advance care planning. The government and medical professionals should think about how to promote patients' rights in the future. Secondly, this study showed the importance of healthcare professionals providing advice to patients and their family members, especially when the patients are more likely to insist on their own will being carried out when using advance care planning. While the government and the hospital authority should continue to promote advance care planning to patients and in the public community; there should be more education among healthcare professionals regarding advance care planning so as to improve their knowledge and the communication skills required to handle such issues. This is very important as healthcare professionals are on the frontline in terms of informing the public of their medical options [32]. They also play a crucial role in promoting advance care planning, so more education among healthcare professionals is needed. --- Limitations and Future Research This study has several limitations. While the sample of this research was collected in a residential area in Hong Kong with a random sampling method, this study was a crosssectional design and was exploratory in nature , thus limiting the ability to identify substantial implications. Causality can only be inferred cautiously. Furthermore, the possibility of type 1 error could not be excluded in this study due to the low frequency of advance care planning favorers. This study has tried to recruit the elderly as much as possible. However, because the interviewees were recruited through sampling, it was impossible to know how many people had heard of advance care before the interview. This was different from snowball sampling. Although very few of the interviewees had heard of an advance care plan yet said they would make one, this does not mean that this research is worthless. This research not only reflects the attitude of the interviewees towards advance care planning, but also proves, as Chung et al. found, that the public awareness of advance care planning is low [11]. It should also be noted that due to the legal issue related to the Privacy Ordinance of Hong Kong, it is difficult to obtain all the names and personal details of all residential addresses to generate the sampling frame of all residents in Hong Kong. In other words, it was not possible to do a random sample study of all of Hong Kong [15]. As a result, the location of this research is selected purposely, because Kwun Tong is a district with the largest elderly population in Hong Kong [2,3], and there were open-minded local councilors willing to help and provide the list of all residential addresses in their wards to generate a sampling frame. Although this research was only conducted in one district in Hong Kong, this study was an attempt to survey the unknown waters of the use of advance care planning of the community-dwelling older adults in Hong Kong. When reading this article, readers should also refer to previous studies carried out in other settings in Hong Kong. For future research, researchers should consider increasing the number of samples when studying advance care planning in a community setting. This can reduce the probability of type 1 error. In addition, Hong Kong's residents' awareness of and intention to use advance care planning are low comparing with previous studies in Western countries. It is generally believed that education level and religious belief will affect the results of this type of research, because previous studies found that the favorer rate of advance care planning in the United Kingdom and the United States is higher than that of Hong Kong [33,34]. Whereas Poland and Italy have very low rates and are both have Catholicism as the main religion [34][35][36]. However, in Hong Kong, this study and some previous quantitative studies found that education level and religious beliefs had no significant relationship with preparations for death or advance care planning [11,15]. This may be related to the higher education level of Hong Kong's residents and Hong Kong's freedom of religion, as there is no religion playing a dominant role in Hong Kong. In addition to education and religious beliefs, future research can also focus on the cultural aspect to study whether culture influences the preparation for death and the use of advance care planning, as previous and current research in Hong Kong reported that education and religious beliefs were not associated with advance care planning. Furthermore, as most previous studies were conducted by medical professionals, they rarely involved cultural issues. Yet, culture is often an important indicator of understanding the public's acceptance of the policy from a policy-making perspective. --- Data Availability Statement: The data are not publicly available due to privacy and ethics approval approved by the Institutional Review Board. --- Declaration of Helsinki and was approved by the Ethics Committee of the University of Edinburgh. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

1) Background: Hong Kong is experiencing population aging, but there is little research on advance care planning. This research asks for community-dwelling older adults' views on advance care planning in order to provide a different angle to the results collected from nursing homes and hospitals. (2) Methods: The targeted respondents were people aged 55 or above. A total of 282 questionnaires were collected using the random sampling method. Respondents were asked whether they would make an advance care plan, whether they would prepare for their death, and whether they had received any death education; they were also given eight statements related to treatments and decision making. (3) Results: The study found that only 17% of the respondents would like to use advance care planning, even after it was explained to them. Advance care planning favorers would be more likely to insist on having wills and would be more likely to trust doctors rather than family members. (4) Conclusions: The results also suggested that the medical care and social support for end-of-life patients should be improved. The results also showed the importance of medical professionals as they showed that respondents wanted advice on end-of-life decision-making from medical professionals.

Background The growth and development of children is directly related to their current and future health status. The height of children is an important indicator of growth and development [1]. Height is a multifactorial characteristic which is affected by genetic and environmental factors [2]. Early childhood low height-for-age is associated with a series of irreversible adverse outcomes, including athletic development retardation, cognitive impairment, and poor academic performance [3]. Therefore, it is important to identify the environmental factors associated with height so as to improve the overall health status of children. The average height of Chinese children has increased in the past two decades [4], possibly related to the improvement of individual factors, such as protein intake [5], family income [6,7] and maternal education level [8,9]. These improvements of individual factors resulted from China's economic and social development through increased food supply, better housing conditions, and improved health care services [10]. Chinese government has made great efforts to fill the gap of maternal and child health inequalities between urban and rural areas by explicit policy of ensuring safe birth in health facilities, huge investment in human resources to improve the number of licensed doctors, reducing financial barriers and providing childbirth subsidies, and many other public health programs [11]. However, the rural/urban disparities that concerning health services still exist [12,13]. A study [14] evaluated the effects of China's economic reforms on the growth of children, and showed an increase in the average height of children in both rural and urban areas, while this increase in urban areas was five times that in rural areas. In developing counties like China, urbanization has been found to improve child health outcomes such as lower under-five mortality and lower undernutrition rate [15,16], through increasing access to health care services, education resources, and safe water supply [17]. Smith et al. [18] also indicated that in developing counties urban children were more likely to have well-nourished mothers, which meant better prenatal and birthing care, better feeding practices and greater use of health services for preventive and curative care, result in improved growth and lower morbidity. However, whether and how urbanization is associated with children's physical development in China remain unclear. Understanding the relationship between community-level contextual factors can help explaining the disparity in children's physical development between regions and inform the approaches for improving child's health. In this study, we investigated the effects of urbanization index on child height among Chinese children aged 5-18 years old from the China Health and Nutrition Survey in 2011. --- Methods --- Study population This study used secondary data from the 2011 dataset of the CHNS, which was a large survey conducted in nine provinces and three mega-cities in China. A multistage, stratified sampling design was conducted to ensure that CHNS provided a fair representation of urban and rural areas. Using sampling strategy, two cities and four counties per province were selected based on income . Within cities, two urban and two suburban communities were randomly selected based on urbanicity. Within counties, one community in the capital city and three rural villages were randomly chosen, also based on urbanicity. Twenty households per community were then randomly selected for participation. Survey protocols, instruments, and the process of obtaining informed consent for this study were approved by the institutional review committees of the University of North Carolina at Chapel Hill as well as the National Institute for Nutrition and Health, which is affiliated with the China Center for Disease Control and Prevention. Participants provided written, informed consent. Data, documentation, and details on sampling, representativeness, and validity of data can be accessed through the Carolina Population Center website: . A total of 1712 children between 5 and 18 years old from 290 communities was enrolled in the 2011 dataset. We excluded participants with major medical conditions , and had missing information on main variables . Finally our study included 1606 observations in 272 communities. --- Outcome variable Physical height of child Height was measured without shoes using a portable stadiometer and recorded to the nearest tenth of a centimeter. The height for age Z score , which is an indicator standardized for age and sex, was calculated to evaluate the height levels of children and adolescents. Higher HAZ indicates better height growth. WHO Growth Reference 2007 was used. This reference is a reconstruction of the 1977 National Center for Health Statistics / WHO reference, and it is recommended by WHO as a growth reference for children and adolescents aged 5-19 years [19]. SAS macro was used for calculation as WHO recommended . --- Community level variable Urbanization index Urbanization level of each community/village was measured using urbanization index. The urbanization index was developed by Jones-Smith and Popkin [20] using in the CHNS. It was defined as a 12-component index, capturing community-level physical, social, cultural, and economic environments designed and validated for the CHNS. Urbanicity Scale is used for measurement of the 12 component . Each component was given a score from 0 to 10, and then weighted equally in the overall index and added together for an overall maximum possible score of 120. Higher scores indicate greater urbanization. This scale has been validated for content validity, reliability , and stability [20]. We represented urbanization by quintiles of an urbanization index reflecting population size and density and community infrastructure. --- Individual level variables --- Maternal education CHNS classified maternal education level as follows: no school , primary school , junior middle school , senior middle school , middle technical or vocational school , college , and graduate school . Maternal education level was then categorized into 3 groups: low education; middle education ; high education. --- Family income In CHNS, household income was evaluated by household income per capita inflated to 2011. With the equalized household income values, we created four break points to define income quintiles , with the 1st quintile set as the baseline. --- Percentage of energy intake from protein Dietary intake was assessed using three consecutive in-person 24-h recalls randomly allocated to begin between Monday and Sunday, in combination with a household food inventory conducted over the same 3-day period. Dietary data in children was based on a parent-assisted self-report or self-report questionnaire. Food models and picture aids were used by trained interviewers to assist with estimating portion sizes. For dishes prepared at home, recipe components were taken from the household food inventory, and portion sizes were based on the proportion of the dish reportedly consumed by the participant. Energy and nutrient intake levels for dietary data were calculated using the China Food Composition Table. Details of the process can be accessed through the Carolina Population Center website: . --- Statistical analysis Descriptive statistics on individual demographic variables were calculated. Continuous variables were presented as means and standard deviations . Categorical variables were expressed as percentages. The present study focused on cross-sectional analysis of CHNS data in 2011. We applied multilevel models and statistical software SPSS 21.0 to conduct a two-level regression analysis. We examined the relationship between urbanization index and child height after controlling for individual variables. The modelling was done in four steps: Model 1 examined only within-group homogeneity. Model 2 included the community-level contextual variable . In model 3, the individual-level explanatory variables were added to Model 2. These individual variables consisted of child gender, age, maternal education level, maternal height, family income per capita, and percentage of energy intake from protein. Then in Model 4, the urbanization index was modified to 12 components of the urbanization index. The individual variables were the same as in Model 3. Finally, subgroup analysis was conducted to explore the heterogeneous effects by different age groups . In each model, the inter-class correlation was calculated as the ratio of between-community variance to total variance in children's heights. --- Results Demographic and anthropometric measurements are shown in Table 2. In total, 1606 children were included. Among them, 91.47% were Han ethnicity. The average percentage of energy intake from protein was . The average height-for-age Z score was -0.19 ± 1.24. The proportion of height-for-age Z score below 1 was 85.24%. For the maternal education level, the percentage of 'no school, primary school and middle school' was 80.45%. Both family income per capita and urbanization index were categorized by quintiles . Table 3 shows the results of multilevel models. Model 1 constructed an empty model, because the intercept of random effect was statistically significant , The inter-class correlation coefficient in Model 1 was 0.26, suggesting between-community heterogeneity in children's height. Model 2 shows the fixed effects results for community-level factors. Urbanization was significantly associated with an increase of height-for-age Z score. Compared with 1st quintile, children living in a community with higher urbanization levels reported higher height-for-age Z scores . Model 3 added individual and community variables. Boys, higher maternal height, higher maternal education levels, higher family income and higher --- Discussion In the current study, we found that urbanization index was associated with child height. Among the 12 components of urbanization index, 'education' was associated with child height in multilevel models controlling for clustering by community. Additionally, 'population density' and 'housing' were associated with height of adolescents aged 13-18 years. Generally, our results were consistent with previous studies. Smith et al. [18] reported that urban children generally have better nutritional status than rural children in developing countries. Eckert et al. [21] summarized that urbanization was associated with a lower risk of undernutrition of children. In China, with the rapid economic growth, the inequalities between urban and rural areas was obvious. The effect of urbanization on child health reflected the inequality between urban and rural areas [22]. We observed a significant association between child height and the 'education' segment of the urbanization component. Some studies have documented a positive impact of parental education on child height [8,9]. However, less is known about the effect of community mean education relating to child height. As better education levels often correlate with better family income, people with better education level may choose to live in better communities with improved health-related infrastructure, as well as better educational institutions for their child. Those parents with better education level may respond better to community health educational and health promotion efforts, and may pay more attention to their children's growth and development. Therefore, these children may have healthier lifestyle habits, diet habits, and health care. Therefore, improving a population's education level, as well as strengthening community health services, may have important practical and theoretical significance. The influence of urbanization on height seemed different in younger and elder age groups. In the present study, we divided all the participants into two age groups, 5-12 years and 13-18 years. Because most of the Chinese children go to middle-school at the age of 13, their education environment and life styles might be quite different from children under 12 who were commonly in primary school. According to the result, children aged 13-18 years were more likely affected by urbanization, with three statistically significant factors . This result was similar to previous studies [23]. Generally, elder children acquire more physical, emotional, cognitive, social and economic resources that have effect on health [24]. But the pathways of population density and housing influencing child height need further study. Higher population density and better housing reflect higher urbanization level, that may help elder children to experience less poverty, better social environment and health services, and lead to a better physical development. Regarding influence factors at the individual level, gender [25], family income [6,7], protein intake [5] maternal education [8,9], and maternal height [26] were previously demonstrated to be associated with child height. These findings were consistent with our findings. Because the present study is a cross-sectional design, these factors may provide important reference points for making health policy at the individual level. There are some major strengths of this study. First, the urbanization index is a more comprehensive composite index, based on the specific study region . It is typically applied to assess the socioeconomic environment of a community in China. Using the urbanization index may produce better findings regarding the relationship between community socioeconomic conditions and child height. Second, in most previous studies, a single-level model was commonly used which ignored the inter-correlation of children within same community. We overcame these limitations by using a multilevel model. A multilevel design can help researchers to examine relevant community-level characteristics that may be associated with child height, and may provide evidence to identify disadvantaged communities and help children living there. This study also has some limitations. First, as we all know, the CHNS is a longitudinal structure data with several waves, but we only used the data of 2011. The main consideration was that Chinese society has experienced rapid urbanization during the recent decade, by the time we did the data analysis, the newest data was the data in 2011, which reflect the latest condition of Chinese Society. Second, though multi-level model was meaningful for the current data, the sample size of each community was small. Large-scaled study is needed in further research. Third, the study was a cross-sectional design, which cannot explain the causal relationships between child height and urbanization. Further prospective study design was needed. Forth, individual factors which may be associated with child height were limited in the current study, and more individual factors are needed to be involved in further studies, for example genetic factors, excises, etc. --- Conclusion Community-level contextual factors were significantly associated with child height, especially for elder children, in a representative national population in China. Our findings points to the role of contextual factors that generate differences between regions in shaping the distribution of child physical health outcomes. Our study suggests that public health programs and policies for child's physical development may need to combine individual-centered strategies and also approaches aimed at changing residential environments. --- Availability of data and materials Data, documentation, and details on sampling, representativeness, and validity of data can be accessed through the Carolina Population Center website: . --- Abbreviations CHNS: China Health and Nutrition Survey; ICC: The inter-class correlation.; SD: Standard deviations Authors' contributions YZ analysed and interpreted the data, drafted and revised the manuscript. HW analysed the data and revised the manuscript. XW, ML and YW1 review and revised the manuscript. YW2 conceptualised the study and review the manuscript. HZ conceptualised and designed the study, edited, revised and critically reviewed the manuscript. All authors read and approved the final manuscript. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Recent economic development in China has been accompanied by well-documented health inequalities between regions. The impact of individual factors on child height has been widely studied, but the influence of community-level factors has not yet been fully studied. Methods: The cross-sectional data of 1606 Chinese children aged 5-18 years from the China Health and Nutrition Survey 2011 were used. Multilevel analysis was used to examine the association of community factors (using urbanization index) with child height. Child height was measured following standardized procedures, and heightfor-age Z scores were calculated as outcome variables. Datasets were presented at two levels: community variable (Level-2) was an urbanization index which is a composite score summarizing 12 community-level contextual factors. Individual variables (Level-1) were child gender, ethnicity, percentage of energy intake from protein, maternal height, maternal education level, and family income. Results: Urbanization index was associated with child height. Among the 12 community-level factors, 'education' were positively associated with child height. Additionally, stratified analyses by age showed that 'population density' and 'housing' were positively significantly associated with the height of elder children (13-18 years). At the individual level, male sex, higher maternal height, higher maternal education levels, higher family income, and higher percentage of energy intake from protein, were significantly positively associated with child height. Conclusions: Our findings point to the role of contextual factors that generate differences between regions in shaping the distribution of child physical health outcomes. Our study suggests that public health programs and policies for child's physical development may need to combine individual-centered strategies and also approaches aimed at changing residential environments.

alcohol . Alcohol use is a major contributor to morbidity and mortality worldwide, causing 3.3 million deaths each year . Initiation of alcohol use during early adolescence is an important predictor of alcohol-related motor vehicle crashes , suicide, neurocognitive impairment , and alcohol dependence/abuse at later ages . Furthermore, early use of alcohol and binge drinking are common among Latin American adolescents. In 2014, approximately 70% of Argentine adolescents aged 13 to 17 years had ever consumed alcohol, with a lower prevalence in Mexico . Prevalence in these countries is similar to other Latin American countries , 2010) showing that underage drinking is an important public health problem in this region. Previous studies have identified numerous factors that influence the risk of alcohol use among adolescents, including parents and peers , school and work , socioeconomic status , other drug use , risk taking and sensation seeking , and drinking attitudes , among others . Media and marketing represent another set of risk factors . Alcohol advertising, such as direct advertising on television, movie theaters, and magazines has been associated with increased adolescent drinking , and distribution of alcohol branded merchandise is associated with future alcohol use . Experimental studies have shown that alcohol portrayals in films directly influence actual alcohol intake, presumably by imitation and cue-reactivity processes . Finally, cross-sectional and longitudinal associations have been reported for the relationship between exposure to alcohol use in films and alcohol use and binge drinking among adolescents in the United States, England and Germany . That alcohol companies pay for alcohol brand placement in films is important, because it means that film alcohol depictions could be reduced if payments were restricted, as was the case with smoking in films . The studies mentioned above have been conducted in high income European countries and in the United States. We were unable to find studies assessing the relationship between film exposure to alcohol and alcohol use among Latin-American adolescents. In Latin American countries, like in most Western nations, film exposure to alcohol for adolescents comes primarily from Hollywood films . However, Latin-American adolescents may not have the same level of viewership or exposure. Furthermore, they may not react to the exposure the same way adolescents do in other Western countries. For example, studies of US adolescents show stronger associations between exposure to film smoking portrayals and adolescent smoking behavior among white compared to Black adolescents . Black adolescents appear responsive to film smoking, but only to smoking by Black actors or films oriented towards Black cultural demographics . Similarly, the lack of cultural congruence between film characters and Latin American adolescents may dampen film social influence effects. Therefore, we conducted this study to examine exposure of Latin American adolescents to AUF and its association with alcohol use. --- Methods --- Study sample and procedure The study was conducted among students in Argentina and Mexico middle schools. In Argentina, during May and June 2014, a convenience sample of 33 schools from three large cities participated in the study , with public schools identified by the Ministry of Health and Ministry of Education and private schools identified through personal contacts . In Mexico, in February and March 2015 60 public middle schools were selected using a stratified random sampling design in Mexico's three largest cities . Sampling strata were based on: a) high and low levels of socioeconomic marginalization using 2010 census data for the census tracts where schools were located b) city-specific tertiles of retail establishment density in school census tracts . Within each of these six strata, three or four schools were randomly selected with selection probability proportional to the number of students in each school and a quota of 20 schools per city. When a school did not agree to participate, a replacement school was selected randomly from the same stratum. Passive consent was requested from parents or caretakers, and students signed an active consent form. Study protocols were approved by NIH-certified human subjects research boards in Argentina and Mexico . --- Development of Questionnaire Measures The aim of the survey was to assess media/marketing exposures and their association with adolescent risk behaviors. The questionnaire included items used in surveys for adolescents previously implemented in Argentina, Mexico, and in the US . Items in English were translated and reviewed by Spanish-speaking research staff, and the final survey instrument was pilot tested with students both countries to ensure adequate understanding of questions, instructions and confidentiality statements. The self-administered questionnaires were completed in the classroom under the supervision of trained research staff. Surveys included questions about attitudes that predict the onset of alcohol use, alcohol use, exposure to AUF and pertinent covariates. --- Assessment of alcohol attitudes and behavior Alcohol susceptibility was measured among those who never drank, using items that captured future intent to drink during the next year and resistance to peer offers, with four response options ranging from "definitively yes" to "definitively no". The susceptibility construct has been validated as a predictor of smoking onset in longitudinal studies of adolescents, and also predicts the onset of drinking in longitudinal studies of adolescents . To be consistent with how the measure is coded for smoking , participants who stated "definitely not" to both questions were coded as "nonsusceptible never-drinkers", the rest being coded as "susceptible never-drinkers". A respondent was considered to be a current drinker if he or she reported any number greater than zero to the question "During the past 30 days, on how many days did you drink alcohol?" We assessed binge drinking by asking if he or she had ever drunk more than 4 or 5 drinks in a row, with the quantity used depending on gender of the student . --- Exposure to alcohol measurement Films chosen for this study included films released in Argentina between 2009 and 2013 and listed by the Argentinean National Institute of Cinema and Visual Arts amongst the top 100 revenue-grossing films for the year released. The top 100 films for Mexico were listed by the Mexican Institute of Cinematography , for the years from 2010 to 2014, because data collection took place one year after Argentina. To estimate exposure to AUF, we used methods validated for measuring exposure to film smoking by the Dartmouth Media Research Laboratory . Adolescents' exposure to films was assessed by randomly selecting 50 film titles for each participant from the total film sample, with participants indicating which films they had seen. Thus, each adolescent questionnaire contained a unique sub-sample of film titles . For each film, depictions of alcohol were timed when there was real or implied use of an alcoholic beverage by one or more characters, including purchases and occasions when alcoholic beverages were clearly in the possession of a character. All alcohol use and implied use was timed in seconds from the moment the alcohol appeared on screen. Empty alcoholic beverage containers and those displayed but not implied as being consumed were not timed as alcohol use. To evaluate inter-rater reliability for the US films, a random sample of 10% of films was coded by two coders yielding kappa of 0.76 for alcohol time depictions. These statistics represent the overall reliability for all films coded by the DMRL. Due to the smaller sample size of Mexican and Argentine films, 20% were double coded, yielding Cohen's kappa's of 0.74 in Mexico; and 0.76 in Argentina. Film alcohol exposure was determined by: 1. summing the seconds of alcohol exposure across all films the adolescent reported having seen; 2.dividing seconds of alcohol use seen by the total seconds of film alcohol exposure across all 50 films in the participantś unique list; 3. multiplying the proportion in step 2 by the total seconds of alcohol use across the full list of films for that country. Exposure to film alcohol use consisted of a continuous variable, scaled in hours of exposure for Figure 1, then scaled as a standardized score for Figure 2, then classified into quartiles, based on the distribution in each country for use in logistic regression. --- Covariates Covariates included age, sex, parents' years of formal education , parenting style, access to media, peer friend drinking and sensation seeking . Parent drinking was not assessed because it was considered a sensitive question by school personnel, and furthermore has not been found to be particularly influential in our prior studies of media use and drinking behaviors . --- Statistical Analysis All data analyses were conducted with Stata version v13 . Local scatterplot smoothing was used to graphically represent the crude relationship between exposure to AUF and alcohol use, binge drinking and alcohol susceptibility among never drinkers for each country. To compare the dose-response curves, we standardized exposure to AUF for each country so that the lowest value was 0 and the highest was 1 after recoding outliers in the 95 th percentile that otherwise substantially skewed the exposure distribution. Univariate linear regression models were used to compare continuous variables and logistic regression models to compare categorical variables, between countries, in both models random intercepts for schools were used. Multilevel logistic regression models were used to assess the relationship between exposure to AUF and current drinking, binge drinking and alcohol susceptibility among never drinkers. All models included the covariates listed above. Age and indexed variables were entered as continuous variables. Adjusted ORs were estimated across country-specific quartiles of AUF exposure with quartile 1 as the referent category. We also tested for an AUF-country interaction. Multilevel logistic regression models using exposure to AUF as a continuous variable instead of quartiles were also estimated separately in a sensitivity analysis. For this, we entered exposure to AUF measured in hours of exposure. The findings were similar in direction and statistical significance for both types of variables. --- Results --- Description of the film samples The Argentina analytic film sample had 427 films, of which 47 were produced in Argentina and 380 in the US; the whole sample depicted 24.74 hours of alcohol use. The Mexican analytic sample of films contained 446 films, 46 of which were produced in Mexico and 400 in the US; that sample depicted 24.85 hours of alcohol use. --- Description of the population samples Of all eligible students in Argentina , 1.3% had parents who refused participation, 4.5% declined participation, and 11% were absent the day of the survey, for a final sample of 3172 students . In Mexico the school participation rate was 92% . Of eligible students in Mexico, 5% of parents declined permission, 0.02% of students refused to participate, and 11% students were absent the day of the survey, for a final sample of 10,123 students . The overall mean age of participants was 12.5 years , 51.9% were male; other characteristics are described in Table 1. The prevalence of current drinking in the total sample was 19.8%; among never drinkers 28.5% were susceptible to drinking, and the prevalence of binge drinking was 10.9%. There were many statistically significant differences between the Argentinean and Mexican samples. In Argentina, more boys participated than in Mexico , and students from Argentina were approximately four months older, and their parents had more education and tended to have a more authoritative parenting style compared to Mexican students ; means for sensation were significantly higher among Argentinean adolescents. Alcohol consumption was also higher among Argentine than Mexican students . --- Exposure to AUF and its crude association with drinking The median estimated exposure to AUF was 6.0 hours in adolescents from Argentina and 5.9 hours in those from Mexico. Figure 1 shows the distributions for the estimated exposure to alcohol use in films. Both histograms were positively skewed, with some adolescents having exposures that ranged upwards of 15 hours. Figure 2 shows the unadjusted association between a standardized measure of exposure to AUF and current drinking, binge drinking, and alcohol susceptibility for adolescents of both countries. For the most part, the curves show a dose-response association between exposure to film alcohol depictions and prevalence of the three outcomes studied. Any deviation from a linear dose-response is restricted to adolescents with very high exposure, as has been described in past studies of film smoking . --- Multivariate analysis Table 2 shows that in both countries, and after controlling by age, sex, parental education, friends who drink, sensation seeking, parenting style and media access, adolescents with higher exposure to AUF were significantly more likely to be current drinkers , to have engaged in binge drinking , and to have a drink during the next year . The ORs comparing quartiles 2 and 3 with quartile 1 were also statistically significant, with increasing odds ratios across quartiles that mirrored the linear dose-response relation illustrated in Figure 2. To determine whether the relationship between exposure to AUF and alcohol use varied by country, interactions between quartiles of exposure to AUF and country were also examined. No significant interaction was detected for any outcome . Adolescents from Argentina tended to be more likely engage in binge drinking and to be more susceptible to drink in the next year in comparison with Mexican youth independent of the exposure to AUF. --- Discussion Our study is the first to confirm the association between AUF and drinking behavior in adolescents from Latin America. Our results are consistent with studies conducted in other countries . Although our study suggested different mean levels of exposure to AUF in Argentina and Mexico than for adolescents from the United States , or Germany we found a similar dose-response association between exposure to AUF and alcohol use, engagement in binge drinking and alcohol susceptibility. Some authors suggest that it is difficult to attribute substance use to film depictions of the substance because youth at risk for alcohol consumption may self-select to watch films that contain more alcohol portrayals than youth who are not at risk. These associations were independent of many potential confounders that included peer drinking, sensation seeking, and other risk factors that could promote both higher alcohol use and higher likelihood to seek out films with drinking. The fact that the association between exposure to AUF and drinking persists after adjusting for covariates that are plausible confounders of media exposure effects, including sensation seeking , access to media , and parenting styles supports the idea that exposure to AUF is an independent social risk factor. This study has several limitations which should be acknowledged. First, data on exposure to AUF and alcohol use were all cross-sectional; therefore, we cannot provide information on the temporal sequence of events. Second, while alcohol susceptibility is a significant, unique predictor of change in alcohol consumption among adolescents in the US, longitudinal research is needed to confirm if exposure to AUF has a similar effect on Latin-American teenagers. Third, the samples may not be representative of the entire Argentinean or Mexican populations, as schools were not randomly selected. Therefore, the observation that the Argentinian sample had higher risk for drinking and higher drinking rates could be a function of our sampling and not necessarily a reflection of how these countries compare vis-à-vis adolescent drinking. Finally, we examined exposure to only one type of entertainment media. We are not able to estimate how much overlap there is between exposure to AUF and exposure to alcohol use in television through programming or advertisements; additional research is needed to clarify the contributions of these sources. Despite its limitations, this study confirms that the association between exposure to AUF and uptake drinking found in other countries exists in Latin America. Taken together with multiple cross-sectional and longitudinal studies published to date, the results strongly suggest that steps to decrease exposure of adolescents to AUF could prevent some young people from transitioning to problem drinking. The combined evidence implicates movies as a disease vector that begins in one country and may affect alcohol use, not only among US adolescents, but also in most other western nations, where Hollywood movies are a staple in the media diets of children and adolescents. As mentioned above, alcohol companies pay to have alcohol placed in these movies, so they represent a form of marketing. Moreover, alcohol use is common in movies rated as appropriate for teens . What should be done to affect this vector? Firstly, we know that the most effective way to address the film alcohol depictions would be to prohibit product placement. We know this because of our experience with cigarettes. Prohibition of cigarette brand placements that were imposed by the 1998 Master Settlement Agreement between major cigarette manufacturers and the US State Attorneys General heralded an exponential decline in cigarette brand placements, along with a substantial immediate decline in tobacco screen time . This suggests that similar restrictions on alcohol brand placement would also lower screen time and, therefore, youth exposure to this risk factor. More progress could be made in this area if the US Centers for Disease Control and Prevention began to emphasize movie alcohol as part of their program to address youth exposure to alcohol advertising. The CDC could post annual reports on movie alcohol that included titles and companies, just as they do for smoking in movies . Secondly, the Motion Picture Association of America could take movie alcohol more seriously by conferring an adult rating for any depictions of youth or young adult drinking, partying, or drunkenness. This would move the most objectionable alcohol depictions out of youth-targeted movies, which have much higher youth viewership compared to adult-rated movies . In summary, youth exposure to alcohol depictions in movies is widespread and consistently linked with problematic alcohol use. It is time to do something about it. Crude association between exposure to alcohol in popular films and alcohol use susceptibility, current alcohol use, and binge drinking.

Objectives-To assess whether exposure to alcohol use in films (AUF) is associated with alcohol use susceptibility, current alcohol use, and binge drinking in adolescents from two Latin American countries. Methods-Cross-sectional study with 13,295 middle school students from public and private schools in Mexico and Argentina. Exposure to alcohol use in over 400 contemporary top box office films in each country was estimated using previously validated methods. Outcome measures included current drinking (i.e., any drink in the last 30 days), ever binge-drinking (i.e., more than 4 or 5 drinks in a row for females and males, respectively) and, among never drinkers, alcohol susceptibility (i.e., might drink in the next year or accept a drink from a friend). Multivariate models were adjusted for age, sex, parental education, peer drinking, sensation seeking, parenting style and media access. Results-Mean age was 12.5 years (SD = 0.7) and the prevalence of alcohol consumption and binge drinking was 19.8% and 10.9% respectively. Mean exposure to alcohol from the film sample was about 7 hours in both countries. Adjusted models indicated independent dose-response associations between higher levels of exposure to AUF and all outcomes; the adjusted odds ratios (OR) comparing quartiles 4 and 1 1.99 (95% CI 1.73 -2.30) for current drinking, 1.68 (1.39 -2.02) for binge drinking, and 1.80 (1.52 -2.12) for alcohol susceptibility. Compared to Mexican

Methods Participants. COVID-19. This sample was recruited via an online questionnaire that was set up as part of a larger ongoing international multisite project , during the most stringent lockdown restrictions . The inclusion criterion was pregnant women when completing the survey. Two participants were excluded due to a pattern of random responses; hence, the final sample consisted of 1419 women. No other exclusion criteria was used. From the final 1419 participants, 747 had some missing data. These were generally pairwise-deleted 21 ; yet for the mediation analyses, listwise deletion was performed 38 . Recruitment was performed through midwifery centers , word of mouth , social media , and others . The Ethics Review Board of Tilburg University [RP2019-143] approved the study, which was conducted according to the Declaration of Helsinki. Participants provided informed consent before completing the survey and were compensated with 10€. --- Pre-COVID-19. A sample of 1439 Dutch pregnant women, recruited from March 2017-September 2018, constituted our comparison group. The inclusion criterion was pregnant women when completing the survey. This sample was recruited as part of an online questionnaire study investigating prenatal mental health treatment uptake 8 and screening for participants for an intervention study 39 . An additional number of women were recruited but excluded from the study for not signing the informed consent , not completing the questionnaire and for complicated pregnancies needing specialized treatment . Ninety-five percent of women were recruited via 2 ultrasound scan centers, while the rest via midwifery centers , a lactation practice , and social media . Women received an invitation email and upon providing informed consent, completed an online questionnaire. Ethical approval was obtained from the Faculty of Social Sciences of the Radboud University [ECSW2016-1710 -42]. COVID-19 lockdown in The Netherlands. The Dutch lockdown in April/May 2020 entailed the closing of schools, day-care centers, restaurants, bars, gyms and other contact professions such as hairdressers, while shops were allowed to stay open, provided clients kept at a safe interpersonal distance . No curfew was implemented. Moreover, people were encouraged to work from home as much as possible and limit outings and social visits. Healthcare checkup visits, for example to a midwife, were unaccompanied and shortened, or delivered online or via telephone. --- Instruments Psychological distress. State-Trait Anxiety Inventory 40 was used to assess anxiety symptoms. Here, we focused only on the state dimension, assessing anxiety feelings in the present with 20 items on a 4-point Likert scale 41 . Total scores vary between 20-80, with scores ≥ 40 indicating clinically relevant symptoms of anxiety 42 . Internal consistency was excellent in the pre-COVID and the COVID samples, as previously reported 43 . Edinburgh Depression Scale 44 was used to assess depressive symptoms. This is a 10-item self-report questionnaire, on a 4-point Likert scale 45 . Total scores range between 0-30, with scores ≥ 13 indicating clinically relevant depressive symptoms during pregnancy 46 . Consistent with previous evidence 47 , internal consistency was sound in the pre-COVID and the COVID sample . 48 was used to assess COVID-19-related experiences. This questionnaire is a comprehensive assessment of the impact of COVID-19 on one's life; COVID-19 exposure and symptoms, healthcare, finances, social support, community, coping, emotions, mental and physical health, addictions, and demographics. Here, we focused on perceived support during the COVID-19 crisis and related stress. Support systems. Three support systems were investigated: partner, social network and prenatal healthcare support. Partner and social network support were each assessed through two slider-items from 0.0-10.0, with higher scores indicating more support: "How well were you supported by your partner/social network prior to the COVID-19 outbreak?" for support prior to the pandemic and "How well are you now supported by your partner/social network?" for support during the pandemic. To calculate the partner/social support change, the past reported support was subtracted from the present. As an indication of women's social network composition, we also asked from whom they receive social support. Prenatal healthcare support was assessed with a 3-point Likert scale item "How well are you currently supported by your prenatal healthcare professionals?" with 1 = very well supported, 2 = neutral and 3 = not very well supported. The item was reverse coded in the analyses, such that higher scores consistently indicated better support. Changes in prenatal healthcare support was assessed on a 5-point Likert scale item "Has the support you receive from your primary antenatal healthcare provider changed due to the COVID-19 outbreak?", where: 1 = badly worsened, 2 = slightly worsened, 3 = no change, 4 = slightly improved, 5 = greatly improved. Healthcare support and changes were used as two separate items in the analysis, differently from the composite scores of partner/social support. Moreover, we asked participants who the main prenatal healthcare providers were. The complete instrument can be retrieved online https:// osf. io/ uqhcv/. --- COVID-19 experiences. COVID-19 and Perinatal Experiences COVID-19-related worries. Worries in relation to COVID-19 were assessed with 8 slider-items from 0.0-10.0, with higher values indicating more worries . We conducted a factor analysis and principal component analysis to identify the latent factors underlying the data . Three components were extracted: general COVID-19 worries , social support worries , and work and finances-related . Each component was computed by averaging the items loading on each component, with higher scores indicating more worries. --- Statistical analysis. Descriptive statistics summarize the characteristics of the two samples . Summary statistics and the correlations amongst the variables are reported in Table 2. For descriptive purposes, we conducted paired sample t-tests assessed perceived support changes during the COVID-19 crisis. Moreover, we also performed repeated measures ANOVA to test mean differences between COVID-19-related worries components: general, social, and work and financial. To answer the first research question, independent sample t-tests assessed mean differences of anxiety and depression scores between the pre-COVID-19 and COVID-19 samples. Further, to answer the second research question, namely whether better support reduced COVID-19-related worries, and in turn psychological distress, a parallel mediation analysis was performed separately for each support system. The mediation analyses were conducted with 5000 sample bootstrapping 49 . All analyses were also performed with education and gestational week as control variables, due to statistically significant differences Table 1. Demographic characteristics of the samples. M = mean, SD = standard deviation, t = t-test, X 2 = Chisquare, p = significance level set at < .05. Income information was not available in the pre-COVID sample. Education = low: primary education or secondary pre-vocational education, medium: secondary education or vocational education, high: Bachelor or Master's degree or higher . *11% of respondents in the COVID sample indicated that they preferred not to answer the question on annual household income. --- Pre-COVID sample COVID sample --- Test statistic M or N M or N Age in years www.nature.com/scientificreports/ between the two samples on these characteristics, but results remained unchanged. The data analyses were conducted with IBM SPSS Statistics 23 50 and PROCESS 38 . --- Results Preliminary analyses. Given the variations in anxiety and depression across different trimesters of pregnancy 51 , we assessed differences in symptoms of anxiety and depression between pregnant women in the second trimester of pregnancy, given the prevalence discrepancy of this group in the pre-COVID sample , compared to the COVID sample . The results on this subgroup confirmed those presented for the whole group, suggesting significantly higher [t and anxiety in the COVID-19 compared to the pre-COVID sample. Note that while women with complicated pregnancies were excluded from the pre-COVID sample, in the COVID-19 sample, all pregnant women were included, and here 14% reported high-risk pregnancies. We re-ran the t-test and Chi-square analyses excluding high-risk pregnancy women and obtained comparable results. Hence, we retained all women in the COVID-19 sample to maximize the sample size. Furthermore, due to the high correlation between anxiety and depression in the COVID-19 sample [r = 0.78, p < 0.001], we computed a composite score of psychological distress as the mean of centered anxiety and depression variables, to use in further analyses. worries , confirming our hypothesis that better support leads to fewer worries, which in turn have a smaller effect on psychological distress. An illustration of our results is provided in Fig. 3, whereas the details of the statistical results of the mediation analyses are reported in Table 3. --- Support systems, COVID --- Discussion Pregnant women reported significantly more symptoms of anxiety and depression during the COVID-19 crisis, compared to pregnant women prior to the pandemic. More than 1 in 10 women experienced clinically relevant symptoms of depression, and nearly 1 in 2 women experienced clinically relevant symptoms of anxiety. Three types of COVID-19-related worries were identified: general worries about COVID-19, worries about work and finances, and worries about social support, and all led to heightened psychological distress. Note that worries were moderately associated to anxiety symptoms, with correlation coefficients ranging between 0.38 and 0.55, suggesting that although related, the COVID-19 worries are also distinct from anxiety symptoms. Importantly, having more support was related to fewer worries and consequently less psychological distress. Finally, women reported an increase in partner support during the pandemic, compared to pre-pandemic, but a decrease in social support. More than half of pregnant women also reported a decline in healthcare support. The results on mental health worsening during pregnancy, at the peak of the Dutch COVID-19 pandemic first lockdown, confirm those from other countries . Women's most reported worries were general worries about COVID-19 . This finding is consistent with other reports 52 , and may reflect the little knowledge and information regarding the virus profile in the early stage of the outbreak and its potential vertical transmission to the fetus. Next, worries extended onto the financial domain, probably due to the global recession that the world witnessed with businesses closing, increased unemployment, and governments being challenged to find economic solutions 53 . The least reported worries were worries related to disruptions in social support. This is intriguing, given Dutch COVID-19 containment strategies of social distancing and interpersonal isolation. While all these three worries contribute to psychological distress, general worries about COVID-19 contributed the most to psychological distress, followed by social support worries. Despite women reporting considerable amounts of work and financial worries, these worries had the smallest association with psychological distress. This may be due to the strong COVID-19 financial support measures immediately taken by the Dutch government to protect the economy, which are already known and implemented at the time of our study. The central finding of this study is that pregnant women reported less worries, and consequently were at lower risk for developing psychological distress, when they experienced more and/or increased support from their partner, social network, and especially their healthcare providers. This is consistent with the buffering hypothesis 23 Table 3. Worries as mediators between each source of support and psychological distress . The column on the far left presents the predictors for which we ran three separate analyses . The ensuing columns present the mediators , in the order in which they were added to each of the three mediation analyses. If the confidence interval includes 0, there is no effect. If c' < c there is a mediation effect, if c' is no longer significant, then it is a full mediation. B = unstandardized coefficient, SE = standard error of the mean, t = t-test value, p = p value with significance set at .05, CI = confidence interval, N = total sample for each analysis. Path a = direct effect of each support system on each worry ; Path b = direct effect of each worry on psychological distress; Path c = direct effect of each support system on psychological distress; Path c' = indirect effect of each support system on psychological distress via the suppressing effect of each worry ; Path c'tot = indirect effect of each support system on psychological distress via the suppressing effect of all the worries together . positing that support helps individuals to deal with hardship. Not surprisingly, however, the profound structural changes in response to the COVID-19 crisis , might have translated into changes in perceived support. For example, partner support might have increased because of a shift to working at home, which leaves more time for the partner to help in the household and support the pregnant woman. Despite this general increase in partner support, the cases in which it decreased may be associated to relationship conflict, which was shown to increase in non-pregnant populations during COVID-19 [54][55][56] . Consequently, cases that report low and/or decreased partner support during crises such as COVID-19 deserve further attention, as both indicators were associated with more psychological distress. Contrary to partner support, social network support was lower to that prior to the pandemic. This decline has already been reported in "normal times" during pregnancy and the transition to parenthood, and may be the consequence of life changes associated with this period, including changes in couples' social dynamics 57,58 . A similar trend emerged for healthcare, with 1 in 2 women reporting a decrease in support from their providers during the COVID-19 crisis. Amongst all sources of support, healthcare provided most relief against COVID-19 worries and heightened psychological distress. Under the circumstances of the sudden and exponential increase in the number of COVID-19 contagions, the healthcare system became saturated, understaffed and often unable to deliver clear and timely information and/or care. Given the primary importance of healthcare providers support for preventing psychological distress, the fact that 53% of pregnant women reported worsening of their healthcare support is worrying. Additionally, it may be worthwhile for future studies to examine support through objective measures, such as number, nature , and duration of maternity care visits, to gain insights into the structural aspects of the healthcare system that contribute to perceived support and in turn improved mental health. An additional consideration could be the location from which healthcare was received. It could be the case that specific regions and/or hospitals that experienced a higher number of COVD-19 infections may coincide with those in which women reported less perceived support. Prenatal mental health deterioration during COVID-19 holds important implications for treatment, in light of recent evidence indicating that even prior to the COVID-19 crisis, only 15% of women with heightened psychological distress are actually treated, possibly due to symptoms going undetected or low treatment uptake rates 8,59 . This phenomenon could have been even exacerbated during the COVID-19 crisis, with even more pregnant women experiencing psychological distress, and even more symptoms going undetected because of worsening healthcare quality. Prenatal mental health worsening thus needs timely attention, especially during times of crisis. Our findings highlight the necessity for universal screening for psychological symptoms during routine health check-ups in the perinatal period, and for interventions aimed at increasing healthcare support during the vulnerable period of pregnancy. Interpersonal psychotherapy , for example, may be a promising intervention as it has been found effective in improving mood and decreasing depressive symptoms in pregnancy and the perinatal period in general [60][61][62] . Two main aims of IPT are to enhance social support and decrease interpersonal stress during times of transition. Our findings that higher support leads to fewer worries and in turn psychological distress are in line with the IPT framework and as such provide further support for this therapeutic approach. Other therapies that involve social support, such as person-centered approach -based and cognitive-behavioral therapy -based interventions, may also be effective in reducing psychological distress in pregnancy 63 . Moreover, online support groups for pregnant women, led by healthcare professionals, might help to address the feelings, emotions and concerns that pregnant women experience as a result of the pregnancy and of living in a pandemic or other type of crisis. Also, timely information should be given about the COVID-19 health risks for pregnant women and their unborn child. Taking action is crucial to avoid psychological distress becoming chronic and spilling over into the postnatal period, continuing to affect mother and child, as previously documented in prior natural disaster studies 64,65 . Our findings hold implications for both prevention and intervention work, to establish support systems for vulnerable populations and to facilitate timely access to mental health structures, respectively. Indeed, in future work, it would also be important to carefully document pregnant women's access to mental health during a major crisis such as the COVID-19 pandemic. This study documented the impact of the COVID-19 pandemic on prenatal mental health, with a large sample of 2858 pregnant women: half assessed prior to the pandemic and half during the pandemic. Moreover, the pandemic data were collected real time through online questionnaires at the peak of the first Dutch COVID-19 outbreak and lockdown at a national level. Nonetheless, some limitations are noteworthy. Firstly, the crosssectional nature of the study design limits the ability to identify the direction of associations. Moreover, the sample did not have a balanced prevalence of women in each trimester of pregnancy, which may have yielded differences in psychological distress. This is however unlikely given that performing the analyses solely on the second trimester subgroup confirmed the results of the whole group. Furthermore, our sample was prevalently well educated, in a marital relationship and reported a medium-high annual household income, indicating a selection bias of the participants in this research. It could be argued, however, that these results may be even more pronounced in women with fewer resources that may contribute to higher stress and mental health issues. An additional limitation was the length of the survey , and the fact that demographic information was gathered at the end. This resulted in a large amount of missing demographic data, which informed our decision of not including covariates in the analyses. Nonetheless, the sample was sufficiently large to obtain well-powered reliable results. Finally, the two samples were not perfectly matched: the pre-COVID sample was regional 8 , while the COVID sample was national, and the two samples also differed in education and gestation. However, the two samples were very similar in size and were recruited relatively close in time, providing a unique opportunity for comparison. To conclude, our study indicated a twofold increase in the prevalence rate of women experiencing depression and anxiety symptoms during the COVID-19 crisis. Importantly, support systems, especially from healthcare providers, counteracted the negative effects on COVID-19 related worries and psychological distress. Our results --- Scientific Reports | 11:20261 | https://doi.org/10.1038/s41598-021-99662-6 www.nature.com/scientificreports/ indicate a major opportunity for healthcare providers, including midwives and gynecologists, to reduce COVID-19 worries and mental health problems in pregnant women by providing additional support. --- Data availability Anonymous data can be made available upon request. Received: 14 June 2021; Accepted: 21 September 2021 --- --- Competing interests The authors declare no competing interests.

While pregnant women are already at-risk for developing symptoms of anxiety and depression, this is heightened during the COVID-19 pandemic. We compared anxiety and depression symptoms, as indicators of psychological distress, before and during COVID-19, and investigated the role of partner, social network and healthcare support on COVID-19-related worries and consequently on psychological distress. A national survey, conducted during the first lockdown in The Netherlands, assessed COVID-19 experiences and psychological distress (N = 1421), whereas a comparison sample (N = 1439) was screened for psychological distress in 2017-2018. During COVID-19, the percentage of mothers scoring above the questionnaires' clinical cut-offs doubled for depression (6% and 12%) and anxiety (24% and 52%). Women reported increased partner support during COVID-19, compared to pre-pandemic, but decreased social and healthcare support. Higher support resulted in lower COVID-19-related worries, which in turn contributed to less psychological distress. Results suggest that a global pandemic exerts a heavy toll on pregnant women's mental health. Psychological distress was substantially higher during the pandemic than the pre-pandemic years. We identified a protective role of partner, social, and healthcare support, with important implications for the current and future crisis management. Whether increased psychological distress is transient or persistent, and whether and how it affects the future generation remains to be determined. Pregnancy involves profound physiological and psychological changes in women 1-3 , due to the hormonal and biological changes in the body 4,5 , and due to the surrounding context 6,7 . These changes have been associated to elevated prenatal symptoms of anxiety and depression [8][9][10] , which in turn are related to poor outcomes in the offspring [11][12][13] . Accordingly, pregnant women's known vulnerability for anxiety and depression has become a concern during the COVID-19 pandemic and the severe lockdown measures, including social distancing, workrelated changes, and limited access to healthcare services 14 . Whilst reports show a general rise in anxiety and depression rates associated with COVID-19-related worries [15][16][17][18] , pregnant women might experience even more worries. These may include the uncertainty around the transmission of the virus in utero and its effects on the fetus, and the implications for healthcare and birth arrangements 16,[18][19][20] . A recent meta-analysis found heightened mental health problems with 43% of pregnant women experiencing anxiety and 32% depression during the COVID-19 pandemic 21 . Yet, how and which risk or protective factors contribute to anxiety and depressive symptoms, henceforth 'psychological distress' , during the COVID-19 pandemic remains unexplored. Subjective experiences due to the COVID-19 pandemic may vary considerably across pregnant women. Availability of social support may play a significant role in managing COVID-19-related worries, contributing in turn to diminishing the risk of developing psychological distress 22 . According to the buffering hypothesis 23 , support from others, defined as regular positive interactions and integration in a larger network that provides help during hardship (financial, legal, health, emotional, etc.), is one of the most important protective factors from adverse events. Likewise, social support is a central focus of mental health interventions, such as in interpersonal psychotherapy that views psychiatric disorders as a precipitation of the interpersonal context and support systems 24,25 . In the context of physical distancing regulations, support systems are fundamental for

INTRODUCTION The global losses due to luxury brand counterfeiting have reached US $600 billion annually . The trade of illicit goods is expected to continue growing in the coming years. Particularly in Indonesia, based on the results of the Indonesian Anti-Counterfeiting Society survey in 2016, counterfeit products had already caused an economic impact of US $612 million on the national economy during that year, with the government losing approximately US $30 million in indirect tax revenue annually. Specifically, the prevalence of fake luxury goods and counterfeit products is closely tied to consumer motives for purchasing luxury products to establish their own identity. The acquisition of identity can be achieved through the use of luxury items. The urge of an individual or social groups to showcase themselves to appear attractive is often done by displaying a glamorous lifestyle through the use of luxury brands. Such motives appear to be prevalent across various social strata. Motive is an individual's driving force for behavior . These motives can be both negative and positive. It's the negative motives that drive consumers to knowingly engage in using counterfeit products in markets that intentionally sell counterfeit or non-deceptive products . The consumer motives across all classes/strata in using luxury products are aimed at signaling social status as symbols of materialism , without considering the authenticity of the original products , wherein the true satisfaction comes from. Satisfaction in obtaining status through the consumption of luxury products stems from audience reaction . Status represents one's position in the social hierarchy, determined by honor and social influence . Historically, this position could be obtained through lineage or recognition, but today, it's not solely applicable, as an individual's status is viewed through achievements that generate wealth, such as possession of money, high income, and prestigious positions . The social status hierarchy in ancient Rome included the patricians, parvenus, poseurs, and plebs, which were associated with brand prominence . Brand prominence is a branding concept involving soft and loud logo designs on a product . More specifically, strong brands are described as striking and prominent, with visible and observable brand signs that send out a "louder" signal to others, as opposed to subtle brands. The phenomenon of signaling status within the patrician class when purchasing authentic luxury goods is not necessarily dependent on loud brand designs. However, newcomers or newly wealthy individuals opt for authentic luxury products with conspicuous brand designs. In contrast, the poseur class attempts to emulate parvenus by purchasing counterfeit products with prominent brand designs to showcase their status to the audience . However, this perspective has been contradicted by several recent studies introducing a new trend called "fake chic," where high-class consumers enjoy buying counterfeit products even though they can afford genuine luxury goods. The rationale behind this is that buying counterfeit products offers similar quality to genuine items, an easy and enjoyable process, and significantly lower prices. The objective of this research is to explore consumer motives across different classes using prominent or non-prominent logo products to signal status to others. The motives of each class among consumers differ significantly from one another in psychological and behavioral aspects . Prior research has not been specific about which classes or strata and how consumer behavior affects logo choice to convey their status to others . Previous literature also suggests that signaling status is a human behavior motivated by the desire to display products worn to gain recognition from others as symbols of wealth and identity without explicitly specifying the target audience . Recent studies indicate that individual status signaling is not only motivated by utilitarian purposes but also by symbolic meanings underlying products or brands within the power strata . To the best of the researcher's knowledge, the methods through which each class or strata employs its power to send status signals to others have not been deeply explored. Therefore, this research aims to bridge this gap by developing a framework that explains motives regarding product legitimacy and brand prominence, along with purchasing behavior, across three consumer classes/strata simultaneously. The researcher proposes a hypothesis that consumer perceptions in the patrician, parvenus, and poseur classes towards product legitimacy and brand prominence are factors influencing the intention to purchase a product and the brand's strength for signaling status. Additionally, we test this model across three consumer class groups. The following section reviews prior research on motives, counterfeit products, and buying behavior. The research methodology explains the measurements used to test the hypotheses, followed by a discussion and concluding remarks. --- LITERATURE REVIEW Consumer Motives towards Counterfeit Products Based on the literature, two prominent consumption motives stand out, especially in the study of luxury goods consumption today. The first is the wealth accumulation motivation, which portrays the image of individuals as belonging to the highest social circle, being successful and prosperous . The second motive is the unpleasant comparison, where individuals strive to differentiate or distance themselves from others they perceive as being below them . Ustuner and Thompson and Truong and McColl also add that self-expression and vanity are considered primary motivations, reflecting success and pleasure. The use of counterfeit luxury products aims to stay within the circle of peers and be perceived as part of a group, trend, fashion, or social class that is equivalent or even more prominent than their community . The motivation to use fake luxury brand items reflects a desire to be a change agent in fashion, aspiring to be an innovator and influencer . Consumers perceive no difference in quality and appearance between counterfeit and genuine products, which can reduce any shame for users . Moreover, law enforcement agencies, police, and local governments show less seriousness, and ethical standards are low . Negative consumer motives become important predictors of the intention to purchase counterfeit goods , and they represent a consensus within the community of users. Motives for purchasing counterfeit products include social and cultural factors, consumer ethnocentrism, especially when the counterfeit is of foreign brands . Another motive is purchasing counterfeit products to obtain a sense of glamour, admiration, and hedonistic pleasure . Another category involves those who buy counterfeit products due to previous experience with such brands . Lastly, some purchase counterfeit products to acquire unique experiences during their visits to certain places . These motives drive consumers who continuously seek counterfeit luxury products to attain the desired social status. Therefore, we propose the following research hypothesis: H1: The higher the consumer class/stratum, the less positively consumer motives are related to counterfeit products. --- Consumer Motives towards Brand Prominence of Fake Luxury Products Brand prominence explains a brand being marked prominently or vaguely, like the "G" of Gucci or the bold red and green striped signature on a bag to ensure that observers recognize it as a Gucci brand . Brand designs on a product serve as symbols or signals. Previous literature states that the benefits of branding as signals for consumers can reduce product search costs, making the brand highly familiar . Brands are also used to communicate a company's image . Erdem & Swait suggest that a brand can convey a variety of brand associations and brand equity, making it easier for consumers to identify its product characteristics. The choice of a luxury product brand can send social signals to consumers, indicating the status of the user . Consumer motives for purchasing counterfeit luxury products also consider the form of the brand, whether it's prominent or subtle . A prominent logo can be easily seen and recognized by others, especially those who are less familiar with well-known luxury brands . Therefore, consumer motives for using genuine or counterfeit luxury Purwanto., Rahayu, S., & Fitrianti, R. / Jurnal Riset Manajemen Sains Indonesia,14 2023,103104105106107108109110111112113114e-ISSN: 2301-8313 DOI: doi.org/10.21009/JRMSI.014.2.09 goods can influence the choice of prominent or subtle brand designs, with the aim of signaling status to equivalent or lower classes. Therefore, we propose the following hypothesis: H2: Consumer motives for purchasing counterfeit luxury products are related to brand prominence in all classes: patricians, parvenus, and poseurs. --- Perceptions of Fake Products regarding Brand Prominence Consumers' reasons for purchasing counterfeit luxury goods stem from aspiring to possess luxury items without being able or willing to pay the high prices. Counterfeit luxury goods become the target for fashion enthusiasts to signal their status to others , as good counterfeit items serve as substitutes for genuine products, carrying social and personal significance. Brand prominence, largely noticeable, becomes a significant consideration for consumers in the poseur class when buying counterfeit luxury goods. The tendency towards significantly lower prices and more conspicuous brand logos is observed . They desire status by purchasing counterfeit items with prominent brands and lower prices, sending signals to others. Specifically, parvenus have the need to prominently display the brand, as they are often not accustomed to recognizing and evaluating genuine luxury items, hoping others will quickly identify them . On the other hand, the patrician class seeks to distance themselves from motives to purchase counterfeit products and prominent brands . Consequently, the consideration of brand prominence is significant when purchasing counterfeit luxury goods. Therefore, the proposed hypothesis is: H3: Perceptions of counterfeit luxury products are related to brand prominence with a conspicuous brand design. --- Brand Prominence and the Purchase Behavior of Fake Luxury Goods According to the Theory of Planned Behavior, attitude is the most influential factor in predicting intentional behavior . This relationship has been supported by numerous studies across various disciplines. Specifically referencing counterfeit luxury goods, Eisend & Schuchert-Guler and evidence from Schlegelmilch & Stottinger suggest that attitudes towards counterfeiting arise when the price disparity between counterfeit and genuine products is too high, which will positively correlate with purchasing behavior. Various previous studies have indicated that higher prices are positively associated with counterfeiting and buying behavior . Attitudes towards using counterfeit luxury goods are the most influential factor in intentional behavior . Thus, the characteristics of counterfeit products have a positive influence on consumer buying behavior. Attribute considerations such as benefits, brand design, product appearance, durability, and perceived quality significantly affect purchasing behavior . Additionally, previous research indicates that brand prominence also creates specific brand images for counterfeit products, which influence buying behavior . Therefore, the hypothesis that can be proposed is: H4: Consumers who prefer brand prominence have a stronger tendency for buying counterfeit products. --- RESEARCH METHODS --- Procedure and Sample This survey was conducted with consumers encountered at various locations, such as well-known boutiques selling genuine branded fashion products, prominent malls in metropolitan cities, and several retailers accustomed to selling counterfeit goods in Jakarta and Surabaya. The sample used was purposive sampling. The sampling procedure was carried out meticulously, as the classification of classes/strata was intentionally not disclosed to respondents. Instead, it was based solely on the signaling behaviors they exhibited, as well as their expertise and status needs. While we believe that wealth serves as an indicator for each class they occupy, we did not explicitly test this. Questionnaires were distributed by involving 30 students, adopting techniques from previous research on product or service marketing distributed 10 questionnaires to anyone shopping at predetermined locations. In the questionnaire, respondents were asked to mention one product they purchased during a specific period and circle their perceptions of that product. --- Sample Characteristics A total of 300 questionnaires were distributed to respondents, with 230 deemed eligible, resulting in a response rate of 76.6% that could be accurately identified. The majority of respondents were female, totaling 190 individuals , while the remaining 40 were male. Their ages ranged from 25 to 60 years . Respondents' income distribution revealed that approximately 39.13% fell into the low-income category, 38.268% into the middle-income category, and 26% were classified as high-income. The sample sizes for each class/stratum were determined subjectively by the researcher, based on screening questionnaire responses regarding respondents' income and knowledge of branded luxury goods criteria. The researcher honestly acknowledges the inability to extensively validate this information. However, through in-depth interviews with 10 individuals outside the closed questionnaire, the researcher believes that the information provided can depict the actual situation. The key points in the interviews were organized based on respondents' perceptions of branded luxury goods, understanding of such goods, prevalence and impact of using counterfeit luxury items, and their affiliation with social circles. The response data were analyzed to formulate classifications based on classes/strata for this study. The results of the classification are as follows: 52 respondents were classified as patricians, having experience purchasing genuine luxury items as well as counterfeit ones; 87 respondents were categorized as parvenus, with experience buying counterfeit luxury items but recently purchasing genuine ones; and 91 respondents were labeled as poseurs, having no experience buying genuine luxury items. --- Measurement Based on previous studies, we developed questionnaire items to measure consumers' motives for purchasing counterfeit luxury goods and brand prominence. Examples of these items include using counterfeit luxury brands to appear successful, the significant price difference between counterfeit and genuine luxury goods, the desire to experience wearing counterfeit luxury items without spending much money, and the satisfaction of accurately distinguishing between counterfeit and genuine luxury products . To measure the choice of brand prominence and counterfeit products, we developed questionnaire items based on three studies . For instance, buying luxury products with a prominent brand design is very satisfying, prominent brand designs are widely available in the black market, and inconspicuous brand designs aim to camouflage counterfeit luxury products. To measure buying behavior, we assessed consumer attitudes towards counterfeit luxury products. Consumers exhibit a positive attitude towards purchasing counterfeit products when the price is significantly lower, the quality is comparable, and they are willing to buy counterfeit products or vice versa . Loureiro et al. also added that behavior to buy counterfeit products is measured by the willingness to continue using counterfeit items and recommending them to others. For all items, a seven-point Likert scale was employed . Respondents were also asked to state which luxury fashion brands they have purchased and whether they prefer inconspicuous or prominent brand designs. If a respondent indicated a preference for inconspicuous brand designs, they were asked whether their class/strata peers would recognize the type of item they were using. On the other hand, respondents who preferred prominent brand designs were asked this question to assert that the item they were using was indeed luxurious. Additionally, questions were posed regarding experiences with counterfeit luxury products, and finally, to understand the poseur class/group, our sampling was conducted in locations where counterfeit products were freely available. The research results are presented in Table 1, which displays the means, standard deviations, construct reliability, average variance extracted , and bivariate correlations between latent factors. The measurement model exhibits a good fit with the data . The items included in the measurement model have estimated construct reliabilities ranging from 0.76 to 0.81, demonstrating strong convergent validity and high reliability of the measurement instrument. The latent constructs included in the confirmatory factor analysis show strong evidence, as all items have strong significance levels. This indicates that the items have strong explanatory power on error variance . Furthermore, the AVE values for each latent variable exceed 0.50, indicating that the variance explained by measurement error is smaller than the variance explained by the construct. Collectively, convergent validity provides robust evidence supporting the scales for consumer motives, counterfeit luxury products, brand prominence, and purchase intentions. Lastly, the AVE for all constructs surpasses the shared variance among constructs and all other variables, thus demonstrating strong discriminant validity . --- RESULTS AND DISCUSSION --- Hypothesis Testing To analyze whether H1 -H4 are supported in the patrician, parvenus, and poseur classes, the data were categorized into three groups and parameter estimates were freely estimated for each group using LISREL 9.1. Subsequently, all parameter estimates in a specific class group were constrained to be equal to the other class groups . To evaluate the difference in fit between the unconstrained model and the constrained model, a χ2 difference test was conducted. Differences between the two χ2 values ranged from 22 to 136 across the three class groups, indicating that the constrained and unconstrained groups significantly differed in the estimated parameters. The unconstrained model for the poseur class demonstrated generally moderate fit . While this model had a strong foundation, potential model specifications should be considered to assess the extent to which the conceptualization encompassing the data can enhance validity . In the poseur class model, we identified an additional path from counterfeit products to brand prominence. As poseurs lack experience with various genuine luxury brands and even actively seek counterfeit items , their expectations for signaling status are lower compared to the parvenus class. If poseurs encounter counterfeit luxury goods with prominent branding, they are more likely to engage in purchasing behavior compared to the parvenus class . Consequently, this class feels proud and confident in their ability to select the best counterfeit luxury items, feeling accomplished compared to the two classes above them. Such feelings become stimuli for consumer motives and confidence in purchasing counterfeit luxury products . Thus, the path between consumer motives and purchase behavior through brand prominence and counterfeit products can be substantiated for the poseur class, as depicted in Figure 1. The results of the study show that all parameter estimates are significant, supporting H1 -H4. The χ2 value is 447.7 , which is lower than the initial model , and the CFI = 0.94; GFI = 0.89; TLI = 0.86; RMSEA = 0.07; SRMR = 0.05. The difference between the two χ2 values is 3.3, which is greater than the significance level of 2.51 . Additionally, the coefficient γ22 is 0.04, which is also significant at p < 0.05. These results indicate that the model fit is acceptable and improved significantly compared to the initial model, which did not include the path from Fake Luxury Product to Brand Prominence. For the unconstrained Patrician model , the χ2 is 236.5 , CFI is 0.91; GFI is 0.85; TLI = 0.88; RMSEA = 0.06; SRMR = 0.07, indicating an overall acceptable model fit. However, one path is not significant in Figure 2. The path from Consumer Motive to Fake Luxury Product and Brand Prominence is not significant because the Patrician class has a sense of prestige and negative emotions towards fake luxury brand products. 2015) state that using fake luxury items with eye-catching brand designs is indeed embarrassing, lowers prestige, and elicits negative emotions. Lastly, the relationship between fake luxury products and brand prominence towards purchasing behavior is also not significant , indicating that the perception of fake products and prominent brand designs does not trigger this class to make purchases and even leads to a negative response. However, there is also a hidden consumer motive behind the purchase of fake luxury goods with subtle branding to camouflage the fact that this class has never bought counterfeit products. Some respondents admit to being intrigued to experience the sensation of seeking counterfeit goods in the black market . This can also be explained through interviews with certain respondents considered part of the elite class . Therefore, we can add a direct path from consumer motive to purchasing behavior, which is significant . This is what we refer to as the "dark motive" in the Patrician class. This is supported by the prevailing perception that whatever is worn by entrepreneurs, highranking officials, celebrities, and famous lawyers is believed by society to be luxurious and expensive. For the unconstrained model in the Parvenus class , the χ2 is 282.5 , CFI is 0.92, GFI is 0.83, TLI = 0.86; RMSEA = 0.08; SRMR = 0.07, indicating overall acceptable model fit. In Figure 3, the significant paths are from consumer motive to eye-catching brand prominence and from brand prominence to purchasing behavior . The reason for this finding is that the Parvenus class tends to purchase genuine luxury products, but they desire a brand design that is eye-catching. This is because, apart from showcasing themselves to the class below, they also signal to the class above that they have achieved success and can be aligned with that class. Consumer attitudes in this class towards fake products are negative. This is because they want to build a positive image that portrays them as newly affluent individuals who aspire to gain status within their own group and the class above them. As a result, the path from consumer motive to counterfeit products is not significant for this class. Even though this class deeply understands the characteristics of fake luxury products, they are extremely cautious when it comes to the legitimacy of luxury goods. This caution stems from their desire to ensure the success of the social status they have built. --- Discussion In this study, we applied the concept of consumer decision-making in aspiring for status with luxury branded products and brand prominence with either conspicuous or subtle designs in an empirical study. The research results indicate that consumer motives are significantly positively related to counterfeit luxury products and conspicuous brand prominence, as well as buying behavior within the poseur class. Conversely, in the patrician class, there is a negative relationship between consumer motives and the perception of counterfeit luxury products, conspicuous brand prominence, and buying behavior. The parvenus class only exhibits a positive relationship between consumer motives and conspicuous brand prominence as well as buying behavior. These research findings partially support the findings of Han et al. and Wilcox et al. , wherein consumers in the poseur class, when signaling their status, are only capable of purchasing counterfeit luxury products with conspicuous brands. This is because products with conspicuous brands effectively serve the social function of self-expression and self-presentation. Similarly, for brands with conspicuous designs, they can evoke consumer memories and strengthen their relationship with the company. Since poseurs feel incapable of aligning themselves with the two classes above them, they resort to buying counterfeit goods to signal their status within their group. Without hesitation, they purchase counterfeit luxury products in the black market to appear wealthy, fashionable, in line with trends, and as something commonly done by many . Thus, imitating parvenus is a way for poseurs to establish their status within their group. In the parvenus class, the motive is to use genuinely branded luxury products with conspicuous designs as signals to clarify that they are not part of the lower class . For the parvenus class, the patrician class is aspirational, while the poseur class is dissociative . The parvenus group is a newly elevated social class that hasn't acquired the skills associated with their new position, so they strive to align themselves with the patrician class. Since they are new to luxury goods, they aren't familiar with intricate details like ultra-luxury fashion brands. They prefer popular luxury products with conspicuous brand designs to signal their success. For them, the distinctive "LV" monogram of Louis Vuitton or the Chanel brand, favored by red carpet celebrities, serves as a way to showcase their status, even though the prices reach millions of dollars. Lastly, the patrician class possesses expertise and experience with luxury goods, along with substantial wealth . Therefore, their purchase of products is not intended for display to lower classes, as they consider themselves exclusive/superior. This group carefully maintains its identity, choosing products that can be recognized by their in-group. They view buying luxury goods as a pleasure or a way of life. For instance, they might purchase a $5 million Hublot Big Bang watch that appears quite ordinary. For the patrician class, the use of luxury products signifies elegance and refined taste . When signaling to their group, the patrician class employs abstract methods that are difficult for outsiders to understand. Some individuals within the patrician class exploit their inherent self-image for their own benefit. They might buy counterfeit luxury items with subtle branding, rare products that are almost perfect. Although such behavior is risky for their group, as it could undermine their overall self-worth, they view their actions as mere indulgence, assuming that the lower classes are unaware. This validates previous research by D 'Amato Thanos, 2013;Perez et al., 2010, indicating that consumers are indeed capable of purchasing genuine luxury items. However, for the thrill and experimentation, they enjoy purchasing counterfeit luxury products and consider what they wear as expensive, genuinely believing it's authentic. In conclusion, patricians, parvenus, and poseurs vary in terms of expertise and status needs, which motivate them in how they intend to use luxury goods as status signals . Expertise in signaling status means that consumers need a strong understanding of prices, product knowledge, and other cues of quality . The most elite class do not rely on conspicuous branding as a signal, while newcomers require conspicuous branding to convey their message. Poseurs, trying to emulate parvenus, opt for more conspicuous counterfeit products. --- CONCLUSIONS AND SUGGESTION The findings of this research prove that products with conspicuous and lower-cost branding are targeted towards the poseur consumer class, while those that are more expensive and subtly branded are directed towards the patrician class, and conspicuous for the parvenus class. The patrician, parvenus, and poseur classes exhibit distinct ways of showcasing their status, which are demonstrated by consumers' strong understanding of prices, product knowledge, and other cues of quality. The most elite class do not rely on conspicuous branding as a signal and sometimes, to the untrained eye, their products might appear ordinary and less appealing, yet they are exceptionally elegant. On the other hand, newcomers require conspicuous branding to convey their message. Poseurs, attempting to emulate parvenus, resort to purchasing more conspicuous counterfeit products.

This research aims to explore the relationship between consumer motives mediated by brand prominence selection in the purchasing behavior of counterfeit products among three consumer groups/classes (patricians, parvenus, and poseurs) in the luxury fashion brand context. The data were obtained from a sample consisting of 230 respondents who were considered eligible. There are three findings. First, for the poseur class, consumer motives in purchasing products are positively related to counterfeit products and prominent brand prominence. Second, for the parvenus class, consumer motives are not related to counterfeit products, but they are related to prominent brand prominence. Third, for the patrician class, consumer motives for purchasing products are not related to counterfeit products and subtle brand prominence.Penelitian ini bertujuan untuk mengeksplorasi hubungan antara motif konsumen yang dimediasi oleh pemilihan brand prominence pada perilaku beli produk palsu pada tiga kelompok/kelas konsumen (patrician, parvenus dan poseur) dalam fesyen brand mewah. Data diperoleh dari sampel yang terdiri dari 230 responden yang sudah dianggap memenuhi syarat. Ada tiga temuan, pertama, untuk kelas poseur, motif konsumen dalam membeli produk berhubungan positif terhadap produk palsu dan brand prominence yang mencolok. Kedua, kelas parvenus motif konsumen tidak berhubungan terhadap produk palsu, tetapi berhubungan terhadap brand prominence yang mencolok. Ketiga, kelas patrician, motif konsumen membeli produk tidak berhubungan terhadap produk palsu dan brand prominence yang lembut.

Background People's state of health and the manner in which it is cared for is indeed regarded as a very important component of economic development of any country [1,2]. The health sector targets often relate to traditional hospital functions such as diagnosis, outpatient treatment and inpatient care. Outpatient services are those hospital services that do not require an overnight stay and may include care such as diagnostic tests, prescriptions or simple treatment/procedures [3]. These services are offered on ambulatory basis, and they account for the majority of patient-medical professional encounters than any other hospital services . Few studies have examined patient experience for quality of care in resource-scarce environment like sub-Saharan African countries such as Nigeria. Measurement of quality can be very useful to stakeholders who choose between different health care providers, and to the policy makers who strive to enunciate better health policies [4]. Standardized surveys of patients and relatives can reliably measure hospital performance by assessing patients' experience and outcomes of treatment. Patient experience evaluates what happens at the point of contact between the patient, the practice, and the provider [5]. It captures health system responsiveness, including the manner and environment in which people are treated when they seek healthcare [6]. It also includes sufficient information and education of the patient, coordination of care, physical comfort, emotional support, respect for patient preferences, involvement of family and friends [4]. Patient experience is not the same as perceived quality which is predominantly a cognitive assessment of what happened and how it happened [7]. It is also different from patient satisfaction which is referred to as patients' emotion, feelings and their perception of delivered healthcare service [8]. Patient satisfaction is regarded as the degree of congruency between patient expectations of ideal care and their perception of the real care received [9] and it tends to seek subjective responses from patients. In contrast, PE asks patients to give factual responses to questions about what did or did not happen during episode of care. A major challenge to measuring healthcare quality in low-and middle-income countries was highlighted by a study carried out by Dunsch et al., on more than 2200 patients in Nigeria using positive and negative framed satisfaction statements [10]. The result showed that patient satisfaction measurements are deeply sensitive to the framing of the questions and hence the need to adapt patient experience that avoids a short-laced response of agree/disagree and yes/no questions. It is believed that PE survey questionnaires that are well designed and appropriately administered can provide a robust measure of quality of care and reliably measure hospital performance against explicit standardization [11,12]. Several studies have been carried out on quality of healthcare services especially in developed countries; quite a handful in African region and very few in sub-Saharan African countries like Nigeria. Many reviewed literatures on quality of healthcare show that waiting time is one of the most important indicators or variables of healthcare quality. One of such is a cross sectional observational study by the Patels on waiting time and outpatient satisfaction at Gujarat medical education research society hospital India, using 135patients from the outpatient department [13]. A cross sectional survey of nurses and patients in 12 countries in Europe and the United States on patient safety, satisfaction and quality of hospital care, using hierarchical modelling and robust logistic regression, showed that deficits in hospital care quality were common in all countries [14]. Mejabi et al., in their work on dimensions of hospital service quality in Nigeria, as published in European Journal of Social Sciences, used probability and quota sampling methods on 6 service points and applied correlation matrices/factor analysis to evaluate quality of healthcare in two Nigeria teaching hospitals. Their findings show that eight dimensions of resource availability, quality of care, condition of the clinic/ward, condition of the facility, quality of food, attitude of doctors and nurses, attitude of non-medical staff and waiting time adequately describe service quality phenomenon in Nigerian hospital setting [15]. The aim of the present study is to evaluate patients' experience on quality of care among clients accessing ambulatory healthcare services in teaching hospitals, Southeast Nigeria. There is paucity of knowledge on the effects of socioeconomic variables on PE for ambulatory healthcare services in hospitals. The present study focused on how socio-economic factors represented, in the context of this study, by level of education and employment status of outpatients affect PE on quality of care. Level of education and employment status were used because the two are the commonest socio-economic parameters that are used by the teaching hospitals in Nigeria when disaggregating socio-economic status of their patients. --- Methods The study design was a cross-sectional exit survey. Three tertiary hospitals were randomly selected from seven teaching hospitals in Southeast, Nigeria. The study population was 7847 patients, which was the projected outpatients flow for the 3 hospitals over a period of 3 months the data collection lasted. The hospitals are: Enugu State University Teaching Hospital , University of Nigeria Teaching Hospital and Federal Teaching Hospital Abakaliki . The sample size was determined using a formula for calculating required sample size for a patient population of less than 10,000 persons. N f = n/1 + ; N is average number of target population. Value of n was calculated using: n = Z 2 pq/d 2 as the formula [16]. Where n is minimum sample size required, Z is normal standard deviation at 95% confidence level and is 1.96, p is prevalence of the factor under study and from previous studies it is 84% for outpatients [17]. A pre-tested structured patient experience questionnaire with scores assigned to the questions was developed and used for this study. The PEQ is designed to elicit actual experiences, ranging from the duration of hospital's waiting time to the environmental condition of the outpatient department, the quality of care rendered by the doctors and other health workers, the responsiveness of care and indeed the patient's overall rating of his experience [18]. The study generated and attached relative weights to each question as an indirect measure of the quality of ambulatory healthcare services. This was based on plausible measurements from previous studies that were adopted for the context of the study area [18][19][20]. The weights in the present study were represented by scores, ranging from zero to ten . The questionnaire was pre-tested in a secondary level hospital that is located within the same geographical region, using about 10% of the sample size. The instrument was then revised for language and better understanding. Hence, there was no obvious problem with the respondents comprehending the questions and providing plausible answers to the questions. A reliability test for the questionnaire was carried out for internal and external consistency using Cronbach's alpha test and this gave Cronbach's alpha coefficient of 0.632 , showing that the questionnaire was consistent and therefore reliable. A total of 422 questionnaires were administered to respondents in the teaching hospitals by well-trained interviewers. The responses were elicited without patient's identifier after a written consent were obtained from respondents [18,20]. The data were analyzed using statistical methods such as Z-test and ANOVA to examine mean differences, and Chi-square/Log Linear association tools to compare the relationship between PE variables with level of education and employment status. --- Results Out of the 422 questionnaires that were administered a total of 408 were fully responded to. This represents a response rate of 96.7%. The study results show that 50.7% of the respondents were male, whilst 49.3% were female. Majority of the patients were within active age range of 18-65 years. About 24% were above 65 years and 2.9% were below 18 years of age. It was found that 40.7% of the respondents had university education and 25.2% had high school education, whilst the remaining 34.1% had either primary school education or no formal education. Less than half were employed, while 28.2% were unemployed and 18.1% retirees that were no longer economically active. Table 1 also shows that slight majority of the patients received healthcare services at the surgical outpatient department , while 49% were cared for in medical outpatient department . Table 2 shows that there were significant statistical differences among hospitals for mean patient experience scores on waiting time, quality of doctors' care and that of overall rating. FETHA had the highest mean PE score for quality of doctor's care and for overall PE rating , UNTH had the best score for waiting time PE score . Table 3 disaggregates the healthcare services into medical and surgical, and compared the differences in their mean PE scores, within and between the hospitals. FETHA's MOPD had mean PE score of 27.22 ± 0.43 points for its environment, better than that of its SOPD which had mean PE score of 25.36 ± 0.52 points. FETHA's MOPD overall PE rating was 78.37 ± 1.14% and significantly higher than that of SOPD . Similarly, in ESUTH the MOPD services were significantly better than those of SOPD for quality of doctor's care, quality of care by nurses/other health professionals, as well as for overall rating. Only UNTH's SOPD overall PE rating of 76.96 ± 1.51% was significantly better than that of its MOPD . Table 4 shows that higher proportion of outpatients without a formal education had mean PE score of more than 10 points for waiting time, compared to 34.3% of outpatients with university education and 41.7% of those with high school education. The result shows significant association between PE scores on waiting time and level of education. This was not so for PE score on OPD environment, quality of doctors' care and responsiveness of care for outpatients . With quality of care by nurses/other care givers, the result show significant association with educational status. Again, larger proportion of outpatient without formal education scored this domain high compared to 68.6% of outpatients with university education. In addition, the result shows that employment status only had significant association with the overall PE rating; about 75.7% of retirees and 64.7% of employed outpatients recorded higher overall PE rating in the hospitals studied. Students and the un-employed had least overall PE rating. --- Discussion The present study evaluated how outpatients of two different socioeconomic groups rate their experience in respect to various domains of care at Teaching hospitals in Southeast Nigeria. The study is an attempt to know how patient experience can serve as metric for health industry competition and differentiation, since it reflects quality of care from the patient's perspective [21]. The study confirms that measurement of patient experience is an important aspect of evaluation of healthcare services; and it provides an opportunity to improve care, meet patients' expectations, enhance strategic decision making, as well as effectively manage and monitor health care performance [21]. These are vital because there is no doubt that in the public eye, hospitals will continue to be the 'face' of the health system, and upon it the public assesses the quality of services provided [22]. Moreover, there is this emerging consensus that patient experience is a fundamental aspect of provider quality [23]. An inference from the findings is that UNTH had the shortest waiting time because patients spent less time waiting for services from doctors or other care givers. The other hospitals could learn from what UNTH is doing right and apply the same procedures in their The figures in the bracket, , are % along the column facilities in order to decrease their waiting times and enhance PE for quality of ambulatory care. It has been shown that increased waiting time also affect the overall treatment provided by physicians and other care givers [24]. In UK the national standard or accepted waiting time is 30 min [25]. In Nigeria, previous studies show that the majority of outpatients wait as long as 80-180 min or more in the OPDs, and the commonest reason for this long waiting time is the large number of patients as against few health workers [17,26]. A study in India obtained average waiting time outside the various OPDs of only 12 min and 98.52% of patients were very satisfied with it [13]. The finding that very educated patients, unlike the illiterate ones, are less satisfied with waiting time, could be a reflection of their increased awareness of their rights and privileges because of their level of education and therefore more discerning of the expected quality of healthcare services. The educational status of the respondents was also related to their expectations of the quality of care by the nurses/other health workers. The poorly educated outpatients rated waiting time and quality of care by nurses/other health workers higher than the more educated people, probably because they were not aware of their right to quality services and care. On the other hand, educational status was not significantly associated with patients' rating for OPD environment, doctors' care and responsiveness of care. However, this differs from the findings of Zalmanovitch and Vashdi who reported that a lower level of education predicates greater responsiveness of care for primary and preventive healthcare than higher level of educational status [27]. The mean overall patient experience rating in this study, though higher than that of similar study in a Federal Medical Centre in Southeast Nigeria , is slightly below 83.0% obtained in a hospital of similar status in Northern Nigeria [28][29][30]. The present study showed that employment status, and not level of education, had direct significant association with patients' rating for overall quality of care. Higher proportion of employed and retired outpatients rated the quality of care from the hospitals high. This, to some extent, is at variance with the findings of Arpey, et al. who in their recent study observed that patients' SES had no impact in the way they are viewed or treated by their physicians [31]. However, our findings agreed with that of Myers, et al. and Bernheim, et al. who found that physicians as a group perceive and treat low SES patients differently from those of higher SES [32,33]. Maharlouei, et al. had also reported on how the overall patient experience was associated with different SES [34]. The limitations of this study include its inability to capture all the domains of patient care in the hospitals. It was restricted to measures of outpatient or ambulatory healthcare services. Thus, the findings cannot be generalized to include that of admitted patients. Another limitation is the fact that the data collection instrument used both coding and tick-box approaches, which could have led to some confusion for the enumerators/interviewers. However, the thorough training that was undertaken by the interviewers before field work ensured that they understood the response formats and could navigate between coding and tick-box approaches. Coding framework from previous studies was adapted [18][19][20] and pretested in the study area, hence the possible occurrence of bias is potentially insignificant. Although, the pre-test showed that the instrument worked well within the study context, it is recommended that a uniform coding approach be used in future studies. --- Conclusion The study revealed how employment status was significantly associated with overall patient experience rating of the quality of care for ambulatory healthcare services in Nigeria hospitals. It also showed that level of education significantly impacted on how outpatients perceived waiting time and quality of care from nurses and other care givers in the hospital. Further study will be required to assess other drivers of the rating of quality of care, the provider-side influences on quality of care and the effect of socio-economic status on inpatients type of healthcare services in the hospitals. --- Recommendations The study has underscored the need to put into consideration the socioeconomic status of patients in the course of providing healthcare services for a given population. --- --- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12913-020-05332-0. Authors' contributions HA conceptualized and designed the study and coordinated all the research activities including the drafting of the manuscript. OA coordinated the data collection. OO and IO contributed to the design of the study and oversaw the supervision the study. CN analyzed and interpreted the data. All authors reviewed the study findings, read and approved the manuscript before submission. --- Funding The data collection stage of the study was funded by the corresponding authors. The individual authors' time on the research design, data collection, analysis, interpretation and report writing were funded by each authors, respectively. Informed written consent were obtained from all patients that participated in the study. For those patients who were below 18 years of age, parental written consent were obtained. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: To determine how socioeconomic factors, such as level of education and employment status, affect patient experiences on quality of care for ambulatory healthcare services in teaching hospitals in southeast Nigeria. Methods: The study is of a cross-sectional design and exit poll was used to collect its data. A pre-tested structured questionnaire was administered to clients accessing care in the outpatient departments of three tertiary hospitals in Nigeria. The assessment of patient experiences for quality of care was based on five (5) domains of care: waiting time; environment of the outpatient department; quality of doctor's care; quality of care by nurses/other health workers; and responsiveness of care. In addition, the overall quality of care was assessed. Results: The mean rating of patient experience for quality of care for ambulatory healthcare services (outpatients' care) was 74.31 ± 0.32%. Moderate differences were observed between the hospitals assessed for various levels of patients' care, especially for waiting time, quality of doctors' care and overall quality of care. Employment status was a statistically significant (p ≤ 0.05) determinant of overall patient experience rating for quality of care, while the level of patient's education was an influence on the perception of waiting by the patients and their rating of care from nurses/other healthcare providers (apart from medical doctors).The study showed that educational and employment status (measures of socioeconomic status) of patients determined how patients receiving ambulatory (outpatient) healthcare services perceived the quality of care in the hospitals. Hence, in order to ensure equity, there is need to institutionalize patient-centered care, while full consideration is given to the patients' socioeconomic status.

Introduction Refugees experience multiple forms of trauma, including persecution, physical and sexual violence, and life-threatening situations, prior to and during the process of migration [1,2]. These experiences can have severe and long-term mental health consequences [3,4]. In addition to trauma, studies have called attention to the ways in which postmigration stressors tied to resettlement in another country pose significant risk for psychological problems and poor mental health [5][6][7]. In contrast to refugees, less research examines the mental health effects of trauma and stress at pre-and post-migration phases for non-refugee immigrants [8,9]. These limitations can be attributed to the ways in which studies classify foreign-born or migrant groups as "immigrants" broadly, or examine disparities between immigrant and native-born populations without accounting for important differences in subgroups of migrants [2,10,11]. Generally speaking, immigrants leave their countries of origin by choice in search of social and economic opportunity while refugees are forced to migrate in search of safety from conflict and persecution. Yet, in the U.S. non-refugee immigrants often survive conditions characterized by mass violence and traumatic events prior to emigration but do not qualify for legal status as a refugee [9,12]. In the case of immigrants who enter the U.S. without authorization, many endure violence during the process of transit, including detention, verbal and physical assaults, and other human rights abuses [13][14][15]. A number of non-refugee immigrants may emigrate under circumstances related to family reunification or other temporary statuses, but have also experienced political violence and displacement [16]. Confounding the issue, some individuals who have legal refugee status may reject public recognition as a refugee due to the term's association with stigma and past adversity [17]. Additionally, few studies examine the prevalence and impact of trauma experiences after migration to the U.S. According to the American Psychiatric Association [18], trauma includes having direct exposure to or witnessing 1 3 an event that involves actual or threatened death or serious injury and violence. The voluminous refugee mental health literature often assesses trauma in one's place of origin, in the process of flight, and during temporary settlement though often without temporal delineations in these events [12]. Prior research has recognized specific forms of trauma, such as intimate partner violence, in immigrant populations [19], yet few studies look at trauma experiences broadly after settlement in a new country. Researchers have long conceptualized the migration process as having multiple stages [1,2], and described ways in which prior trauma increases vulnerability to subsequent traumas and stress [6]. Yet, the explicit study of trauma after resettlement has not been applied broadly across refugee and non-refugee immigrant populations. To address existing gaps, we draw on a U.S.-based representative sample of Asian and Latino refugees and non-refugee immigrants to address the following research questions: How are traumatic events, prior to and after migration, associated with mental health problems among refugees and immigrants? Accounting for trauma exposure, what post-migration stressors are associated with mental health problems? This study has a number of unique features. First, with notable exceptions [10,11], this paper is among the few to use national data to compare a range of stressors and mental health outcomes for refugees and immigrants of diverse Asian and Latin American national origins. Our study builds on prior findings by investigating the contribution of both pre-and post-migration stress on outcomes that include depressive disorders, anxiety disorders, and psychological distress. Furthermore, we examine the timing of trauma experiences in relation to resettlement in the U.S., as few studies assess for post-migration trauma. After accounting for trauma, our analyses also explore mental health outcomes linked to post-migration stressors, including acculturative stress, discrimination, neighborhood factors, and family conflict. Challenges associated with sociocultural adjustment in a new country resulting from dissonance between one's culture of origin and the host culture as well as experiences of racial/ethnic discrimination are robust predictors of poor mental health [20,21]. Similarly, migrants are prone to neighborhood contexts affected by residential segregation and poverty, which play important roles in shaping health behaviors and wellbeing [22]. Finally, these adjustment stressors can adversely affect family relationships and lead to family conflict, which is strongly linked to psychological distress and mental health in migrant populations [23]. In summary, the current study examines the mental health effects of trauma and stress prior to and after migration among refugees and immigrants in the U.S. We hypothesize that both pre-migration trauma and post-migration trauma are associated with greater risk of mental illness and increased psychological distress for immigrants as well as refugees. Similarly, we hypothesize that post-migration stressors will amplify risk for mental illness and elevate psychological distress. --- Methods --- Data and Sampling Data from this study were drawn from the National Latino and Asian American Study , an epidemiological survey of mental illness and mental health service use among Latinos and Asian Americans in U.S. The NLAAS used a complex three-stage stratified sampling design that has been described in detail elsewhere [24,25]. Eligible respondents were age 18 years or older and were not in the military or institutionalized. The NLAAS recruited a total of 2554 Latino and 2095 Asian participants between 2002 and 2003. Lay interviewers conducted interviews with participants using computer-assisted survey instruments in the participants' preferred language . The final overall response rate for Asians was 65.6% and the rate for Latinos was 75.5% [25,26]. We analyzed data on 3268 respondents born outside the U.S. . The use and analysis of the NLAAS was approved by the Interuniversity Consortium for Political and Social Research and the authors' University Institutional Review Boards. --- Measures --- Depressive and Anxiety Disorders in the past 12 Months Participants were classified with DSM-IV diagnoses in the past year using the World Health Organization's expanded version of the Composite International Diagnostic Interview [WHO-CIDI, 27]. Any depressive disorder included at least one diagnosis of depressive disorder or dysthymia in the last year. Any anxiety disorder was based on diagnosis of at least one of the following disorders in the past year: panic disorder, agoraphobia without panic, social phobia, generalized anxiety disorder, or posttraumatic stress disorder . --- Psychological Distress The Kessler Psychological Distress scale assessed the frequency of experiencing mental and emotional distress in the past month [28]. Items included how often participants felt depressed, hopeless, restless/fidgety, and tired for no good reason. Responses ranged from 1 to 5 . The index demonstrated high internal consistency . --- Pre-migration and Post-migration Trauma Exposure Twenty-six items captured whether participants experienced a variety of traumatic events, with a subsequent follow-up item for each regarding the age they first experienced the aforementioned traumatic event. Taken from the WHO-CIDI, these items were included in the NLAAS to assess PTSD symptoms. Representative items included whether participants were an unarmed civilian in a war zone, a civilian exposed to ongoing war, saw injuries or dead bodies, were mugged, or sexually assaulted . As was done in prior research [5,10,11], to determine the timing of pre-and post-migration events, we subtracted participants' age of migration from the age they first experienced the traumatic events; negative values represented traumatic events prior to migration to the U.S. and positive values represented those after migration to the U.S. Affirmative responses were summed for each period . --- Discrimination Participants reported the frequency of unfair treatment with the 9-item Everyday Discrimination scale [29]. Representative items, ranging from 1 to 6 , asked how often participants were threatened/harassed, called names/insulted, and treated with less respect than others. Higher summed scores reflected more frequent experiences of discrimination . --- Acculturative Stress A 10-item scale adapted from the Mexican American Prevalence and Services Survey [30] assessed acculturative stress. Items tapped into strains associated with adjustment to a new country, including whether participants felt guilty about leaving family/friends in their country of origin, felt respected in the U.S. compared to their country of origin, had difficulty finding work due to Latino/Asian descent, or were questioned about their legal status. Dichotomous responses were summed, with higher summed scores indicating greater acculturative stress . --- Family Conflict Five items drawn from the Hispanic Stress Inventory assessed the relative frequency of perceived family conflict due to incongruent cultural values [31]. Participants responded on a scale of 1 to 3 to statements including "Being too close to family interfered with my goals" and "I argue with family over different customs" . --- Neighborhood Environment A seven-item scale focused on respondents' perceptions of safety and social cohesion in their neighborhood [24,32]. Representative items included whether people in the neighborhood could be trusted, get along with each other, and help in an emergency. Two items were reverse coded . Responses ranged from 1 to 4 , with summed scores ranging from 4 to 28 . --- Covariates We controlled for gender, age, ethnicity, education, marital status, duration in the U.S., work status, and social desirability. To assess social desirability reporting bias, a 10-item measure assessed respondents' agreement to statements such as "I never met a person I didn't like," "I have never been bored," and "I am not bothered by someone taking advantage of me" [33]. Summed scores ranged from 0 to 10 . --- Analysis We conducted all analyses in Stata 15 and used the appropriate sampling weights to account for the NLAAS multistage survey design [34]. After describing and testing for group differences across migrant status in the Latino and Asian American samples, we examined associations between preand post-migration stressors and mental health outcomes. We employed logistic regression for binary outcomes and multivariable linear regression to model effects on psychological distress. Because missing data was minimal we proceeded with complete cases. Our analyses were stratified by migrant status based on a single item that asked foreign-born participants the following question: "Were you ever a refugee-that is, did you ever flee from your home to a foreign country or place to escape danger or persecution?" This item indicates self-reported rather than legal status as a refugee and has been used in prior research with this data [5,10,11]. --- Results Table 1 presents characteristics of both Asian and Latino samples, comparing immigrants and refugees, respectively, within each sample. Among Asians, a significantly greater proportion of refugees were older and of Vietnamese heritage , had lower levels of education and English language proficiency, and a longer duration of residence in the U.S. Furthermore, the proportion of Asian refugees who were unemployed was double that of the proportion of unemployed immigrants, though refugees had comparatively lower levels of poverty. Asian refugees had significantly higher levels of pre-migration trauma and lower levels of perceived everyday discrimination compared to immigrant counterparts. There were no significant differences between refugees and immigrants in the rate of 12-month disorders or psychological distress. Among Latinos, a greater proportion of refugees were male, older, and of Cuban descent compared to immigrants. Latino refugees had higher levels of education, greater English language proficiency, higher levels of poverty, and were less likely to be uninsured compared to immigrants. Additionally, Latino refugees had significantly higher levels of pre-migration and post-migration trauma than their immigrant counterparts. Refugees and immigrants did not differ in rates of 12-month disorders or psychological distress. Next, we present odd ratios and OLS regression coefficients for the associations between pre-and post-migration stressors and mental health outcomes for Asians and Latinos. Among Asians , pre-migration trauma was associated with greater odds of depressive disorder and psychological distress for refugees; pre-migration trauma was associated with greater odds of anxiety disorders for immigrants. Post-migration trauma was linked to depressive disorders for both refugees and immigrants. For refugees, discrimination was associated with greater odds of anxiety disorders. For immigrants, discrimination was associated with greater odds of depressive and anxiety disorders as well as psychological distress. Acculturative stress was linked to lower odds of anxiety disorders and greater psychological distress for refugees, but not linked to mental health for immigrants. Across both refugees and immigrants, family conflict increased odds of depressive and anxiety disorders and psychological distress. Finally, there was no association between one's neighborhood context and mental health outcomes. Among Latinos , pre-migration trauma increased risk of psychological distress for refugees; pre-migration trauma was associated with greater odds of disorders and psychological distress for immigrants. Post-migration trauma was linked to greater psychological distress for refugees; post-migration trauma was associated depressive disorders and psychological distress for immigrants. Discrimination was linked to poorer mental health across all outcomes for immigrants, but not associated with mental health outcomes for refugees. Acculturative stress was linked to elevated odds of depressive disorder for refugees; for immigrants acculturative stress was linked to greater odds of depressive disorders and psychological distress. Family conflict was associated with poorer mental health across all outcomes for refugees, and with anxiety disorders and psychological distress for immigrants. Similar to Asians, neighborhood context was not linked to mental health outcomes for Latino refugees and immigrants. --- Discussion This study compared effects of pre-and post-migration trauma and stress on mental illness and distress across refugees and immigrants in a representative U.S. sample with Latino and Asian origins. In support of our primary hypotheses, pre-and post-migration trauma was linked to mental disorders and distress, with varied associations by racial/ethnic group and migrant status. For Asians, trauma exposure prior to and after migration was similarly linked to poorer mental health across refugee and immigrant groups. Among Latinos, our results indicate both pre-and post-migration trauma had deleterious effects across a broader range of mental health problems for immigrants compared to their refugee counterparts. The findings regarding pre-migration trauma align with prior research demonstrating the destructive, long-term mental health consequences of war and political violence migrants face in their countries of origin and in transit [8,9,12]. Our results are also consistent with the refugee mental health literature indicating traumatic events are the most common pre-migration factor associated with psychiatric symptoms [35]. Numerous studies highlight pre-migration trauma among Latino immigrants escaping individual, institutional, and state-based violence [8] as well as Asian immigrants escaping everyday violence tied to repressive regimes in their home countries [12,36]. In all, these data highlight the importance of understanding effects of pre-migration trauma broadly in migrant populations, including those not labeled or seen as refugees. A unique contribution of our study was the inclusion of post-migration trauma as a risk for mental health. For both Asian refugees and immigrants, post-migration trauma heightened risk for depressive disorders, though the odds for disorder were double for refugees. A history of severe war trauma and barriers to appropriate mental health services among for Southeast Asian refugees has been well-documented [37,38] and these factors combined with contemporary traumas may heighten trauma's effects in the Asian refugee sample [39]. In contrast, for Latinos, post-migration trauma similarly increased risk for psychological distress across refugees and immigrants but also increased risk for depressive disorders among immigrants only. Though we did not have data on visa type or authorized legal status, these findings may partially reflect experiences of undocumented Latino immigrants. Many endure perilous journeys to the U.S. and, upon arrival, can encounter threats of deportation, ineligibility for government services, and anti-immigrant rhetoric [40], which can heighten effects of post-migration trauma on mental health. Other post-migration stressors detracted from mental health outcomes after accounting for trauma exposure, aligned with a growing body of literature underscoring the salience of the post-resettlement context on migrants' health [4][5][6][7]. Discrimination consistently predicted poorer mental health for Asian and Latino immigrants. This finding echoes the substantial literature illustrating the negative psychological and health consequences of discrimination [41,42]. People often migrate to the U.S. in search of increased freedoms and economic opportunities in order to provide better lives for themselves and their families, arriving with great optimism and hope for their future [43]. However, immigrants encounter discrimination due to racial/ethnic, religious, and language biases in the U.S. as well as harmful social and political discourse regarding immigrants from developing countries. Although discrimination increased risk of anxiety disorders among Asian refugees, discrimination largely did not influence mental health outcomes for refugee groups. One explanation is that due to refugees' experiences with trauma and severe violence in their home countries, they may minimize everyday discrimination in the U.S. Furthermore, despite their potentially greater need for material and social support upon arrival, refugees are provided with some financial and housing support from refugee resettlement agencies to ease the transition to a new country; it may be that the need to maintain relative safety supersedes refugees' concerns with everyday negative treatment. In contrast, immigrants who leave their homelands with expectations for a better life in the U.S. may be especially vulnerable to the effects of discrimination. We found acculturative stress increased risk of depressive disorders for Latino refugees and immigrants and contributed to greater psychological distress for Asian refugees and Latino immigrants. These results are consistent with prior literature describing the negative influence of acculturative stress on the psychological adjustment of Latino and Asian immigrants [44,45]. However, the finding that acculturative stress was associated with lower risk of anxiety disorders among Asian refugees was unexpected. Anxiety is characterized by excessive fear and worry about the future [46]. Asian refugees in our sample who escaped war-torn pasts might view stressors tied to the cultural adjustment process as a type of "immigrant tax" [47] paid in exchange for resettlement in the U.S., which nonetheless frames the future with optimism rather than fear. Research has shown that coping in the form of forbearance, or emotional restraint in light of challenges, has buffered the stress of discrimination among Southeast Asian refugees in Canada [48]. More research is needed to investigate variables omitted in our analysis that may capture mechanisms underlying this anomalous finding. The most consistent predictor of negative mental health across all refugee and immigrant groups was family conflict. Our data parallel the vast literature indicating that family conflict rooted in value differences and acculturation gaps predicts poorer mental health [49,50]. Though value clashes in families are normative, migration-related stressors and experiences of displacement may uniquely shape problems in migrant family relationships and functioning [51], which in turn detract from mental health. Thus, interventions that address family-based conflict may hold significant promise in reducing risk of mental health problems for individuals in migrant families. Finally, we did not find a link between neighborhood context and mental health. Many refugees and immigrants in urban areas live in ethnic minority-concentrated neighborhoods characterized by residential segregation and economic disadvantage [52]. However, prior analyses with this data have found that co-ethnic neighborhood density can confer social and cultural resources that benefit health [32]. It may be that the inclusion of trauma exposure in our analyses captures some the environmental variability tied to risk for disorder and distress. While not the focus of this study, additional research is needed to further examine if trauma exposure mediates the relationship between neighborhood context and mental health in migrant populations. We acknowledge a number of study limitations. First, our analyses are based on self-reported refugee status, and the extent that self-reported status aligns with legal distinctions of migrant status in the data is unknown. This measure is an improvement upon prior studies that may assume refugee status based on country of origin [8,53]. Still, the lack of reliable data on legal refugee status is pervasive in large, non-clinical studies of immigrants and refugees and should be addressed in future research [54]. Second, the measures of traumatic events were based on retrospective accounts and are subject to recall bias. Due to the sensitive nature of trauma, participants could have repressed or forgotten such experiences, or chose to not disclose this information to interviewers. Relatedly, higher scores on these measures assessed exposure to a greater variety of traumatic events rather than a higher frequency of trauma exposure . These concerns, and the relatively low prevalence rates of trauma in our study, may reflect an underestimation in the measurement of lifetime exposure to trauma. Furthermore, with cross-sectional data we caution against causal statements among variables in our study, particularly with regards to post-migration stressors and mental health outcomes. The reverse relationship is possible, such that refugees and immigrants with psychiatric problems may be vulnerable to the impact of subsequent traumatic and stressful events once they are exposed. Longitudinal research is needed to confirm directionality in these relationships. It is also important to note that most migrants in our sample had lived in the U.S. for more than 10 years and that we do not measure lifetime mental health symptoms; thus our data cannot speak to reactions to and processes of adaptation following trauma that can change over time. Finally, we did not have data on refugees and immigrants from parts of the world outside Asia and Latin America, including the Middle East and Africa. Because a significant proportion of migrants have origins in these regions, future research must include these populations. Taken together, our study findings highlight the importance of understanding pre-and post-migration experiences as they relate to mental health for refugees and immigrants. Notably, it is critical for research to examine trauma's effects on mental health for migrant populations, regardless of status as a refugee or immigrant. As our results suggests, traumatic experiences tied to the migration process are perhaps more common among immigrants than is widely recognized. Furthermore, our results underscore how attention to racial, ethnic, and cultural factors that shape the experiences of refugee and immigrant populations continues to be imperative for understanding disparities in risk and resilience for psychiatric illness and distress. Trauma-informed, culturally grounded interventions, as well as humane immigration policies, are needed to reduce the risk of psychiatric illness and distress for refugees and immigrants alike. In sum, the U.S. is one of the leading recipients of the global share of immigrants and refugees, with over 43 million foreign-born individuals [55], and various factors influence negative mental health outcomes for these populations. Community organizations, social service agencies, and mental health service providers are wellpoised to address the needs of these populations but may need appropriate training to identify mental health issues rooted in trauma before, during, and after migration to the U.S. World events will continue to create new immigrants and refugees, and it is therefore vital that their mental health needs are better understood, assessed, and supported. --- Author Contributions C. C. Sangalang led the study conceptualization, data analysis and interpretation, and writing. D. Becerra contributed to the writing and interpretation of data. F. M. Mitchell, S. Lechuga-Pena, and K. Lopez contributed to the writing and theoretical content. I. Kim contributed to the study concept and interpretation of data. --- Compliance with Ethical Standards Conflict of interest All listed authors have reviewed and approved this manuscript, report no conflicts of interest, and will accept responsibility for its content. --- Appendix See Tables 4 and5.

Numerous studies describe mental health effects of pre-migration trauma and post-resettlement stress among refugees, yet less research examines these associations with non-refugee immigrants. Additionally, few studies assess the prevalence and impact of traumatic experiences after settlement in a new country. Using a U.S.-based representative sample of Asian (n = 1637) and Latino (n = 1620) refugees and immigrants, we investigated how traumatic events prior to and after migration, and post-migration stressors, are associated with mental illness and distress. Pre-migration trauma posed risk across a broad range of psychological outcomes for Asian refugees and Latino immigrants. Deleterious effects of post-migration trauma were notable for both groups of refugees and immigrants. Discrimination, acculturative stress, and family conflict increased risk for disorder and distress across groups in complex ways. Findings highlight the importance of examining trauma and stress at pre-and post-migration phases across migrant populations, including those not labeled as refugees.

Introduction Many factors influence pregnancy outcome, with consequences for maternal, newborn and child health. Thaddeus & Maine described already in 1994 'The three delay model', which identifies factors that may inhibit women from accessing antenatal care services in limited resource settings. These include delays in seeking care, due to women's low status and lack of power in health seeking decision-making and lack of awareness of danger signs among pregnant women and their close relatives. The model also identifies groups of factors resulting in delays in arrival at a health facility, such as long distances, lack of arrangements and finances for transportation and poor infrastructure. Furthermore, delays in provision of adequate care at the facility, availability of skilled care providers and equipment [1]. Domestic violence and men's controlling behaviors are also factors that influence women's ability to make decisions concerning their health, which could improve their pregnancy outcomes [2]. Antenatal care from a skilled provider may be able to reduce the risks of maternal and infant mortality and morbidity during pregnancy and childbirth [3]. The maternal mortality ratio is a strong indicator of the overall effectiveness of a national health system. In Nepal, the MMR in 2015 was 258 deaths per 100,000 live births [4], which was significantly higher than elsewhere in the world, and far below the Sustainable Development Goals target of not more than 70 deaths per 100,000 live births by the year 2030 [5]. Pregnant women meet the same health care worker, such as midwives multiple times, which creates an opportunity to build trusting relationships and it has been reported that repeated interviews and screening leads to higher rates of identification of DV [6]. A Swedish study conducted in antenatal settings, examined midwives' experiences of women's responses to their questions about men's violence [7]. The midwives described their roles as raising awareness of the problem, reducing the shame associated with being a victim of abuse, giving information and emotional support [7]. The same researchers also examined the women's experiences of being asked about violence and they found that most pregnant women were not opposed to midwives asking about their exposure to violence as part of routine identification of risk factors carried out for every pregnancy [8]. Such disclosures of DV may provide opportunities for health care workers to give information and advice on safety behaviors and how to access safe houses, counselling and other support services, and to make referrals. There is scant evidence of improved rates of midwives' detection of DV in low-income countries. However, a recent Sri Lankan study shows that improvements were made in midwives' detection of DV and the provision of assistance and knowledge following a training program that targeted intimate partner violence and lowering the barriers to discussing the issue [9]. Evidence from high-income countries also suggests that the health outcomes and safety of women living with DV can be improved through interventions to identify survivors and introduce context-specific, safety planning methods to women [10]. Focused antenatal care -an approach launched by the World Health Organization in 2002 [11]-targets all pregnant women who are at risk of developing complications. The FANC approach aims to give holistic and individualized care to all pregnant women in order to maintain normal progress in pregnancy. FANC ensures timely guidance and advice on birth preparedness and complication readiness . The concept of BP/CR addresses the delays described in Thaddeus & Maine's model to seeking, reaching, and receiving health care [1], which result in numerous maternal deaths worldwide [3]. Nepal's Ministry of Health and Population endorses the FANC approach, and recommends that all pregnant women receive basic monitoring and care during pregnancy, and that information and screening for potential complications be provided to them routinely during all ANC visits. The MoHP has implemented a package of birth preparedness interventions as part of Nepal's Safe Motherhood Plan . The package outlines a number of actions that pregnant women and their families should take to prevent delays in accessing childbirth services. Such proactive planning is known to save women's lives, especially in rural locations [12]. Worldwide, reports of preparedness for childbirth vary from 12-65% in studies conducted in Ethiopia, Uganda, Nigeria and Tanzania [13][14][15][16][17][18], to 35-62% [19][20][21][22][23] in India, and 32-65% [24][25][26][27] in Nepal. A hypothesis for this study was that woman's ability to fulfill the criteria of BP/CR can be negatively influenced by experience of DV. DV is defined as any form of physical, mental, sexual, or economic harm, including acts of reprimand or emotional harm perpetrated by one person against another with whom he or she has a familial relationship [28]. One of the main characteristics of DV is controlling behavior, which can include control over women's resources when preparing for childbirth and access to ANC. Another characteristic is the significant association between intimate partner violence and numbers of pregnancy-associated suicides and homicides [29]. Furthermore, a woman's experience of DV during pregnancy can have detrimental effects for her unborn child [30]. A multicountry study conducted by the World Health Organization revealed that the prevalence of abuse during pregnancy ranged from 1% to 28% [31]. In Campbell, Garcia-Moreno and Sharps's review of studies conducted in developing countries [32], the percentage of physical abuse during pregnancy is reported as ranging from 3.5% to 31.7% . According to the Nepal Demographic Health Survey made in 2011, 22% of women in the age range 15-49 years had experienced physical violence at least once since the age of 15 years, and 12% of women had experienced sexual violence at least once in their lifetime [12]. One-third of the women who experienced any type of DV reported their spouse as the perpetrator of the violence. In the same survey, estimates of violence during pregnancy ranged from 2% among women with higher education levels to 10% among women who were divorced, separated, or widowed [12]. The NDHS also found that 50% of pregnant Nepalese women attended all four recommended ANC visits [12]. It is clear from the survey that ANC serve as a common point of contact between pregnant women and representatives of the health care system in Nepal. Hence, pregnant women's attendance at ANCs are valuable opportunities for health care workers to identify and respond to women living with DV, in order to prevent or reduce adverse maternal and neonatal health outcomes associated with such violence. No prior studies of the influence of DV on BP/CR have been conducted in Nepal. Two major earthquakes occurred during the process of data collection. According to studies from China and Japan, women are at increased risk of DV after natural disasters [33,34]. Since there is scant evidence of how large-scale disasters such as earthquakes may affect women's BP/CR, we chose to examine associations between women's BP/CR status before and after the two earthquakes in Nepal. Hence, the aim of this study was to determine if exposure of DV affects women's BP/CR and if the cumulative effect of multiple obstacles of barriers interacted. --- Materials and methods --- Study setting The study was conducted in the antenatal clinic of Dhulikhel Hospital-Kathmandu University Hospital , which is located in Dhulikhel Municipality, Kavre District, 30 kilometres east of the capital city of Kathmandu. Dhulikhel's population of 14,283 live in a total of 3279 households [35]. However, the hospital provides services to approximately 1.9 million people from more than 50 out of 75 districts in the country [36]. The antenatal clinic at DH-KUH is run by midwives for normal pregnancies; high risk cases are referred to obstetricians. In 2015, the hospital received women for a total of 14,612 antenatal visits and there were 2865 childbirths [37]. --- Study design and population From November 2014 to November 2015, a cross-sectional descriptive study was conducted at the hospital ANC clinic, utilizing a self-completed questionnaire. Women visiting the ANC clinic during this period, who met the study's inclusion criteria and were between 12 and 28 gestational weeks, were invited to participate in the study. Women who were visually, orally, audibly and mentally disabled, severely ill, or could not speak or understand Nepali language, were excluded from the study. --- Questionnaire A questionnaire was designed and administered utilizing a color-coded audio computer-assisted self-interview in a tablet computer. The participating women received a tablet and headset, and could listen to the interview questions through the headset while also reading the same questions on the tablet. This allowed the inclusion of both literate and illiterate women in the study. The audio-recording and text were in Nepali language. The women answered the questions by touching color-coded buttons on the screen, indicating "yes" or "no." A five-item questionnaire, the Abuse Assessment Screen , was used to identify DV [38]. The order of one of the AAS questions was modified in our study. Rather than starting the questionnaire with the original first question in the AAS-"Have you ever been emotionally or physically abused by someone important in the family to you?"-we chose to begin with the fifth question, "Are you afraid of anyone within your family?" This modification was based on the assumption that the changed order facilitated a broader and gentler introduction to the questionnaire, rather than immediately beginning with the word "abuse." A questionnaire for birth preparedness and complication readiness, developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics for its safe motherhood and neonatal health program, was used to assess the status of BP/CR among the pregnant women [3,38]. Sociodemographic information and obstetric history were also included in the questionnaire. The complete questionnaire was translated from English to Nepali separately by two professional translators. The first and second authors, both Nepalese, cross-checked the wording in the translated questionnaire before starting data collection and simplified a few words. Then the questionnaire was recorded and the audio file transferred to the C-ACASI platform. The same technique has been used in India, showing both reliability and feasibility for sensitive research topics [39,40]. To our knowledge, this is the first time this questionnaire tool has been used in Nepal. The C-ACASI was pre-tested among pregnant women at Kathmandu Medical College and Teaching Hospital and no changes were needed for use in the study setting in Dhulikhel. --- Sample size Over the course of the study, nearly 6000 women were potentially eligible for the study , but due to staff and software resources, it was only possible to approach 1039 of the eligible women. Of them,1033 consented to participate. Ten women were excluded later as they chose to opt out before answering the questions on violence; 11 were excluded as it became apparent they did not meet the inclusion criteria ; and one was excluded due to missing information. Therefore, data was analyzed from 1011 women, or 97.3% of the women completed the questionnaire . The women were only included once in the study in the same pregnancy. --- Data collection Upon arrival at the antenatal clinic at DH-KUH for a routine visit, all women met a receptionist-midwife. Women with high risk factors were directly referred to an obstetrician. From each woman's ANC card, the midwife was able to determine her eligibility for the study. Eligible women were informed about an ongoing study titled "Women's reproductive health." Each woman was asked if she would like to receive further details about the study and potentially participate. If she agreed, she was accompanied to a separate research room in the clinic where the first author or a research assistant provided her with further information about the study as part of the consent procedure. If the woman declined, she continued with her ANC appointment as normal. However, if she gave consent to participate in the study, she was shown how to use the tablet computer to answer the study questionnaire and assigned a study number on her ANC card. Responding to the questionnaire required on average 15-30 minutes. Upon completion, the woman was accompanied by the data collector to the regular clinic room for her ANC appointment. --- Variables Birth preparedness and complication readiness. The concept of BP/CR comprises five activities: 1) saving money for birth-related and emergency expenses; 2) identifying the location of the closest health care facility; 3) identifying a skilled birth attendant; 4) identifying available transport; and 5) identifying blood donors in case of an emergency [3]. The response alternatives for the questions on BP/CR were "yes" or "no" in the tablet computer. In our definition, a woman was considered to be "Prepared" for childbirth and ready for potential complications, if she reported having undertaken at least three of the five basic BP/CR activities. Those positively responding to two or fewer activities were considered "Not prepared." This scoring system has been used previously in other studies [17,18,41]. --- Domestic violence. The five-item AAS was used to detect DV experienced by pregnant women. This originally American screening tool has been tested internationally with lowincome populations and uninsured women, in Brazil and Sri Lanka [42]. Women in our study were classified as having experienced "Any DV" if they reported the experience of fear of and/ or violence from someone in the family. Women classified as having experienced "Fear only" are those who gave a positive answer to the question on being afraid of someone in the family but whom answered "No" to experiencing violence. Women classified as reporting "Violence" were those with a positive response to any of the questions on physical, emotional and sexual violence, regardless of reporting fear of someone in the family or not. Women reporting having been afraid of someone in the family, independent of their response to the other abuse questions, were classified as having "Fear." Women classified as never experiencing neither fear nor violence were considered to be not exposed to domestic violence: "No domestic violence." Women who had experienced violence were also asked about the time point in which the violence occurred: ever, in the last year, and/or during the current pregnancy. Sociodemographic characteristics, obstetric history and earthquake status. The interview included questions about age, education, the income of the woman and her husband, a woman's autonomy to use her own income, geographic setting, and family structure. Family structure was categorized as either a nuclear family, where the husband, wife and children are living separately from their in-laws, or an extended family, where a woman is living with her husband, children, and in-laws and possibly other members of their families. The variables "Women's own income" and "Autonomy to use income" were computed into three categories: "No income no autonomy," "Income but no autonomy" and "Income and autonomy." The women were also categorized based on caste/ethnicity, which was self-reported and in their identification cards. Members of Dalit communities belong to the most oppressed social class in Nepal; "Disadvantaged Janajati" are indigenous groups with little or no social mobility; "Advantaged Janajati" are indigenous groups with opportunity and access to social mobility, and "Upper castes" are traditionally the most privileged groups in the social hierarchy. The obstetric variables collected included parity, number of antenatal visits, gestational age and pregnancy complications. Of these, "Parity" was computed into three categories: "First pregnancy," "Previous pregnancy without complication" and "Previous pregnancy with complication." An earthquake variable was also included following the two major earthquakes that affected Nepal during data collection, on 25 April and 12 May in 2015. The earthquakes caused extensive damage with reports of nearly 9000 deaths and 23,000 injuries [43]. Inclusion of participants into the study resumed three weeks after the last earthquake. Adding the pre-and postearthquakes variables granted an opportunity to investigate the consequences of the natural disaster on women's BP/CR. --- Data analysis The collected data were analyzed using SPSS version 22. Descriptive analysis was performed to assess the relationships between women's BP/CR status and their sociodemographic, obstetric, earthquake status, and DV characteristics and experiences. The five BP/CR activities, along with a composite score for BP/CR, were compared with experiences of DV and with pre-or post-earthquake status. The prevalence rates for different kinds of domestic violence were compared with the BP/CR statuses. In this study, complete case information was obtained from 954 women after adjusting for the variables of women's age, education and parity. With this population, logistic regression analysis was used to identify the factors associated with BP/CR, by calculating crudes odds ratios and adjusted odds ratios, with 95% confidence intervals . --- Ethical considerations Permission for the study was granted by the Regional Committee for Medical and Health Research Ethics of Central Norway in Norway, the Nepal Health Research Council , and the Kathmandu University Institutional Review Committee . The objective of the study, the principle and practical meaning of "voluntary participation', and possibilities to opt out of the study at any time without giving a reason, were thoroughly explained to the participants before they completed the questionnaires. Verbal consent was approved by the ethics committees and chosen over written consent, due to low literacy rates in the study area. In total, 40% of women and 14% of men have not received a formal education in Nepal [12]. The verbal consent of participants was registered by the data collector before participation started. The participants completed the questionnaires in a private room to ensure their privacy and confidentiality. Additionally, to ensure safety, study participants received an information brochure called "Safe motherhood," produced by the government of Nepal. They also received an anonymous-looking business card with a common female forename and a telephone number printed on it. The card was the contact number for the female psychosocial counsellor employed at the One-stop Crisis Management Centre for victims of gender-based violence, located at Dhulikhel Hospital. These strategies were designed to assist women in potentially justifying why their visits with the midwives took longer than possibly anticipated for anyone accompanying them to the ANC clinic, and in the case that the women did not want to disclose information about answering questions on DV as part of the questionnaire. All study participants were provided the option of private counselling if needed following the interview, but none availed of this. The mean age of marriage for women in Nepal is 17.4 years [12]. Thus, in order to include all fertile women in the study, we included women under age 18, following the age categories in the NDHS. As DV is a sensitive topic and may be hidden from or perpetrated by close relatives, parental consent was not sought on behalf of these women. This was approved by the ethical committees. --- Results Among the 1011 study participants, 45% resided in urban areas and the remaining in rural settings. Ninety-nine percent were married and in a first marriage, and 96.5% were their husband's only wife. The majority, 61.3%, lived in extended families. The women had a mean age of 24.4 years and their husbands were a few years older, 27.6 years . As shown in Table 1, slightly more than three-fourths of women, 76.3%, were not exposed to DV, 14% reported they were afraid of someone in the family but not exposed to violence, and 9.7% had experience of both DV and fear. Among the women who were prepared for childbirth according to our definition, 83.3% had no experience of violence, compared with the women who were not prepared for childbirth, of whom 69.4% had no experience of DV. Among the women who were not prepared, most were from rural areas, had no income of their own nor autonomy to use the available means in the family. Women who were pregnant for the first time and in the second trimester did not prepare for childbirth as consistently as women with previous pregnancy experience. The proportion of women who did not prepare for childbirth increased after the earthquakes. In total, 61.7% of the women were not prepared post-earthquakes, compared with 38.3% before the earthquakes. As shown in Table 2, half of the women in our study were not prepared for childbirth. Slightly more than three-quarters, 77.6%, of the women had identified a health facility for the delivery and/or for obstetric emergencies. More than half had saved money, 64.5%, for the anticipated costs of delivery and emergency if needed. Half of the participants had identified a skilled birth attendant. Less than half of the women arranged transportation, and 20.1% had identified a potential blood donor. However, women with experience of DV were significantly less prepared than those without DV in all of the five activities . Following the earthquakes, women were also significantly less prepared, with the most pronounced decline being in arrangements for transportation and identification of a skilled birth attendant . Approximately one-quarter of the women, 23.7%, reported experiences of any DV. A substantially higher percentage of the women who were not prepared were among the women exposed to DV. A total of 203 women, 20.1%, reported being afraid of someone in the family at the time of completing the questionnaire, while 6.1% reported having experienced emotional and physical abuse combined, 4% physical abuse only, 2.3% physical abuse during the current pregnancy, and 1.6% had been sexually abused . In the binary logistic regression analysis, for the 509 of 1011 women who were not prepared for childbirth there was a statistically significant association between exposure to violence and not being prepared . Further, being of young age, living in rural areas, being of Dalit or other disadvantaged ethnic group status, having no or limited formal education, having a husband with low or no education and low income, and attending less than four antenatal visits, were all positively associated with not being prepared for childbirth. However, there was no substantial association between age of husband or family structure and BP/CR. Two additional predictors for being prepared were having personal income and the autonomy to use it , and having previous pregnancies with or without complication . We did not find support for statistical interaction between being exposed to domestic violence and earthquake status and the odds of not being prepared . Compared with no DV, women reporting fear only had a 2.5 times increased crude odds of not being prepared prior to the earthquake. The corresponding odds ratio after the earthquake was 1.9 . Compared with no DV, women exposed to violence had a 2.4 times increased crude odds of not being prepared prior to the earthquake. The corresponding odds ratio after the earthquake was 3.2 . --- Discussion Several factors will influence a woman's ability to prepare for childbirth. In this study, we focused on exposure to DV, as we identified a gap in information on this matter in developing countries. We found that almost one-quarter of the participants had experience of some kind of DV and they were twice as likely not to be prepared for childbirth compared with those who reported no experience of DV. Vulnerable women in poor social circumstances were more likely to not being prepared for childbirth. Whereas, personal income and autonomy to use it, were predictors for preparing for childbirth. These factors reflects the influence of women's social and economic position on their ability to preparing for childbirth in a patriarchal society. Within the health system, ANC provides services that most women receive during their lifetime, also in Nepal. An ongoing relationship with an ANC provider may facilitate the development of the trust needed for a woman to disclose the occurrence of DV and to accept information about safety planning and BP/CR. Much of the evidence on effective interventions to address DV in ANC contexts has come from high-income countries. Without similar knowledge from low-income settings, interventions and guidelines in the health sector may not accurately reflect the realities for millions of women. Furthermore, many women in lowincome settings such as Nepal are unable to leave violent relationships, and therefore it is critical to mitigate the harm done to them. --- Domestic violence Our findings, that women with experiences of DV did not prepare for childbirth as other women, are similar to those from a community-based study of women with a child under the age of two years in India [44], which demonstrated significant associations between violence and poor birth preparedness. This highlights the importance to public health of ANC providers routinely asking pregnant women if they are living in violent situations. In addition to ANC and other health care providers, communities can play a role in supporting pregnant women's preparations for childbirth, especially those living with DV. This was expressed in a recent study in the same community as we studied, where men and women of all ages and family roles gave suggestions to the researchers for potential improvements that would benefit women living with DV during pregnancy [2]. For example, they suggested community awareness-raising programs about the health effects of DV, and engaging extended family members to address DV and help women to attend antenatal check-ups [2]. --- Birth preparedness and complication readiness According to our definition of BP/CR, half of the women were not prepared for childbirth. This is higher than found in a number of community-based studies of women who had experienced childbirth in Nepal [24], India [19,23], and Ethiopia and Tanzania [13,14,45,46] in recent years. The difference in findings may be due to differences in the study areas or to the implementation of different health programs by government or non-governmental organizations in those areas [27]. Hence, our results may reflect selection bias, since our study was hospital based, while the other studies were not. It is reasonable to assume that women who attend ANC services will be more prepared for childbirth, since ANC visits are an opportunity for health care workers to inform them about danger signs and risks in pregnancy and possible complications that may arise before, during, and after birth in recent years [47]. Nevertheless, our finding that half of our study population was prepared for birth is lower than found in a study conducted in an antenatal clinic in Kenya [48]. Our study revealed that the majority of women attending the ANC at Dhulikhel Hospital had identified a health facility for childbirth and/or obstetric emergencies and had saved money for such emergencies. Similar results have been reported from other studies [14,17]. In addition to identifying a health facility, arranging transportation is essential for reducing delays to reaching facilities when birth is imminent or in the cases of emergency due to complications during pregnancy. Only slightly over one-third, 38%, of the women had taken steps to arrange transportation, which is a low proportion compared with that found in another study in Nepal [27], and in studies conducted in the African countries, Ethiopia, Tanzania and Kenya [14,46,48] and India [21,22]. The comparative lack of preparation for transportation could have been due to geographic challenges in the study area, including poor road infrastructure and limited public vehicles in most rural settings. After the earthquakes, significantly fewer women made efforts to arrange transportation . One-fifth of the women had arranged for a potential blood donor, which is notably higher than found in other studies among pregnant women in which the same type of preparation was found to be critically low [19,24,47], although these studies were conducted in community settings, not hospital-based ones. According to the aforementioned studies, only 3% of the pregnant women in Ethiopia, < 5% in Nepal, and 9.6% in India had identified potential blood donors in advance of childbirth. Dhulikhel Hospital organizes regular awareness campaigns in many communities through its outreach centers, which cover a wide range of public health topics, including ANC and birth preparedness. Furthermore, it is possible that the women who were attending the hospital had been informed about the importance of finding potential donors for childbirth. It is also likely that only those who had received some public health information attended the ANC. --- Other associated risk factors Younger women were three times as likely to be unprepared for birth or complications during pregnancy compared with women who were aged thirty years or older. This result is in accordance with findings from previous studies in Tanzania [46] and India [23], and illustrates the vulnerability of young married women, living in their husband's households, as is the cultural custom in Nepal. Furthermore, women from rural settings were 1.5 times more likely to be insufficiently prepared compared with women in urban settings in our study. This result is corroborated by two studies from Ethiopia [14,45], where the odds of sufficient BP/CR among women who lived in with urban areas were six and two times greater, respectively. This finding may relate to the women having less access to health information through different media in rural areas, and relatively high barriers due to distance and lack of transportation compared with women in urban areas [45]. Additionally, we found a significant association between BP/CR and women's caste and ethnicity in our study. The women belonging to the Dalit caste were three times more likely to be unprepared compared with women from upper castes. This finding is consistent with findings from an analysis of the NDHS survey done in 2011, which revealed that Dalit women utilized ANC services less than did women of other castes and ethnicities [49]. However, our finding conflicts with an Indian study that was conducted among a population of rural women who had given birth [22] and in which no significant associations were found between BP/CR and caste. In addition, in common with other studies [13,14,20,45,46], we found that low education levels or no education were notably associated with not being prepared for childbirth or obstetric complications. Furthermore, women who had attended less than four antenatal visits had a statistically significant higher risk of being unprepared for childbirth compared with women who had attended four or more ANC visits. Similar findings were present in Tanzania [17] and Ethiopia [45]. Women appear to be disproportionately vulnerable to violence and abuse in the aftermath of natural disasters, although research on this topic is limited. A Chinese study after the earthquake in Sichuan Province in 2008 indicated that women experienced more violence following the disaster [33]. A qualitative study with women in Australia describes both new and increased violence from male partners after the Black Saturday bushfires in 2009. [50]. In the aftermath of a natural disaster, surviving and meeting basic needs will be first priorities. Furthermore, health facilities may be destroyed or become overwhelmed, support services for women exposed to DV may be limited or non-existing, and support persons may have to deal with their own emergencies. Stress related to financial burdens on families may lead to increases in DV [2]. Due to culturally accepted gender roles, women may be tasked as the primary care takers for others in disaster situations. This combined with reduced finances and access to transportation, presents difficulties in terms of meeting their own and their families' basic needs, and may be compounded by grief and emotional trauma following the disaster. Consequently, when the earthquakes occurred during our data collection, we decided to analyze whether the added burdens of the disaster influenced BP/CR in interaction with DV. We found an increase in the proportion of women who were unprepared for childbirth after the earthquakes compared with women who did not prepare for childbirth before the earthquakes. However, we could not detect any interference between DV, BP/CR and the earthquakes. --- Strengths and limitations of the study This is the first comprehensive study of its kind in Nepal, where exposure to DV during pregnancy is examined as a potential risk for lack of preparedness for childbirth. This topic remains under-investigated in the world as well. The strength of the study includes its conduct among a non-selected population of pregnant women attending a hospital-based antenatal clinic. Also, the size of the study is large, allowing for multiple adjustments. The knowledge obtained from the study makes a contribution to a previously overlooked topic in the DV research field as well, and will guide ANC providers to identify and assist women who are vulnerable to inadequate childbirth preparation due to living with DV. We also included pregnant women under 18 years in this study , a population that is sometimes excluded from reproductive health research due to the Helsinki Declaration, which recommends obtaining the consent of parents or guardians for all participants under 18 years. In Nepal, however, the mean age of marriage is 17.4 years [12], and the vast majority of married women are living independently from their parents. Including the insights of young women is important for improving ANC services for all women experiencing DV in Nepal. Our study therefore contributes to a fuller assessment of the prevalence of DV and BP/CR across age groups. Another notable strength of the study is the use of a C-ACASI questionnaire, which provided an opportunity for women to respond to sensitive questions in a private, anonymous and confidential way, regardless of their literacy. We asked the women about their opinion of the technology after they had completed the questionnaire. The overwhelming majority reported that they found the method simple. Most importantly, it allowed for the inclusion of an illiterate population, and illiteracy was one of the most significant risk factors for inadequate BP/CR. This is a cross-sectional study which does not allow for cause and effect relationships to be made between potential risks and BP/CR. The study was hospital-based, and this may have limited our potential to generalize the finding to other settings, for example to rural areas with only outreach centers. We included pregnant women between 12 weeks and 28 weeks gestation only, and women may be more prepared for childbirth or complications at a later stage in a pregnancy. Women with hearing and vision disabilities, or whom did not speak Nepali, were excluded from the study, which is a limitation. These women may be vulnerable groups who could have given us more information on possible experiences of DV. However, as we were using C-ACASIs on a tablet computer in Nepali language, it was practically challenging to include these women. A possible bias in our findings could be related to a qualitative study that was done six months prior to this study in the same community. The previous study targeted community members generally, and no pregnant women were included. Also, BP/CR was not one of the topics specifically discussed in the study; rather, the focus of the qualitative study was on perceptions of violence against pregnant women. However, participants in the qualitative study may have discussed the topics raised in the FGDs with friends and families, and we cannot know if this may have raised general awareness and influenced pregnant women's preparedness for childbirth. If pregnancy outcomes were obtained from the same women after childbirth, the results could be compared during pregnancy and post-partum; this would be a valuable future study. Similarly, we did not obtain any information about women's knowledge of obstetric danger signs. This knowledge is important for assessing BP/CR and newborn complications. However, the primary aim of the study was to evaluate if DV influenced the five BP/CR activities [3]. Likewise, data were collected based on pregnant women's perspectives. Since men's involvement is crucial for the realization of birth plans and complication readiness [3], innovative strategies to increase men's awareness of obstetric danger signs and BP/CR are required to significantly improve situations for pregnant women [51]. Finally, underreporting of DV in this study is possible. In spite of the anonymity provided by the C-ACASI questionnaire, women may not have answered the questions about DV truthfully nor understood their personal experiences to be types of DV. As trust between a pregnant woman and her ANC providers is likely to increase over the course of several meetings, women might be more willing to disclose violence in their family situations at a later ANC appointment or stage in pregnancy. --- Conclusions This study identified pregnant women attending an antenatal clinic in Nepal who had experienced DV, which affected their BP/CR. These vulnerable women may need extra care and attention in the health system in order to reduce the potentially harmful effects of violence on maternal and neonatal health, and preparations for childbirth. To gain further information about insufficient birth preparedness, a follow-up study on the outcomes of the pregnancies affected by DV is recommended. This new knowledge could inform and guide interventions by health care providers and other stakeholders. --- The datasets generated and analyzed in this study are not publicly available due to their sensitive nature and given that release of the information could compromise the participants' safety. An anonymized version of the data can be made available upon reasonable request. The data is stored on --- Supporting information S1

¶ Other members of the Addressing Domestic Violence in Antenatal Care Environments (ADVANCE) study group are listed in the Acknowledgments.

Introduction A major premise of the Internet was that it would create a public sphere that fosters democratic deliberation and consensus formation [1][2][3]. Yet, there is increasing concern that the Internet actually reinforces processes of opinion polarization as users interact with like-minded individuals [4], a tendency that personalization algorithms installed in search engines and online social networks further intensify [5,6]. These psychological and computational homophily biases fragment online debate into virtual echo chambers [7]. Formal models of social influence in networks are powerful tools for understanding whether and under what conditions communication in social networks fosters processes of consensus formation or opinion polarization [8]. However, existing models have been tailored to represent offline rather than online communication. Here, we show that taking into account that online communication is characterized by "one-to-many" communication rather than "one-to-one" communication drastically changes the predictions of one of the most prominent models [9]. Specifically, we show that the one-to-many communication regime characteristic of online communication fosters the emergence of isolated individuals and the formation internally homogenous but mutually dissimilar subgroups. Scholars have long recognized that online communication differs in important ways from its offline counterpart , but existing research focused on differences that affect within-individual processes and largely ignored the complexity arising from the communication between individuals. A classical finding from social psychology, for instance, is that computer-mediated communication is much less affected by individuals' physical appearance , which frees individuals from the social roles associated with memberships in high or low status groups [12]. This, it is argued, increases the relative impact that members of low-status groups have on collective dynamics, decreasing intergroup conflict and fostering consensus formation [12,13]. Likewise, research showed that online communication allows shy individuals to overcome the communication barriers that socially isolate them in offline settings [14]. t = 1,one-to-many t = 1,one-to-one Figure 1: Illustration of the intuition that one-to-many communication fosters isolation. Nodes have three characteristics that are open to influence. The number of traits shared by two nodes and, thus, the probability that a sender exerts influence on the receiver is shown by the number of lines connecting the nodes. Panel shows the initial setup before the top-left agent communicated his shape trait either under the one-to-one communication regime or the one-to-many regime . In contrast to the existing research, we focus on the complexity arising from the interaction between individuals, rather than on within-individual processes. To this end, we study Axelrod's prominent formal model of communication that was developed for offline social networks , keeping all assumptions about individual behavior unchanged but implementing communication between actors in a way that captures typical forms of online communication . With analytical tools and simulation, we demonstrate that this change in model assumptions drastically changes model predictions and leads to conclusions that challenge insights from research on within-individual processes. Contrary to the sketched finding that computer-mediated communication fosters the emergence of consensus [12,13], we find that the online communication regime fosters the emergence of mutually disagreeing subgroups in our simulations. Likewise, while social-psychological research found that online communication allows some individuals to overcome social isolation [14], we demonstrate that online communication increases the chances that individuals get socially isolated. We derive these results using an approach that is very different from social-psychological research. While these studies explored how online communication changes the way individuals behave and respond to each other, our work demonstrates that differences between online and offline communication arise through merely a different communication structure. In complexity terms, we find that the "whole" changes not because the "parts" have changed but because the interdependencies between the "parts" are slightly different. Axelrod's model of the dissemination of culture is one of the most prominent models of consensus formation and the emergence of dissimilar subgroups. It is also a typical representative of models implementing offline communication. Axelrod proposed the model to address what he perceived as a fundamental puzzle in research on social influence, asking "If people tend to become more alike in their beliefs, attitudes, and behavior when they interact, why do not all such differences eventually disappear?" [9, pp. 203]. Axelrod then showed with an agent-based model how assimilation at the microlevel of individual interactions can be reconciled with cultural differentiation at the level of society as a whole. Like most contributions to the literature, Axelrod's model represents individuals as nodes in a network that are described by a set of cultural traits representing individuals' cultural preferences . Furthermore, Axelrod implemented the so-called "one-toone" communication regime where in a social encounter one agent always communicates one cultural trait to one of her network contacts. This one-to-one communication regime mimics the face-to-face communication present in many offline contexts, but it differs from a form of communication that is ubiquitous on the Internet and that we label "oneto-many" communication. When Internet users blog or post content on online social networks, for instance, they communicate content to multiple online contacts at once rather than to just one of them. This paper was motivated by the following intuition about the complexity arising from one-to-many communication. Consider, for illustration, the network of four actors depicted in Figure 1. All actors are described by three cultural traits: shape , color , and letter . The number of lines connecting the nodes represents the number of cultural traits the respective two nodes have in common. Implementing homophily [4,15,16], Axelrod assumed that trait overlap increases the likelihood that nodes will adopt a trait from their neighbor. Suppose that the topleft agent ) communicates his shape trait under the two different communication regimes. Under the one-toone communication regime assumed in Axelrod's model, this agent communicates his trait to one of the two agents with whom he already shares the letter and color traits. Assume that the top-right agent is selected for interaction and this agent accepted the trait. Figure 1 visualizes this situation, showing the increased cultural similarity between receiver and sender. As a side effect, the cultural overlap between the top-right agent and the bottom-left agent decreased, but the overall network remains connected. Figure 1 shows that a different outcome arises when agents communicate under the one-to-many regime. The same agent communicates his shape trait, but let us assume now all actors with whom he has nonzero cultural overlap adopt the communicated trait. This has two consequences that we study in this paper. First, a culturally homogenous cluster forms, because after the communication three actors hold identical cultural traits. Communication did not only increase similarity between the sender and the receivers of the message, but also preserve the similarity between the nodes who adopted the trait. Under the one-to-one regime, in contrast, the two nodes on the right-hand side turned less similar to each other. Second, the bottom-left agent no longer shares any trait with the other agents, ending up culturally isolated. The fact that the bottom-left agent was not influenced by the top-left agent did not only exclude that they grew more similar, but also increased the dissimilarity between the bottom-left agent and the other two agents, as they did adopt the cultural trait communicated by the top-left agent. Counterintuitively, this stylized example suggests that cluster formation and cultural isolation are more likely under the one-to-many communication regime, even though there are more instances of social influence than under Axelrod's one-to-one regime. The intuition illustrated in Figure 1 requires a formal analysis for two reasons. First, under the online one-to-many communication regime, the sender transmitted a trait to multiple network contacts, while there was only a single act of communication under the one-to-one regime. It remains unclear whether repeated one-to-one communication could account for this apparent difference between the communication regimes or not. Second, the figure focuses on a tiny population with a simple network structure, leaving open whether one-to-many communication fosters isolation also when larger numbers of agents communicate simultaneously. In order to test the validity of our intuition, we implemented a one-to-many communication regime in Axelrod's model of cultural dissemination, keeping unchanged all other model assumptions . That is, we included that actors simultaneously communicate a trait to their whole network at once. Subsequently, the alters decide individually whether to adopt or reject the trait according to the rules specified in the original Axelrod model. We compared the predictions of the new model with predictions of Axelrod's original model, using analytical as well as computational tools. First, we compared the two models' predictions for very small but analytically tractable social networks, conducting a Markov-Chain analysis, and find that indeed one-to-many communication increases the chances that individuals become isolated. Second, using computational methods, we show that our conclusions hold also for bigger populations, variations in the structure of the underlying social network, and higher cultural complexity in terms of the number of cultural traits and features. Moreover, we find that medium sized clusters emerge under one-tomany communication at a low, but consistent rate. --- Literature Axelrod's model of the dissemination of culture provides a prominent explanation of the emergence, diffusion, and stability of distinct cultural profiles. In this literature, an individual's culture is defined as the set of her personal characteristics that are susceptible to social influence [9, p. 206-7]. Cultural dynamics unfold from the conjunction of two social forces, the selection of culturally similar communication partners and the social influence resulting from communication. As social influence increases cultural similarity between communication partners, it creates in conjunction with selection a positive feedback loop that results in the emergence of cultural clusters that grow internally increasingly similar, and, as a consequence, mutually dissimilar. Distinct cultural clusters remain stable when the cultural overlap between clusters drops to zero, which rules out subsequent communication according to the selection principle. Axelrod's model shares this critical assumption with many alternative models, such as the prominent models of bounded confidence [18,19], as summarized in a recent literature review by Flache et al. [8]. Many contributions have extended Axelrod's work [20], testing the sensitivity of his predictions to adjustments in model assumptions about, for instance, the impact of mass media [21], institutions [22], and the scale of the cultural features [23][24][25]. An important advancement was the introduction of noise in the process of communication-partner selection and social influence [24,[26][27][28]. It turned out that allowing agents to sometimes deviate from Axelrod's assumptions with a small probability can cause the system to inevitably move towards monoculture, i.e., perfect cultural homogeneity. Model predictions are more robust, however, when agents are assumed to interact only with network contacts that share multiple cultural traits [25,29], when network ties to contacts that are culturally too dissimilar are dissolved [30], or when agents are allowed to form institutions bottom-up that, in turn, influence the agents top-down [22]. Recently, Battiston et al. [31] conceptualized exchange discussion networks as a multiplex system in which different topics are discussed among different peers. Multiple disseminations of culture models are layered on top of each other, creating distinct and robust clusters of cultural identities. Another extension to the model that can explain the persistence of cultural diversity despite random deviations is the so-called "multilateral social influence" [32], a form of social influence that is similar to the concept of "complex contagion" from the literature on diffusion processes in social networks [33]. Unlike Axelrod, who modeled influence as a dyadic, one-to-one process where an agent adopts a cultural trait from a network contact, Flache and Macy [32] assumed that agents always consider the cultural traits of multiple network contacts when they reconsider their cultural profile and adopt the trait that dominates in their neighborhood. This "many-to-one" form of cultural communication makes predictions much more robust to noise and is the reverse of the "one-to-many" communication regime that we study here. That is, while Flache and Macy assumed that an agent is always influenced by multiple network contacts, we consider that an individual agent exerts influence on multiple contacts. Modelers have also incorporated assumptions about one-to-many communication in existing models [34,35]. However, while there are social influence models that implement communication regimes similar to the one-tomany communication that we study, the literature lacks an analysis of whether and under what conditions one-tomany communication generates different cultural dynamics compared to one-to-one communication. Thus, unlike earlier contributions, we implement one-to-many communication in Axelrod's model keeping all other model assumptions unchanged. Next, we compare predictions of the new model with the predictions of the original approach. --- The Model The aim of the present analysis is to test our intuition that one-to-many communication generates more isolation than one-to-one communication. Axelrod's used a very abstract representation of agents' cultural characteristics. Features can represent something as basic as the person's favorite song or something as complex and multidimensional as the person's music taste. Likewise, it can model the person's view on abortion or her much more complex preference for a specific political party which may be a function of her view on abortion and many other aspects. In Section 4.2.6, we study how the dynamics emerging from one-to-one and one-to-many communication are affected by cultural complexity measured in terms of the number of features and traits per feature. Table 1 summarizes and compares the two variants of Axelrod's model. At every time step 𝑡, an agent 𝑖 is selected at random from the population. This agent is the source of influence. Second, in the original model, one of 𝑖's neighbors is selected for communication with 𝑖, a step that is not necessary under one-to-many communication where 𝑖 communicates with all of her neighbors who are open to influence and not yet culturally identical. In Step , one of the cultural features on which there is not yet consensus between agent 𝑖 and her neighbors is selected. In Axelrod's original model, this translates into the exclusion of all features where 𝑖 and 𝑗 hold the same trait. In the variant with one-tomany communication, however, one of the features where 𝑖 disagrees with at least one of her neighbors is picked. Unlike in Axelrod's model with one-to-one communication, this implies that 𝑖 might transmit a trait to one of her neighbors 𝑗 that 𝑗 already adopted, making this dyadic communication ineffective. However, similar to Axelrod's model, also the variant with one-to-many communication excludes that a feature is chosen in which cultural change is impossible, as there must be at least one neighbor who disagrees with 𝑖 on the selected cultural dimension. Step implements social influence and is, therefore, the part where one-toone and one-to-many communication are implemented. In Axelrod's original model, actor 𝑗 adopts the selected trait with a probability equal to the overall cultural overlap between 𝑖 and 𝑗. For instance, when 𝑖 and 𝑗 hold the same trait on half of the features, then the chance that 𝑗 will adopt the trait chosen in Step is 50 percent. This implements homophily, the notion that individuals tend to be influenced by likeminded communication partners. Empirical research showed that homophily is a strong force both online and offline [4,36,37]. The same principle is implemented in the new version of the model but here every neighbor of 𝑗 adopts the selected trait with a probability equal to the pairwise cultural similarity between 𝑖 and the respective neighbor 𝑗. --- Comparison of the Two Communication Regimes We compared the models with two different methods. First, we studied small populations of only four agents described by only three dichotomous cultural features. The simplicity of this setup allowed us to conduct a detailed analysis and provide an analytical proof using a Markov-chain analysis. Second, we conducted agent-based simulations in order to test whether the conclusions from the Markov-chain analysis also hold in more complex settings with more agents, higher numbers of cultural traits and features, different neighborhood sizes, and more complex network structures. Using a larger population size in the second analysis also allowed us to address what Axelrod was primarily interested in, cultural diversity. More precisely, we could test in the second analysis how the communication regime affects the degree of and conditions for cultural clustering, the coexistence of local consensus, and global diversity highlighted by Axelrod's original analysis. --- Markov-Chain Analysis. To be able to compare the two models with analytical tools, we first analyzed a setting that is very simple but where the intuition outlined above, nevertheless, suggests that predictions of the two model variants differ. According to the described intuition, isolation in the one-to-many model might arise when an actor 𝑗 is not influenced by a network neighbor 𝑖, but their joint neighbors are influenced. Clusters form because an actor 𝑗 exerts the same influence on multiple network contacts. Testing this intuition requires a network consisting of sender 𝑖, receiver 𝑗, and at least two other receivers 𝑘 and 𝑙, that is fully connected. Furthermore, we set the number 𝐹 of cultural features to 3, as this creates sufficient variation in probability that agents influence each other. If two agents do not share a trait on any of the three features, their communication probability 𝑝 𝑖𝑗 = 0. If they share 1 trait, then 𝑝 𝑖𝑗 = 1/3. If they share 2 traits, then 𝑝 𝑖𝑗 = 2/3; and if they share all traits, 𝑝 𝑖𝑗 = 1. Finally, we assumed that all three features are dichotomous . The system with 𝑁 = 4, 𝐹 = 3, and 𝑄 = 2 has a finite number of cultural configurations. A cultural configuration is a mapping that assigns to each of the 𝐹 features of each of the 𝑁 agents a value from the set of possible trait values . The total number of possible configurations is 𝑄 𝐹𝑁 = 2 12 = 4096. The dynamics of this system can be fully represented as a Markov chain that assigns to every ordered pair of cultural configurations a probability to move from one configuration to the other within one iteration of the simulation of the model. With 4096 configurations this Markov model of the system is prohibitively large for an exhaustive analyses. However, we can partition the set of all configurations into subsets, called classes hereafter, which have the property that for every ordered pair of configurations 𝑋 and 𝑌 of which 𝑋 falls into class 𝑆 1 and 𝑌 falls into class 𝑆 2 , the transition probability from 𝑋 to 𝑌 is the same. Analyzing the dynamics of the Markov Chain constituted by these classes and transition probabilities between them is equivalent to analyzing the Markov Chain of all configurations. As we will show, we can reduce the system to a number of classes that is small enough to derive analytically the probabilities that cultural isolation arises from a random start under one-toone and one-to-many communication, respectively. To arrive at a partition of the configurations into classes, we first observe that each feature 𝑓 is always in exactly one of the three different states. Consensus. All agents adopt the same trait on feature 𝑓. According to Rule 3 of both models, any future communication changing this feature is excluded because consensus has been reached. 1-3 Split. One agent adopted trait 𝑞, while the three others have 𝑞 󸀠 . 2-2 Split. Two agents share trait 𝑞, while the other two agents adopted 𝑞 󸀠 . A first classification of configurations can be obtained from distinguishing configurations that have a different distribution of states over the three features. All configurations that have the same number of features in the states C , 13 , or 22 fall into the same semiclass. The number of distinct semi-classes can be obtained from computing the number of possible outcomes if for every feature its state is drawn randomly and independently with replacement from the three possible values C, 13, or 12. Thus, for the case where a feature can be in 𝑟 = 3 different states and there are 𝑛 = 3 features constituting a cultural vector, this number is given as the number of unordered permutations for a set when sampling with replacement as ! 𝑟! ! = ! 3! ! = 10 However, a semi-class can consist of several classes; thus the number of classes is larger than 10. The reason is that transition probabilities from a configuration containing features with more than one 1-3 split or 2-2 split may be different, depending on whether the splits separate the set of agents along the same lines or are asymmetrical. We distinguish three degrees of symmetry within the semiclasses with more than one nonconsensus feature and assign the labels: symmetrical , semi-symmetrical , or nonsymmetrical . 1 For example, the 13-13-13 semi-class consists of three different classes: symmetrical, semi-symmetrical, and non-symmetrical. Examples are shown in Figure 2. Even though the three configurations are part of the same semi-class, they have very different probabilities of communication and transition into another class. The symmetrical 13-13-13 class is an absorbing state of the dynamic and is characterized by one cluster of three culturally identical agents and one isolate. The isolated agent in this class is different from the same three others on all three features, and thus no further communication is possible. The configurations 13-13-13ss and 13-13-13ns shown in Figure 2 instead allow for communication between some or all agents. An overview of all classes and the proportion of states that fall into each class is included in Appendix A. For both model variants, one can identify a partition into a small number of classes of configurations and calculate for every pair of classes the probability that the corresponding transition occurs within one iteration. Figures 3 and 3 visualize the transition probabilities for both models variants. In the figures, nodes are colored according to whether they represent an absorbing class , a class from which consensus is the only reachable equilibrium , or whether more equilibria are still reachable . 2 Edge color corresponds to the probability that the system moves from one state to another with darker edges indicating higher transition probability. Recursive paths are not shown. Both model variants have three possible absorbing classes; these are classes that once selected by the dynamics will never be left again: the consensus class , the isolation class , and the polarization class . Consensus is stable since social influence will never lead to changes in agents' features. Isolation and polarization are group split states; they are stable because actors are either perfectly similar or perfectly dissimilar from their neighbors. In both cases, communication will never lead to changes in the cultural features. As can be seen in the transition diagram, as well as in the transition matrix diagonal, these are the only classes that are "sinks" with an out-degree of zero in the Markov graph. Given that from every other class there is path towards at least one of the absorbing classes, we know that in the long run the system must end up in one of the absorbing classes. Figure 3 illustrates how isolation can more readily emerge under one-to-many communication. For example, once the system has reached a configuration in which one agent is "almost" isolated but still agrees with the three others on one single feature and 3), it is under one-to-many communication three --- Communication regime Class One-to-one One-to-many C-C-C . 8 0 1 . 7 1 3 22-22-22s . 0 6 4 . 0 7 3 13-13-13s . 1 3 5 . 2 1 5 times as likely that this agent will end up isolated after the next influence than it is under one-to-one communication. 3 More generally, using the Markov chain convergence theorem, one can calculate for each of the three absorbing classes the probability to be reached under both communication regimes, given the initial distribution of configurations. This requires a row vector 𝑞 of the initial distribution of states and the transition matrix 𝑇. The stationary distribution 𝑝 * is then given by 𝑝 * = 𝑞𝑇 ∞ Table 2 reports the stationary distributions for both model variants given a uniform probability of initializing the system in any of its 4096 configurations. These results support our intuition that isolation is a more likely outcome of the dynamics of cultural influence under the one-tomany communication regime than under the one-to-one communication regime. More precisely, we find that the probability of the outcome of cultural isolation is about 1.6 times higher under one-to-many communication . We also observe that one-to-many communication reduces the likelihood of consensus to emerge and thus increases the likelihood that cultural diversity persists despite social influence. Next, we turn to exploring how one-tomany communication affects the likelihood and persistence of isolation and cultural clustering in larger populations. --- Isolation and Cultural Clustering in Bigger Populations. The Markov-chain analysis supported our intuition that isolation and polarization are more prevalent in the one-tomany communication regime. However, with only 4 agents, we can not distinguish polarization from cultural clustering into a larger number of distinct local clusters. To test whether and under which conditions our analytical finding is robust and generalizes to cultural clustering also in larger networks, we conducted computational experiments with bigger populations, always starting from a random initial assignment of traits and 1,000 independent replications per experimental condition. All simulations were executed until dynamics had reached an equilibrium. In the following subsections, we first compare one-to-one and one-to-many communication in three different network configurations. First, we focused on a regular torus network, as this is the framework that Axelrod used . Second, we compared the two communication regimes in ring networks with different degrees of network transitivity, in order to test whether the micro-level intuition illustrated in Figure 1 is indeed responsible for the macro differences that we observe in bigger populations . Using the ring networks, we also varied the size of the agents' neighborhoods to test whether or not cultural clustering and isolation persist when individual's communication networks grow bigger under one-to-many communication . Next, we studied spatial random graphs, as these networks have been argued to mimic human social networks better than torus networks and ring networks . Subsequently, we describe ideal-typical simulation runs under one-to-one and one-to-many communication to illustrate differences and replicate our main findings for populations consisting of agents with more features and a higher number 𝑄 of possible traits per feature. --- Population Size Effects. There are at least two reasons for increasing the number of agents in the model. First, already Axelrod found that monoculture is virtually unavoidable once population size exceeds a critical threshold [9, pp. 214-5], because dynamics last longer in bigger populations. This increases chances that two subgroups A and B that have grown maximally dissimilar at some moment restart communication because one agent adopted a trait from a third subgroup C that increased cultural similarity between A and B. This finding raises the question whether the differences between the two communication regimes persist when bigger populations are assumed. Second, the aim of the present analysis is to contribute to the development of a valid representation of online communication, a setting where huge numbers of individuals interact. Manipulating the communication regime whilst keeping all remaining characteristics of Axelrod's model unchanged, we first compared the two models in the same cellular-world structure that Axelrod assumed in his seminal work and that many follow-up studies adopted . That is, we assumed that 𝑁 agents are distributed over a wrapped square lattice such that every agent occupies one cell. All agents are linked to their neighbors in the so-called "Moore neighborhood" and can thus interact with eight other agents. 4 The first simulation experiment focused on populations characterized by a torus network and agents with three cultural features with two possible traits. To study population-size effects, we created populations with 𝑚 2 = 𝑁 agents and varied 𝑚 between 2 and 10. In Appendix B, we show that our findings are robust when 𝑚 is increased to 30 which translates into populations of 900 agents. Figure 4 compares the two communication regimes in terms of the share of runs that ended with at least one isolated agent. An isolate is defined as an agent that is maximally different from all of her network contacts. The blue lines show that isolation still occurs under one-to-many communication even in larger populations, while isolation virtually disappears in the one-to-one regime. Under the one-to-many regime, isolation is most likely in very small populations, but once population size exceeds 36, the model with one-to-many communication generates a constant share of about 12 percent of the runs that are characterized by isolation. This finding was confirmed by simulations with populations of 900 agents . Figure 4 furthermore shows that the proportion of runs that end in monoculture decreases with 𝑁 under one-to-many communication, while the share of runs generating monoculture increases in population size under the original model. Axelrod already found that the original model implies more monoculture in larger populations [9], a result that generalizes to various extensions of the model . Axelrod deemed this a counterintuitive finding, confronting it with contradictory empirical evidence from a study of language diversity on islands in the South Pacific, which found that there is more language diversity on larger islands. Our results here suggest that one-to-one communication plays an important role in the generation of Axelod's counterintuitive finding. In his original model, dynamics generate monoculture in big populations because whenever a culturally homogenous region begins to form, the emerging local consensus can be disrupted by a single communication event of one member of the region with an outside source of influence. In large populations, these disruptions are more likely, simply because dynamics last longer than in small populations. Such outside influences are also possible under oneto-many communication. However, the main difference is that one-to-many communication offers many more possibilities how a "deviant" is reached by influences from members inside of the emergent region to which the deviant belongs. In Axelrod's original model, the algorithm always randomly picks two communication partners 𝑖 and 𝑗 and in Table 1), which implies that the chance that a deviant 𝑗 is influenced back by a neighbor who belongs to the cultural region is only 1/8 in a population with Moore neighborhoods. With our implementation of one-to-many communication, 𝑗 will always be targeted by 𝑖, as 𝑖 exerts influence on all neighbors. This greatly increases the robustness of cultural regions. Further support for this interpretation is given by similar findings that Flache and Macy [32] obtained with a model assuming many-to-one communication. To test whether one-to-many communication fosters not only isolation but also the formation of clusters, Figure 5 shows how population size affects the relative frequency of clusters of different sizes. Even though clusters of size one and size 𝑁 are consistently the most likely outcome to be generated by the model, there is a remarkable difference between the two communication regimes. Under one-to-one communication, the occurrence of "medium sized" clusters diminishes as 𝑁 increases, whereas one-to-many communication does generate clusters of all different sizes at all levels of 𝑁. In the simulation runs with 𝑁 = 100, for example, we found that with one-to-one communication 1.2% of the replication runs end with at least one isolate and 1.6% of the runs generate medium sized clusters. Under one-to-many interaction, the proportion of runs with at least one isolate rises to 7.7% and medium sized clusters appear in equilibrium for 49.4% of the runs. Moreover, these medium sized clusters seem to emerge at a similar rate. Any given cluster size between 2 and 99 has an average probability of exactly 1.00% to appear in a given run . This demonstrates how oneto-many communication stabilizes cultural diversity and clustering. Both communication regimes typically generate cluster size distributions with peaks at both ends of the scale . Independent of population size, however, one-to-one communication generates more monoculture, less isolation, and less clustering than one-tomany communication. Figure 6 informs about the effect of the communication regime on the relative size of the biggest subgroup in the population , a standard outcome measure in the literature. The figure shows that the few runs with bigger populations under the one-to-one regime that did not end in monoculture were always characterized by one very big cluster. Under one-to-many communication, the size of the biggest subgroups can be much smaller, in contrast. --- Effects of Network Transitivity on Cultural Diversity. Figure 1 illustrates a key element in our reasoning why one-tomany communication fosters both isolation and clustering. According to our intuitive argument, one-to-many communication generates isolation and cluster formation when an agent is not adopting a trait from a network contact but their joint network contacts do adopt the trait and, therefore, grow similar to each other and dissimilar to the agent who was not influenced. Such a series of events can only occur, however, when the sender and the agent that becomes isolated have common friends. In other words, a high degree of transitivity in the sense that many network triads are closed can be expected to contribute to both cultural clustering and isolation and amplify the difference between the regimes. To test whether transitivity is indeed responsible for the differences between the two communication regimes, we compared populations characterized by different degrees of network transitivity. We replicated parts of the analyses presented in the previous section, manipulating the degree of transitivity in the population's social network. 5 In this simulation experiment, we focused on populations of 100 agents holding three features that could adopt two traits . To manipulate the average transitivity in the network, we created symmetric ring networks where agents were connected to the four closest neighbors to the right and to the left [38]. In the resulting network, all agents had the same degree , just as in the simulations with the torus network. Furthermore, the network was characterized by a very high degree of transitivity, as connected agents tend to be connected to the same nodes . Next, we rewired network links following the algorithm proposed by Maslov and Sneppen , which decreases network transitivity while preserving the degree distribution. The Maslov-Sneppen rewiring algorithm first picks two edges 𝐴 ←→ 𝐵 and 𝐶 ←→ 𝐷, making sure that 𝐴 ∉ {𝐶, 𝐷} and 𝐵 ∉ {𝐶, 𝐷} and that 𝐴 󴀈󴀂 󴀠 𝐷 and 𝐵 󴀈󴀂 󴀠 𝐶. If any of these conditions is not met, a new pair of edges is picked. Otherwise, the algorithm removes the links 𝐴 ←→ 𝐵 and 𝐶 ←→ 𝐷 and adds 𝐴 ←→ 𝐷 and 𝐵 ←→ 𝐶. This procedure is repeated until the algorithm has successfully rewired a share 𝑅 of the total number of edges in the graph. We studied the two communication regimes for different shares 𝑅 of Maslov-Sneppen rewiring, namely, 𝑅 = {10 -𝑖/10 } 10 𝑖=-30 . Figure 7 visualizes how the share of rewired links translates into network transitivity. Transitivity is defined as the share of closed triplets in the network or, formally, Transitivity = 3 × number of closed triangles number of triplets Figure 8 depicts the association between transitivity and the relative size of the biggest subgroup in the population. The box plots show that, under the one-to-one communication regime, network transitivity is not meaningfully related to the outcome measure. In contrast, the bottom panel of the figure shows a strong association under the one-tomany communication regime. This supports our conjecture that one-to-many communication fosters cultural clustering only in networks characterized by a sufficient amount of transitivity. Note that the scatter plots on the very left and on the very right of the figure represent more simulation runs, as the used rewiring algorithm generates more networks with very high and very low transitivity . --- Varying Neighborhood Size. So far, we have studied networks where all agents had a degree of eight, because this resonates with Axelrod's work. However, we also tested whether one-to-many communication fosters cultural isolation also when agents have more than eight network contacts. To this end, we studied populations of 49 agents interacting in ring networks as described in Section 4.2.2. Agents were described by three features and two traits per feature. To study effects of agents' degree, we varied the number 𝑘 of neighbors from 2 to 48 in steps of , conducting 1,000 independent replications per condition. Thus, under 𝑘 = 2 the network was a perfect ring where every agent had one neighbor to the left and one to the right. Under 𝑘 = 4, agents were connected to the two closest neighbors to the right and to the left, and so on. A degree of 𝑘 = 48 implemented a complete graph. Figure 9 informs about how agents' degree affected how often we observed cultural isolation or monoculture under the two communication regimes. In line with Axelrod's work, the solid lines show that under the classical one-to-one communication dynamics tend to generate monoculture when agents have bigger neighborhoods. The figure shows only a small difference between the two communication regimes in very sparse networks , which supports our conjecture from Section 4.2.2 that network transitivity is a necessary requirement for generating more cultural clustering under one-to-many communication. A ring network with 𝑘 = 2 is a periodic line network with zero triplets. As a consequence, rejecting a trait communicated by a neighbor does not make agents more dissimilar from their other neighbor, which implies that the mechanism responsible for isolation under one-to-many communication is not activated. In contrast, Figure 9 shows stark differences between the two communication regimes when agents have bigger network neighborhoods. Unlike Axelrod's original model, the model with one-to-many communication predicts that monoculture is less likely when degree is increased. As 𝑘 increases, also the number of closed triads in the network rises, which sets into motion the isolation mechanism. As a consequence, the proportion of runs ending in monoculture drops to about 0.65 under one-to-many communication. In about half of the simulation runs with a high degree that did not end in monoculture, there was at least one isolate. Figure 10 illustrates how degree affected the relative size of the biggest cultural cluster in the network. Under one-tomany communication, the average size of the largest cluster decreases as degree rises from 2 to 8. However, the average cluster size rises again when degree is increased further. Nevertheless, even when agents have very high degree, there remains a noticeable difference between one-to-one and one-to-many communication. We believe that the nonmonotone effect of degree under the one-to-many regime results from the interplay of two processes. On the one hand, a higher degree increases the proportion of closed triads in the network, fostering the extent to which one-to-many communication can produce cultural clustering and isolates. On the other hand, a higher degree also increases the share of the population to which an agent is directly exposed. The larger this share, the less likely it is that an agent disagrees with all network neighbors. The resulting cultural influence pushes the population towards more consensus, as already demonstrated by Axelrod. The combination of both processes generates a dynamic in which cultural clustering peaks at a degree of about 6, with lower levels of cultural clustering observed at both lower and higher degrees. --- Spatial Random Graphs. Considering that both torus networks and the rewired ring networks are somewhat artificial network topologies, we also studied spatial random graphs, as these networks have been argued to mimic the structure of human social networks [39]. In particular, spatial random graphs exhibit many features of real social networks such as low tie density, short average geodesic distance, a high level of transitivity, a positively skewed actor-degree distribution, and a community structure [40]. We conducted a third simulation experiment to test whether the differences between one-to-many and one-to-one communication found with the torus networks also appear under these less controlled but more realistic conditions. Like in the previous simulation experiment, we assumed that agents are described by three features that could adopt two traits . We manipulated population size in the same way as in Section 4.2.1 and conducted 1,000 independent runs per experimental condition. We initialized the network in two steps. First, all agents were randomly assigned two real numbers from the set [0, 5] that defined their position on a 5 × 5 plane. Subsequently, we looped over all agents creating 𝑘 ties probabilistically with agents with whom they did not share a tie yet. Whether a tie between 𝑖 and 𝑗 was created depended on the Euclidean distance between the two agents on the plane and the parameter 𝑦 that controls the strength of the relationship between distance and the probability to form a tie. We set 𝑘 = 8 such that each agent had a neighborhood of at least eight neighbors. 6 The probability that a tie was formed depended on the value of 𝑓, proportional to the sum of this function over all possible 𝑗's, where 𝑓 = exp The resulting social networks are characterized by a transitivity value of 0.523, on average, which is slightly more transitive than the torus graph with Moore neighborhoods that we studied in Section 4. agent in equilibrium . Figure 12 shows how the relative size of the biggest cultural subgroup was affected by population size and the communication regime. Both figures are markedly similar to the two corresponding figures for the torus networks, showing that our earlier findings are corroborated also when a more realistic network structure is assumed. --- Typical Simulation Runs. Figure 13 shows one typical simulation run for each communication regime. Under Axelrod's original one-to-one regime ), one can see that the culture that eventually dominates does not diffuse from one strong cluster. In all snapshots the dominant culture is present in all regions of the network. For the lion's share of the total body of simulation events, about 1/3 of all attempted communication events result in a change of culture by an agent. In the last stage , this rate drops to approximately 1/7 as the dominant cluster assimilates the last deviants. The typical dynamics under one-to-many communication differ, as Figure 13 demonstrates. Between the outset and the second snapshot, the dynamics generate three clusters, each located in a distinct region. This happens at a high rate of about 1 cultural adjustment per simulation event. 7 As a population with three cultural subgroups can never be stable under 𝑄 = 2, dynamics continue until two cultural groups remain. The rate of 𝑠/𝑡 drops to 1/5 until converging to a situation with a majority cluster , one minority cluster , and one isolate. The isolate has been locked inside the majority cluster from a very early stage and remains isolated from communication with other clusters throughout the rest of the run. --- Cultural Complexity. The main innovation of Axelrod's model was to show how cultural diversity can emerge and persist despite relentless pressures on individuals to assimilate to cultural influence. Axelrod and many followup studies also demonstrated how, in the framework of this model, stable cultural clustering is a feasible outcome only in a particular "sweet spot" in the parameter space in which the cultural space is not too complex, meaning that neither 𝐹 nor 𝑄 are too large. If the cultural space consists of too many different features , this increases the chances that neighboring agents happen to agree on at least one of them by random chance, exacerbating the emergence of cultural boundaries and thus promoting monoculture. If there are too many different traits per feature , it is unlikely that two neighboring agents happen to have the same trait at the outset, which precludes interaction between them and entails cultural anomie [9,26]. We wanted to know whether our model can replicate these fundamental results of Axelrod's model under both communication regimes, to establish that, besides the differences we have shown, the two communication regimes generate consistent behavior. For the region where cultural clustering is feasible according to Axelrod's model, we wanted to know whether the larger degree of cultural isolation and cultural clustering for the one-to-many regime generalizes to a broader range of parameter values for 𝐹 and 𝑄 than those we have used hitherto. For this purpose, we compared the two communication regimes under different assumptions about the complexity of the cultural space. Figures 14 and15 identify the region in which cultural clustering occurs both for Axelrod's original model and for the model with one-to-many communication. Our results show that clear differences between the communication regimes occur throughout the region in which Axelrod's original model navigates in between anomie and monoculture. In this region, the one-to-many regime produces more cultural isolation and more cultural clustering than one-to-one particularly when both the number of features is small and the number of traits is small or intermediate . With high 𝐹 or high 𝑄, the behavior known from Axelrod's original model is replicated also by the one-to-many version. In this region, the forces pushing towards monoculture or isolation largely overwhelm the distinct effects of the communication regime and strongly reduce the differences between them. Nevertheless, even in those conditions we find a consistent Every distinct combination of traits is visualized with its own unique color. The top graphs show the initial setup and the bottom graphs show the two populations in equilibrium. The remaining graphs visualize the distribution of cultural traits after 33% and 66% of the number of simulation events needed to reach equilibrium. 𝑡 is the number of simulation events, and 𝑠 is the number of events where an agent adjusted her set of cultural traits. but very small difference in the expected direction: more cultural clustering and more isolates under the one-to-many regime. This supports our observation that one-to-many communication generates different influence dynamics than one-to-one communication in those areas of the parameter space where cultural diversity can be sustained at all under Axelrod's model. --- Discussion and Directions for Future Work Public debate about the role that online social networks, personalization algorithms, and fake news played in recent political events such as Brexit and the election of Donald already provides a rich arsenal of formal models, our analyses demonstrated that it can be misleading to readily adopt models developed for communication dynamics in offline worlds to the analysis of online contexts. In particular, we compared one-to-one communication, a communication regime implemented in many models of offline communication, with oneto-many communication which seems to be a more plausible representation of communication in online contexts such as blogs and online social networks like Twitter and Facebook. We reasoned that one-to-many communication fosters isolation and the emergence of cultural clusters, because an agent who happens to not be influenced by a message received from a network contact does not only fail to grow more similar to the source of the message. In addition, the agent also grows more dissimilar to those contacts of the sender who were influenced by the message and adopted the trait of the source. Building on Axelrod's cultural-dissemination model [9], we implemented one-to-many communication where a sender emits one message across his entire local network rather than just a single network contact. We started with a Markov-Chain analysis of a simple but tractable part of the parameter space and found support for our conjecture that one-to-many communication fosters the emergence of isolated individuals as well as polarization. Next, we conducted a series of simulation experiments to demonstrate that one-to-many communication fosters the isolation also in bigger populations, that network transitivity fosters the emergence of isolated individuals and cultural clusters, and that these findings hold for network topologies that mimic the structure of real social networks. These findings add a new perspective to research on differences between online and offline communication. Earlier research was inspired by a psychological perspective and found that individuals are not affected by the physical appearance of their communication partners when communication is mediated by a computer [12,13]. As a consequence, when communicating online individuals neglect the social roles associated with memberships in high or low status groups, which decreases intergroup conflict and fosters consensus formation. In contrast to this within-individual perspective, we focused on between-individuals effects, showing that differences between online and offline communication may not only arise from the fact that individuals behave differently when they communicate online or offline. We demonstrated that differences between online and offline communication can arise from differences in communication structure, because in many online settings individuals communicate to multiple receivers at the same time. This difference in the way communication is structured in many online settings turned out to foster cultural isolation and clustering rather than consensus formation. While our results support our conjecture that assuming one-to-one communication in models of online settings can lead to false conclusions, there is reason to expect that also the model that we studied may still deviate in critical ways from communication in real online settings. Future theoretical work should, therefore, explore further to what extent existing models can capture important features of online communication and which further model developments are needed for that purpose. We propose three possible directions. First, a potentially important difference between Axelrod's model and our extension on the one hand and Internet communication on the other hand is that online network ties are flexible. On the one hand, intuition and earlier modeling work suggests that making networks dynamic will foster cultural diversity, as isolated agents and subgroups will cut off ties to their dissimilar network neighbors [30]. This should further decrease chances that isolates are influenced by former contacts. On the other hand, the Internet makes it easy to identify and connect to like-minded individuals even when they are geographically very distant [41]. This might allow isolated individuals and subgroups to join clusters that still communicate with individuals who are similar to their former connections and, thus, act as a bridge over the cultural divide. Given these competing intuitions, future research is needed to explore the conditions under which dynamic networks foster isolation under the one-to-many communication regime. Second, future theoretical research should explore populations that are more heterogeneous. For instance, empirical research showed that the degree distribution of the Facebook graph is skewed [42, pp. 4], which suggests that some users may be more effective than others in spreading cultural attributes across the graph [43]. Future research should, therefore, study how variation in neighborhood sizes affects cultural dynamics. Furthermore, Internet users differ in their online activity. Research showed, for instance, that on Facebook politically active users emit more online content than users who are not politically engaged [44]. It is an open question, how these forms of heterogeneity affect isolation dynamics under the one-to-many communication regime. A third important direction for future research is the study of one-to-many communication with alternative models of social influence. Unlike Axelrod's model, many alternative approaches represent cultural attributes on a continuous scale and not as distinct categories [8]. Many political opinions, for instance, tend to vary between extremes and are, thus, better described by metric scales. Models of continuous opinion dynamics can also capture more complex socialinfluence processes, such as gradual opinion-adjustments [45], negative influence exerted by too dissimilar sources [46], and the reinforcement of opinions when two actors communicate persuasive arguments that support each others' views [47]. Future research should explore whether and under what conditions assuming one-to-many communication alters the predictions of these models. We expect that the mechanism responsible for isolation and clustering under the one-to-many regime is activated also in models assuming continuous cultural attributes. If an actor refuses to be influenced by a communication partner, he does not only refuse to grow more similar to this actor. In addition, the actors grows more dissimilar to those joint network contacts that were influenced and, therefore, were pulled closer to the sources of communication. Another important avenue of future research is to empirically test our theoretical prediction that one-to-many communication fosters isolation and cluster formation. We propose a three-step design that resembles the structure of the theoretical analysis in this paper. First, we propose to study the minimal case that we explored with analytical tools in a computerized laboratory environment, with four human subjects discussing their stance on three binary issues. In this setting, one can manipulate whether subjects communicate in pairs or emit messages to all participants at once . With this experimental design, one can also test our theoretical prediction against the finding from the psychological literature that computer-mediated communication fosters consensus formation in demographically diverse groups. In particular, it would be interesting to test whether the integrating effects of computer-mediated communication are stronger or weaker when communication is implemented according to the one-to-one or to the oneto-many regime. Second, laboratory experiments are also a fruitful approach to compare the two communication regimes in bigger populations. Our theoretical analyses suggest that these experiments should focus on social networks characterized by high clustering and settings with relatively Complexity small cultural complexity, as the differences between the two regimes were strongest under these conditions. Third, one might try to test macro predictions in the field, comparing influence dynamics in online communities with different local network structures. Contrary to intuition, our results suggest that the chances that individuals turn culturally isolated are higher when their local network is characterized by high transitivity. There is strong public and scholarly interest on the effects of communication in online worlds. On the one hand, our results illustrate that the formal analysis of abstract models can contribute to exploring the complexity of online communication systems. On the other hand, our findings also show that pundits, experts, scholars, political decision makers, and also developers of online communication systems need to be very careful when reasoning about the consequences of online communication. Being based on modeling work and empirical studies focused on offline settings, the current scientific state of the art does not yet allow drawing reliable conclusions about the effects of online communication on societal processes of consensus formation and opinion polarization. --- Appendix A. Classes in the 𝑁=4, 𝐹=3, 𝑄=2 Model --- B. Replication with Large Populations In Section 4.2.1, we studied the effect of population size, conducting simulations with populations of up to 100 agents. In addition, we also analyzed populations of 900 agents , conducting 100 independent replications per communication regime. Under the one-to-one interaction regime all replications ended in complete homogeneity. Under the one-to-many interaction regime only 23 replications ended in monoculture, and of the remaining 77 replication runs 26 generated at least one isolate. Figures 16 and 17 compare model outcomes under the one-to-one and the one-to-many communication regimes. Both figures show that the results found with smaller population are obtained also in substantially bigger networks: oneto-many communication generates more cultural isolation and diversity than one-to-one communication. --- Endnotes 1. Nonconsensus features of the same type are symmetrical if the agents who agree on one feature also agree on the other. If there are three nonconsensus features of the same type and only two features are aligned, we label this class semi-symmetrical. In principal, the alignment on features of different types does not matter for state classification, with the exception of the 13-13-22 semiclass where the two 1-3 split features are not symmetrical. Here we label the class semi-symmetrical if the outliers on the 1-3 split features are members of the same group on the 2-2 split feature and non-symmetrical if they are not. 2. Consensus is inevitable in the red classes because there is at least one feature on which the agents have reached consensus. As a consequence, all pairs of neighbors will always exert influence on each other with a positive probability. This will eventually generate consensus. Likewise, it is not possible that a state of consensus on one or more features can be left. 3. The transition probabilities for going from the 13-13-22s to the 13-13-13s class are 𝑝 = .33 under one-tomany communication and 𝑝 = .11 under one-to-one communication. 4. Axelrod first used the smaller "Von Neumann" neighborhoods but also tested the robustness of his results with a "Moore" neighborhood identical to the one we employ. 5. Besides manipulating transitivity, the implemented method also creates between-node heterogeneity in their network centrality and decreases the average path length in the graph. This might, in turn, affect the dynamics of our model. However, due to the inherit interrelatedness of network descriptive statistics there is no method of manipulating transitivity without changing other aspects of the network structure. 6. Every 𝑖 formed eight ties, but a 𝑗 that already possessed eight ties was not excluded from the set of 𝑖' s potential neighbors. 7. It is not possible to compare these rates between communication regimes without postprocessing. As a sender's whole neighborhood can be influenced in a single simulation event in the one-to-many model, a conservative approximation could be made by dividing the number of successful communication events over the number of iterations times 8. However, only the neighbors for whom 0 < 𝑠𝑖𝑚𝑖𝑙𝑎𝑟𝑖𝑡𝑦 𝑖𝑗 < 1 can be influenced, and this number varies locally as well as over time. --- Data Availability No empirical data were used for this study. --- Disclosure An earlier version of this paper has been presented at the XXXVIII Sunbelt conference. --- Conflicts of Interest The authors declare that they have no conflicts of interest

Online social networks play an increasingly important role in communication between friends, colleagues, business partners, and family members. This development sparked public and scholarly debate about how these new platforms affect dynamics of cultural diversity. Formal models of cultural dissemination are powerful tools to study dynamics of cultural diversity but they are based on assumptions that represent traditional dyadic, face-to-face communication, rather than communication in online social networks. Unlike in models of face-to-face communication, where actors update their cultural traits after being influenced by one of their network contacts, communication in online social networks is often characterized by a one-to-many structure, in that users emit messages directly to a large number of network contacts. Using analytical tools and agent-based simulation, we show that this seemingly subtle difference can have profound implications for emergent dynamics of cultural dissemination. In particular, we show that within the framework of our model online communication fosters cultural diversity to a larger degree than offline communication and it increases chances that individuals and subgroups become culturally isolated from their network contacts.

Introduction Due to aging populations and prolonging dying trajectories, many countries, including Sweden, are experiencing a growing demand for end-of-life care. Consequently, EOL care provision has been identified as a public health challenge requiring a shift toward care provided by caregivers in the community . A critical prerequisite for increased civic involvement in EOL care, however, is competence and preparedness to engage with dying and death. There is therefore a steadily increasing interest for new public health approaches to EOL care focusing on competence building in the community . General EOL competence, beyond the purview of care professionals only, has recently been conceptualized as death literacy, that is, a multidimensional construct encompassing knowledge and skills needed to access, understand, and act on EOL care options and preparedness for engaging with EOL-related issues . The concept of death literacy was developed in Australia from a research by Horsfall et al. ) and represents how experiences of caring for and supporting a dying person at home had transformative effects on awareness, knowledge, and skills in relation to dying and death and attitudes to engaging in EOL care provision . Dimensions of death literacy are said to build on the construct of health literacy . --- Therese Johansson et al. There are several motivations behind efforts to build death literacy. One is to balance the professionalization of EOL care by emphasizing the role of community support for dying people . Another is to promote and support proactive EOL care measures, such as advance care planning . Furthermore, competence building is central to accommodate a shift toward community-based EOL care provision to address growing palliative care needs . The death literacy construct is operationalized and measured in the Death Literacy Index , developed to measure levels of death literacy in adults and evaluate EOL-related educational initiatives . Unraveling factors associated with death literacy might be helpful for understanding the construct and how it develops. During the instrument development process, some sociodemographic variables, that is, older age, having children, relationship status, religious belief, and origin, were found to correlate with death literacy ). Older age has also been found to correlate with Bugen's seminal notion of "death competence, " which involves people's self-perceived ability to cope with dying and death . Gender and education level have also been identified as influential factors of the theoretically linked health literacy construct . Furthermore, since death literacy encompasses experience-based competence, it is likely that interactions with the health-care system, either professionally or as a patient or relative, might contribute to death literacy, as indicated by findings from Graham-Wisener et al. . However, research about death literacy is scarce, and its association with sociodemographic, health, and experiential factors has not yet been thoroughly examined. The aim of this study is therefore to explore factors associated with death literacy, as measured by the Swedish version of the DLI . An additional research question was examined: What are the relationships between factors? We also present a model of posited explanatory pathways, which might guide future research. --- Methods --- Study design This cross-sectional explorative study analyses data from an online survey. The study was approved by the Swedish Ethics Review Authority and adhered to the ethical principles of the Helsinki Declaration . --- The Death Literacy Index As illustrated in Fig. 1, the original Australian DLI encompasses 4 main scales: Practical knowing, which consists of the subscales Talking support and Hands-on care ; Learning from experience , Factual knowledge , and Community capacity, which contains the subscales Accessing help and Community support groups . The DLI contains 29 self-report items that are answered with ordered categories on a 5point Likert-type scale, often ranging from "do not agree at all" to "strongly agree. " The DLI is scored by calculating transformed mean scores, ranging from 0 to 10, for the full instrument, each scale, and subscale. Higher scores indicate greater death literacy, and the total composite score represents overall death literacy . The validity of the factor structure has been supported, and the DLI has demonstrated good internal consistency reliability, for example, Cronbach's alphas of scales ranging above 0.8, in the original Australian context . Similar psychometric properties were recently found with a sample in the United Kingdom . The original English-language DLI is provided in Supplement file 1. --- The Swedish version of the Death Literacy Index In 2021, the culturally adapted Swedish-language DLI was developed and tested in Sweden. The multistep translation and adaptation process is beyond the scope of this article but is described in detail elsewhere . The DLI-S was found to exhibit good validity in terms of content, response processes, and internal structure, with satisfactory psychometric properties for internal consistency , test-retest reliability, and factor structure . The DLI-S and its back-translation to English are provided in Supplement file 2. --- Participants and procedure Data were collected online during September-October 2021 through a survey distributed by a survey agency with an existing panel of approximately 100,000 adults in Sweden. The sampling plan is shown in Figure 2. Survey invitations were sent to a quota sample from the panel, stratified by gender, age, and region, to consider the heterogeneity in the Swedish population. Panel members are compensated at the rate of 1 SEK per minute and can convert accumulated compensation to gift vouchers or charity donations. Participants were informed about the study's aim, topic, and procedure, and their right to withdraw at any time, and provided informed consent before being able to access the survey. In total, 503 participants completed the survey, which consisted of the DLI-S followed by questions about sociodemographic characteristics and EOL-related experiences. These questions are presented in Supplement file 3. Risk to participants was considered low; while survey questions about the EOL have been found to possibly affect immediate mood, cause of lasting harm is unlikely . All data were pseudonymized by the data collection agency prior to researcher access. --- Data analysis Statistical analyses were performed in SPSS , with statistical significance set as p ≤ 0.05. Participants' total DLI-S score was used as the outcome measure of death literacy. Sociodemographic, health, and experience-based factors were used as explanatory variables. Country of origin was not included due to the low counts and heterogeneity within the foreign-born participant group. Direction and strength of bivariate associations between variables and death literacy were assessed using linear regression models. Polychotomous variables were dummy coded or combined to create mutually exclusive variables . Only variables with statistically significant bivariate regression coefficients were retained for continued analysis. Hierarchical regression analysis was used to estimate the collective and relative association of retained variables with death literacy. To select parameters for the regression model, a directed acyclic graph , also called causal diagram, was created using DAGitty . In these graphs, explanatory and outcome variables are represented as nodes, with arrows between them indicating a causal relationship assessed on the basis of assumptions about temporality, face validity, and theory . Absence of an arrow indicates no suggested relationship. In this study, the DAG served as a template to postulate pathways, both direct and indirect, between explanatory variables and outcome. This process, summarized in Supplement file 4, enabled more informed decisions for constructing the regression model by distinguishing potential confounding and mediating variables to control for . Based on the DAG, a hierarchical regression analysis was conducted with 3 blocks. The model in the first block examined the influence of sociodemographic and health factors. In the second block, professional care background and EOL-related education or training were added to the model. In the third block, experiential factors were included in the model. Homoscedasticity of variables in the regression model, that is, whether residuals are equally distributed, was supported through visual inspection of P-P plots . Multicollinearity was evaluated using paired Spearman's 𝜌 correlation coefficients between variables and variance inflation factors for each variable. --- Results --- Descriptive statistics The 503 participants ranged in ages from 18 to 86 . Further participant characteristics are presented in Table 1. There were no missing values, as a mandatory response procedure was used, requiring all survey questions to be answered for participants to continue. Total DLI scores were normally distributed in the sample. The mean total DLI-S score in this sample was 5.15 . --- Bivariate regression analysis Results of bivariate linear regression analyses between death literacy and explanatory variables are shown in Table 2. Two variables, Distant personal loss and Attending end-of-life event, were excluded from further analysis as their correlations to death literacy were not statistically significant. Since only one category, being widowed, was significant from the variable Household composition, it was recoded as a separate dichotomized variable in the regression model. --- Hierarchical regression analysis Multicollinearity was found not to be problematic, with all variables having a VIF < 5. The matrix for pairwise correlation coefficients is presented in Supplement file 5. There was one strong correlation between widowhood and tertiary education, which likely resulted from the low number of widowed people , making the percentual differences large even if the counts are not. All variables were therefore retained for continued analysis. As depicted in Figure 3, the DAG illustrates an exploratory model of posited direct and indirect paths between death literacy and 16 explanatory variables. The results of the hierarchical model are shown in Table 3. The final model accounted for 40.5% of the variance in death literacy, F = 14.75, p < 0.001. The first block included the sociodemographic factors age, gender, education, health status, widowhood , and religious belief, which together accounted for 13.7% of the variance in death literacy. In the second block, professional care background and EOL education or training contributed an additional 15.8% of variance. In the third block, EOL-related experiences were included, accounting for another 11.0% of variance. In this final --- Discussion --- Main findings Using bivariate and hierarchical multivariable regression analyses, this study shows associations between sociodemographic, health, and experiential factors and death literacy in a Swedish sample. Building on theoretical assumptions and Leonard et al. 's empirical research, our findings support the hypothesized relationship between direct lived experiences of EOL-related situations and death literacy, whether in formal or informal care contexts. Furthermore, this study highlights associations between a number of sociodemographic factors and higher death literacy, primarily older age, widowhood, and identifying as religious or spiritual. We did not, however, find a significant association to gender or education level, which have otherwise been shown to correlate with higher awareness of palliative care in the general public, internationally and in Sweden . Being widowed, regardless of gender, showed the single strongest association with death literacy in our final model. While widowhood is theoretically linked to several direct EOL experiences, for example, supporting someone with lifethreatening illness, providing care at the EOL, and loss, the effect was still strong after controlling for these factors. This suggests that there may be additional experiential aspects of widowhood that contribute to death literacy but were unaccounted for in this study. One such aspect could be that the closeness of the relationship with the dying person might influence the level of involvement as well as the salience of the experience. A close relationship likely entails greater involvement in care decision-making, which should, in theory, increase the Factual knowledge scale. Furthermore, a close relationship might heighten the emotional impact of an EOL experience, thereby potentially affecting a scale like Learning from experience. The suddenness of death and duration of illness might also alter the influence of widowhood. Such underlying aspects of widowhood and their association with death literacy remains a question to explore in future studies. Overall, our study complements the existing literature by providing data from a new context that further support the assumption that death literacy is primarily associated with experiential factors. For example, there were several variables that were no longer statistically significant when experiential variables were entered into the hierarchical regression model. The significant negative association between health status and death literacy, that is, participants with poorer health had higher scores, did not remain when experiential factors were added. Curiously, the same tendency was found with experiences of life-threatening illness: neither experience of own illness nor supporting someone else remained significantly associated with death literacy when other variables were accounted for. The significant, albeit weak, association between religious/spiritual belief and death literacy shown here support previous Australian findings . Religiosity has been shown to affect death attitudes in older people with chronic illness and influence engagement in advance care planning . Sweden, however, is known for being among the most secularized countries in the world . Nevertheless, Hagevi has showed that religiosity is more prevalent in Sweden when defined broadly as spirituality by including beliefs in some kind of life force. Our study supports this, although it should be noted that the sample is not representative of the Swedish population, for example, regarding proportion of foreign-born persons, and the proposed model may therefore underestimate the role of religiosity . One possible explanation for the association found could be that experiences of dying and death might awaken religiosity or spirituality. Alternatively, the association might be explained by more exposure to reflection and conversation about dying and death in religious or spiritual contexts, such as EOL-related volunteering. It should, however, be recognized that palliative care is generally publicly funded and run in Sweden, and there is relatively little public engagement in the form of volunteerism and charity work . Thus, potential mechanisms for these findings also demand further exploration. --- Implications for practice Self-perceived EOL competence is known to affect both professional and family caregiver's 6 Therese Johansson et al. behavior and health . The death literacy concept encompasses several dimensions of knowledge and skills of importance for how EOL competence can be understood and developed both in the general public and organizations. The growth of community-based EOL care initiatives and increasing reliance on social care staff and family caregivers to support dying people further emphasizes the necessity for competence-building efforts in these contexts, where increasing ability to access, understand, and act on EOL and death care options will be central objectives. Experiential factors were found to influence the relationships between explanatory variables and outcome. Thus, lived EOL experience, rather than training in care provision , appears to be crucial for death literacy development. This finding raises questions about whether, and how, death literacy can be fostered through educational initiatives. For example, is it enough to encounter situations related to the EOL or is reflection or other forms of facilitated integration needed to build death literacy? Furthermore, what level of engagement in EOL situations is prerequisite and/or optimal for death literacy development? Leonard et al. argue that some of the skills that make up death literacy may not be easily translated into didactics. We have previously shown that exercises that promote reflection, introspection, and knowledge exchange supported development of EOL competence in eldercare . Overall, this study adds to prior literature, suggesting that death educational initiatives targeting EOL attitudes and preparedness benefit from focusing on experiential learning rather than information transfer. Our results suggest that a similar approach might be useful for death literacy development. There might also be other modes of engaging with dying, death, and bereavement with potential to enhance death literacy development. For example, prior research has highlighted the use of art and play and storytelling to help addressing EOL-related issues, which could aid knowledge exchange. In particular, this study suggests that volunteering might promote death literacy, which aligns with existing literature . Further research is needed to investigate what this might mean in practice. Our findings contribute to an understanding of circumstances that foster death literacy and identify several influential variables that are amenable to change. This is useful to consider when designing future public health programs for EOL competence building. For example, as direct experiences were found essential for death literacy, this study indicates that inclusion of people with lived EOL experience, such as widows, may benefit knowledge exchange. There is growing international support for the validity of the DLI; to date, it has been validated in Australia, the United Kingdom, and Turkey, with studies ongoing in, for example, Belgium, the Netherlands, and China. While the cross-national validity of the DLI remains to be explored, its international spread provides opportunity of using it to evaluate and compare educational programs based on inclusive approaches to EOL care encompassing professional and lived experiences, such as the Scottish End-of-Life Aids Skills for Everyone or Last Aid . Such studies would add to the understanding of how death literacy might be developed on the individual and collective level. The DLI is also currently being used as one measure to evaluate an educational intervention about proactive EOL conversations in Swedish residential eldercare. --- Strengths and limitations Using established methods for exploring provisional causal inference from cross-sectional data, this study generated new knowledge about factors related to death literacy in the general public. Adhering to recommendations by Ferguson et al. , we constructed a DAG to conceptualize a model outlining the direction and strength of putative explanatory variables' associations with death literacy, which were tested statistically. Using a hierarchical regression model was considered advantageous, as it controls for the effect of chosen variables, thereby enabling differentiation between total effect and changes in net effect. As the study's aim was to explore possible associations between variables and death literacy and not generate population estimates, neither the use of non-probability sampling nor the low response rate was judged to pose a problem for the internal validity . The sample size was considered sufficient for adequate statistical estimation, given the number of variables in the model . Still, the results should be interpreted with caution, as the variable for widowhood had a very low count and therefore might have had a distorted influence in our model. Future studies might wish to use stratified sampling to explore the association between being widowed and death literacy further. It is also possible that there may be unmeasured confounding variables . Our final model accounted for 40.5% of the variance, suggesting both that influential sociodemographic and experiential factors have been accounted for but that additional variables may also be of significance for explaining death literacy. The presented model thus constitutes a theoretical premise for future studies and requires further testing to assess both fit in other contexts as well as overall explanatory power. Furthermore, we have only investigated the effect of the variables on the overall DLI-S score and not on specific scales and subscales. It is possible that variables influence scales and subscales differently, resulting in distinct explanatory pathways to death literacy. Additional research is needed to disentangle the role of the different dimensions of death literacy. Longitudinal and experimental studies would be useful to address some of the remaining questions regarding causality in death literacy, such as residual confounding and temporality. In addition, it is not clear how participants differentially interpreted questions about their experience of caring for or supporting someone at the EOL. Therefore, it is possible that some participants may have had EOL care experiences that were not conceptualized as such, for example, because they had not engaged in care provision directly or did not identify themselves as carers . In future research, these questions may need adaptation to better distinguish between them. --- Conclusions The findings in this study demonstrate the individual, relative, and collective relationships between sociodemographic, health, and experiential factors and death literacy. Overall, our results support the notion that death literacy builds primarily from prior encounters with EOL care and death-related situations, such as caring for a dying person or supporting a grieving person. Specifically, the impact of working in health care and attending EOL education was shown to be influenced by direct experiences. This suggests that initiatives aiming to develop death literacy need to encompass components of both knowledge as well as reflection about lived experiences to adequately build competence and preparedness for EOL care. Still, further research is needed to account for the variance left unexplained by the model in this study, as there may be additional factors to consider to better understand the death literacy construct and how its development may be supported in both community and organizations. Supplementary material. The supplementary material for this article can be found at https://doi.org/10.1017/S1478951523000548. --- Palliative and Supportive Care Author contributions. Joachim Cohen and Ida Goliath authors share last authorship. Competing interests. The authors declare that there are no competing interests.

Objectives. Death literacy is a recent conceptualization representing both individual and community competence, for example, a set of knowledge and skills for engaging in end-of-liferelated situations. Little is yet known about which factors are associated with death literacy. A cross-sectional survey using the Swedish version of the Death Literacy Index, the DLI-S, was therefore conducted to explore associations between death literacy and sociodemographic, health, and experience variables. Methods. A quota sample of 503 adults (mean age 49.95 ± 17.92), recruited from an online Swedish survey panel, completed a survey comprising the DLI-S and background questions. Results. A hierarchical regression model with 3 blocks explained 40.5% of the variance in death literacy, F(22, 477) = 14.75. The sociodemographic factors age, gender, education, widowhood, and religious/spiritual belief accounted for 13.7% of the variance. Adding professional care factors contributed to an additional 15.8% of variance, with working in health care being significantly associated with death literacy. Including experiential factors explained another 11.0% of the variance, of which experiences of caring for and supporting dying and grieving people, both in a work, volunteer, or personal context, were positively associated with death literacy. Significance of results. This study contributes a tentative explanatory model of the influence of different factors on death literacy, outlining both direct and indirect associations. Our findings also support the hypothesized experiential basis for death literacy development in the Swedish context. The moderate degree of overall variance explained suggests there may be additional factors to consider to better understand the death literacy construct and how its development may be supported.

How are teachers with little background in the visual arts supposed to ask their students questions that the Ontario Ministry of Education suggests that they ask when they do not know the artists' work, nor have the materials on hand with which to teach? How can teachers of Visual Arts develop an aesthetic understanding of the artists' work when they are not provided with any resources or background with which to do this and there is no other information available? How are students "to interpret the works of others either individually or in a group" , as Ontario Ministry of Education documents require, if it does not state in the guidelines how teachers and students are to interpret the artworks, or what their interpretations are to be based on, and when there is no information available on any of the artists, nor suggested ways to go about finding out? Building students' identities while supporting teachers has been a focus of this project. Both teachers and students need open online data banks of videos and teaching resources, where they can readily access research on local artists. I wanted to offer students and teachers "a landscape of multiple possibilities" and a "lived experience of curriculum . . . wherein the curriculum is experienced, enacted, and reconstructed" through creating exemplars inspired by local artists' work. In Ontario, and in Canada generally, Visual Arts, from Kindergarten to Grade 8, is not taught predominantly by specialists, but by generalists who have minimal training in the subject area, and who often teach numerous subjects to the same group of students. In elementary school, when the Browning JCACS 107 subject of Visual Arts is undertaken, it is mostly being taught by teachers who do not feel comfortable to teach this subject discipline. Gaps in the curriculum itself are not helpful; so while the Ontario Ministry of Education encourages critical thinking in the Visual Arts program and proposes many questions for teachers to ask their students, there are no guidelines as to what an acceptable answer would be. Lacking in art education materials in particular, at the time of research project, were descriptions of local artists' work, websites to refer to, and suggested texts to read. In the Ontario curriculum, teachers and students were not being encouraged to research lesser known artists, who, in fact, comprise most of the artists in Northern Ontario. There are very few catalogues published by art galleries in smaller communities in Northern Ontario . Furthermore, even if published, the catalogues are often difficult to find, especially if the teacher has not bought one at the time of the exhibition. While art exhibitions are a lot of work, often no traces remain of the exhibition. Not all artists have websites or books published. Nor do all artists have publications of their artwork with quality, full-colour photographs which teachers and students in schools can access for deep discussions of artists' works. All of this pointed to the ever-increasing need for digital videos on local artists' work, particularly from more remote areas like Northeastern Ontario. It is imperative that teachers and students identify with artists in their own community, and one important way is through digital videos and digital still photography. These could be made readily available through libraries, or online through the Ontario Ministry of Education , and associations like the Canadian Society for Education through Art , the Canadian Society for Studies in Education or the National Art Education Association . However, the central problem has been that there are many Canadian artists, particularly in smaller communities, who are not mentioned in Ontario's curriculum guidelines. During the writing of the OME curriculum guidelines for The Arts, I attended meetings in which I requested that the guidelines include national artists, with a focus on local artists. In fact, my participation in these curriculum meetings was instrumental in getting Aboriginal artists, particularly Ojibway, mentioned; for example, artists such as Daphne Odjig and Norval Morrisseau ), 2009, p. 156), Carl Beam , and Carl Ray . I suggested others, too; for example, Inuit artist Kenojuak Ashevak , Cree artist Tomson Highway as well as Emily Carr, who lived in the forest and was inspired by Indigenous ways of knowing . "Aboriginal cultures in Canada " were also included as a result of these discussions. However, many lesser known Aboriginal and Métis artists were not included; nor were contemporary artists who bring a postmodern digital perspective. Nor did the OME guidelines include Francophone artists or artists from smaller communities. As much as I was thankful for the many suggested artists who were included, there remained many who were not. These gaps still need to be addressed. One question preoccupying the research, therefore, concerned what and who was not mentioned in the curriculum; another question concerned access. How can art educators teach students about "constructing personal and cultural identity" or "developing a sense of self and a sense of the relationship between the self and others locally, nationally, and globally" , if there is no online data bank containing lists of suggested books, as well as links to videos accessible to teachers and students? Accessible data banks of videos of local artists talking about their art were not available, at the time of my research project. YouTube and Art 21 cannot bridge this gap as they lack information on artists in rural areas. I therefore also requested that the Ministry's online data bank include biographies, still photography, and video examples of artists' works as well as of artists talking about their work. It would be a bank created for teachers and students and made accessible to them. While teachers may be able to organize a trip to an art gallery, actually seeing digital videos and still photography of these artists' work is extremely important. Teachers and students, whether in schools or universities, need to be able to access data banks of digital videos where artists from every region are using multi-media tools to share their images and ideas. --- Theoretical Framework: Rurality and Digital Videos The research project that informs this article combined theories of rurality and place with recognition of the importance of digital media. 2 According to Corbett , "rural communities occupy an important place on the Canadian educational landscape" . Rurality is "located in the way it represents the intersection of people and place" . Jokela, Hiltunen, andHärkönen , in discussing the North, have pointed to "the special conditions of the rural and semi-rural urban places outside the cities and culture centres" . To rectify the imbalance, Corbett refers to Castells' and Urry's notion of "spaces of place" as a concept which needs to be better understood, explored and developed for Art Education curricula from rural communities. By offering a greater abundance of information on rural artists, we might redress the paucity of information currently available and try to match the richness of resources ready-to-hand with respect to urban communities. We have long known that digital video has the "power to translate experience into new forms" , that "media are the primary vehicles through which we come to know ourselves and others" . And yet, very little digital video research has been done in this area , particularly on artists in remote areas. The Gulf Islands Film and Television School, British Columbia has published some work . These types of programs offer curriculum possibilities in video not readily available in regular educational settings . Teachers and students need to be able to access data banks of digital videos where artists are talking about their work, with cut-in digital photographs, which help exemplify these descriptions. According to Briggs , "video production involves . . . still and moving images, texts, animations, visual transitions and effects, and a soundtrack that may feature audio that is tied to the visual track sound effects that are 'overdubbed,' and/or 'voice-over' narration" . Teachers can teach students to "learn about some of the elements and principles of design and begin to describe how the elements are used by the artists", this as per Ministry guidelines . Adams believes that digital tools can help rural communities in particular to better understand "practices to enact tangible changes in their community". However, in order to do so, teachers and students need ready access to information about local artists. --- Introducing The 14 Videos Project I am a Producer/Director/Researcher of the 14 Videos Project, and worked in partnership with the Director of the Laurentian University Film Studio, Dr. Hoi Cheu, who acted as the Videographer/Editor. We created videos that were intended to support the implementation of the Visual Arts in Ontario's curriculum: The Arts Grades 1-8 ; The Arts Grades 9 and 10 , and The Arts Grades 11 and 12 . The videos featured 14 local artists, accompanied by fourteen Teachers Facilitation Guides . The Facilitation Guides included pre-viewing and postviewing questions, which could help in teaching and also be used across a variety of other subject disciplines including, to name but a few, Technology, Indigenous studies, Environmental studies, Women's/Feminist studies, Media studies, Curriculum studies, History, English, Literacy studies, and Geography. As already stated, the purpose was to add to the knowledge base of artists in Canada, particularly with respect to more remote areas like Northern Ontario, this through videos, linking and online sites for information access. The completed video series has received the Curriculum Services Canada Seal of Approval and the Canadian Network for Innovation in Education, Excellence and Innovation in the Integration of Technology in the K-12 Classroom Award . Teachers who have taken my workshops describe how, with these resources, they can show a clip, talk about the environment, discuss Indigenous perspectives, or have their students create a piece of art, music, or dance, or write a poem or story. --- Methodology of The 14 Videos Project I approached the development of The 14 Videos Project as a multi-case qualitative research study. After initial telephone and/or e-mail contact, followed by written permissions, I met each of the artists, conducting standardized yet open-ended interviews; Hoi Cheu digitally videotaped our exchanges. All artists were asked the same thirty questions; however artists elaborated in their own ways on such subjects as their creativity as children, educational and artistic influences, how media has evolved, sources of inspiration, use of technology, teaching, and future goals. The videotaped interviews took place in galleries, artists' studios, artists' homes, and outdoor locations. It was important to interview the artists where they felt comfortable and could best represent their artwork . The videotaped interviews and thick descriptions included field notes, thus forming a broad basis on which I could later develop digital stories by conducting inductive comparative analysis of emergent categories using grounded theory , a method I had used elsewhere ). NVIVO was helpful to compare video clips for commonalities. I also digitally photographed the artists and their artwork, which was later cut into the digital video footage to get the best possible high-resolution images of their work. I worked together with the editor to include footage which clearly told each artist's story. We aspired to a respectful, inclusive process. All artists were given a copy of their video after initial editing. Their suggestions were considered prior to making final edits. Final versions were test screened, revised, exported, mastered and copied, before being distributed to the partners to create a video library and online data banks for research and teaching purposes. The partners included the Ontario Ministry of Education , the Knowledge Network for Applied Education Research , and Laurentian University, with links on the websites of associations such as the Ontario Art Education Association , the Canadian Society for Education through Art , the Canadian Society for the Study of Education , and Inspire. Links are also included on the teaching federations' sites, such as the Elementary Teachers' Federation of Ontario , the Ontario Secondary School Teachers' Federation , and the Ontario English Catholic Teachers Association . The videos were streamed at Laurentian University with links to KNAER and the artists themselves. The project was attentive to a creative research process. Final videos of 10 to 20 minutes in length involved shooting up to 7 hours per artist while the very lengthy process of editing took as much as 20 times that, from raw footage to final cut. Further, as part of the creative research process, specific editing styles were chosen for different artists. French-Swiss film director Jean-Luc Godard's jump cut method was preferred by Francophone artist Mariana Lafrance's video as this fast-paced editing style suited her contemporary artwork. Specific music was selected for each video that could support the artists' work, for which musical permissions were acquired. I also sought out and included specific musicians that the artist requested. For example, Jon Butler requested Ian Tamblyn's music. Jon was one of the organizers for a project which included 45 artists who wanted to save the Willisville Mountain from becoming a quarry . The artwork created for this exhibition travelled to five different locations in Northeastern Ontario, bringing attention to the beauty of the white quartzite mountain, as well as the need for its preservation. The project was successful as the mountain was saved for generations to explore. This project, the artists and artwork created was later published as a book entitled The Willisville Mountain Project. Ian also performed and created a CD of music about the mountain. A similar approach was used in presenting many of the other artists and their work. Aboriginal artist Mark Seabrook had a rock band called No Reservations. Its music and lyrics worked well with his video. The music of Phenomenonsemble was used for Nick Dubecki's work, as well as for the videos I created to describe this group's performance artwork, music, and musical instruments. Métis artist Will Morin sang and played a drum while his artwork was videotaped, whereas Métis artist Christi Belcourt requested traditional songs by elder ALOWHITE. Terrance Witzu was hired to create music for Mariana Lafrance's contemporary photography. In short, each video combined the work of local artists with the music of local musicians to create a complexly layered resource that celebrated the creative communities in and around Sudbury and that could serve to show students the richness of their rural identities. --- Exemplifying Rural Creative Culture Regionally developed resources can play a special role in art education. By focusing on the unique diversity of cultures and themes in the Sudbury area, and by extension, highlighting the importance of developing regional resources to support art education outside of the big urban Browning JCACS 111 centres, the research gathered exemplary artists and shared their work in digital forms that were affordable, accessible and enriching, not only to teachers and students in the region, but provincially, nationally and internationally. The project also offered a method by which to do so. Through the videos created, the fourteen artists exemplified creative culture around Sudbury even as they discussed their relationship to the landscape and described environmental projects. For instance, in her video The Urban Connection, Francophone artist Mariana Lafrance talked about what it was like to grow up on Manitoulin Island, how she identified with Sudbury, and how the city affected her. She offered "new perspectives of place, understanding, translation, and anxiety" . For his part, in his video Repairing Beauty, Métis painter and sculptor Will Morin discussed misconceptions about Aboriginal people and the importance of educating others about Indigenous culture. He talked about his own art and how it gave him confidence, as well as about his education and influences on his art. For instance, he spoke about elements found in his artworks, referring to a modern expression of a raven sculpture and explained the significance of ravens in the Ojibway culture. Will also explained the Sudbury Green Stairs Project wherein he worked with local schools to display students' artwork so it can be "heard and seen in public places". He created the frames from recycled materials in which the students' artwork could be displayed annually. His goal was to inspire youth. Will went on to describe his re-appropriation of images in his totem pole sculpture that is created out of car parts. The car parts are made by companies that use names of Aboriginal tribes . He has created many sculptures from recycled materials that can be found throughout Sudbury. Will believes in reusing materials so as to reduce the pressure on the environment . By viewing the work of these selected artists, students and teachers can gain a sense of design, relationship with the land, and the cultures that make up this vital Northern community. Having now provided the objectives, the rationale, the rurality of place, the background and the methodology of the project, I will next discuss the ways in which this online videos series inspired BEd students to create innovative exemplars and conceptualize curriculum for teaching Visual Arts. --- Students' Creative Responses to The 14 Videos Project I teach Primary/Junior, Grades K-6 and Junior/Intermediate, Grades 4-10 Visual Arts in mandatory pre-service BEd courses. There are mostly Physical Education majors in my courses. The majority of students have very little experience in visual arts and have not used a variety of media before. One assignment, called the Artists' Video Curriculum Planning Project, inspires students to use the artists' works as catalysts for their own creation. Through creating art and making exemplars for teaching in a variety of media, the student teachers conceptualize curriculum while being better able to see what and how to teach. Students in groups select artists whose artwork speaks to them while creating and co-creating curriculum that works in relation to each other and the artists. They research and investigate how to best represent their ideas and the artists' works, including the plurality of their voices. The students are transformed through this process and many feel it to be cathartic. Multi-modal artwork uses several modes/media. Materials, placement and organization of the content all create meaning communicated through multimodal visual literacy. Corbett suggests that "it [multi-modality] may be a more academic, creativity-based, and innovation-focused curriculum that fits best with this new reality and the real challenge for 21st-century rural education" . As in Berry, Hawisher and Selfe's born-digital book, the digital video project was conceived to encourage digital literacy by helping students understand the artistic perspectives of local-here rural-artists. Combining ideas through re-composition allowed the students/creators to understand their local artistic community, through a lived experience inspired by video. This transformative process was accomplished by using stills of the artist's work from the videos while understanding the message in that mode and using it as inspiration to create something new. Video clips were incorporated into PowerPoint presentations. Students also learned how to download video clips and still photographs from streamed sites and DVDs and integrate them into their PowerPoints. Students cut and pasted from Windows and Mac computers using a variety of paths to import video stills and clips from the online streamed videos, which were then embedded in their presentations. These streamed, linked and library-accessible videos were then re-imaged. One student even created and included her own video of how to do quilling in her PowerPoint. Students also used the Teacher's Facilitation Guides, artists' websites, and DVDs. The resulting group assignments were presented with artists' background information, images of their inspirations, photographs of their exemplars, explanations of the relationship to The Arts guidelines, lessons for schools, and assessment tools. Each student in the group created in a different media while choosing a different inspiration from their chosen artist. Students were encouraged not to mimic the artists' work. Each student chose a different artwork by the group's selected artist to inspire them. Through my research and in my teaching, I have helped students learn how to interpret artists' works and create art that informs their professional teaching practice. Students can create, reflect, analyze and critically discuss these artists' works by using these digital videos, which support presenting, responding, exploring and valuing visual forms, thus offering a sense of identity in cultural contexts while making connections beyond the classroom. This rich student art education experience has encouraged others in turn to use these ideas and resources in their classrooms while making connections with their own communities. The following are some examples of artists' stills from the videos and inspired exemplars that --- JCACS 114 In his video, Visions of Light, landscape painter, John Stopciati was "inspired by the beauty of Northern Ontario landscapes and historic structures. . . . He discusses how he became a painter and the imagery that inspires him to create" . Amber was inspired by the red chairs in John Stopciati's painting. She then photographed her painted clay chairs in front of different backdrops and also placed the chairs looking out her university residence window. She encouraged others to get their students to create in clay and then make backgrounds that can be drawn, painted, photographed, or photoshopped. Inspired by Jon Butler's photography, Jordan went and took a photograph that reminded him of Jon's work. --- Student: Jordan Walker-Martin When describing his lesson, Jordan suggested that teachers: • Show students exemplars of Butler's sunrise work and ask them to explain colour relationships and the feelings they get out of looking at the photos. • Get students to take photos of the sunrise when they're getting ready for school or of the sunset before they go to bed. • Allow them to create either a digital or print photo montage with their group members. • Have students present a brief two-minute presentation of what feelings their montage is portraying and how it relates to Butler's work. --- Conclusion Through my research that resulted in the 14 Videos project, I hoped to facilitate student teachers' being able to interpret artists' works in a rural cultural context , particularly artists in Northern Ontario where there is otherwise very little information available. The artists gathered, as cases for the videos in this study exemplify, from the creative culture around Sudbury. The 14 artists discussed their relationship to the landscape and to environmental projects. It is imperative that teachers and students in schools identify with artists in their own area, and one way is through online digital videos. Knowledge of the presence and practices of local artists can in turn inspire students to create. Art then becomes a part of the students' own experience as a part of their community, not just an experience in the classroom, or an occasional gallery experience. Specifically, the 14 Videos project was used to inspire students to create, reflect, analyze and critically discuss northern artists' works. The videos then supported the student teachers themselves in presenting, responding and exploring visual forms, offering a sense of identity in cultural contexts while making connections beyond the classroom. The 14 Videos project inspired students to create in a variety of media, thus extending their understandings of multimodality as it becomes more common in classrooms through the creative use of technology. When "students are exposed to a variety of stimulating artistic activities, reflect on-and give meaning to-their artistic learning, and celebrate their success, thus reinforcing their identity building and their positive relationship" with art, the Canadian Teachers' Federation reminds us, learning can become "meaningful and relevant," leading to "exploration, investigation, use of various materials, creation and problem solving" . The pre-service BEd students confirmed that the research project embodied the essence of the artistic ways of knowing of these fourteen artists while also resulting in the creation of artworks that exemplified their understandings of the artists' aesthetic in a smaller community. Students and teachers using these videos now have a better understanding of the sense of place which affects these Aboriginal, Métis, Francophone, and Anglophone artists and what it means to be creatively living and working in a rural community in Northeastern Ontario. As with Adams , I believe that "insights gained from such research can better inform us about the potential of digital tools and spaces, and how we might foster similar applications elsewhere". It is the start of a much larger curriculum project wherein videos of other artists' work can be contributed from other rural areas where there is also a lack of information and resource materials. --- Artist: Mark Seabrook Student: Anthony Scola During her presentation, Mackenzie described both Mark's and her artworks through the elements and principles of design, emphasizing unity and showing how her photographs work together as they are all about the environment and create visual harmony. • Music: Choose a piece of music that you feel represents your artwork. Photographer Jon Butler in his video, The Zen of La Cloche, describes the importance of composition in his photography. Jon also writes Haiku poetry to invoke the sounds and sensory details in his landscapes . Artist: Jon Butler

The article begins with a description of the award-winning online artists' video project, 14 Videos of Visual Artists in Greater Sudbury, and concludes with a presentation of my pre-service BEd students' creative use of this digital resource. The video series was conceived and created with the aim of filling a gap in materials that were sorely lacking to teachers of Visual Arts in Ontario. The video series includes Aboriginal, Métis, Francophone and Anglophone artists and highlights the artists' interconnections with the local community. The streamed, linked and library-accessible videos (see http://www3.laurentian.ca/visual_artists/) served as inspiration for student teachers' creation of their own innovative curricular exemplars. In the article, I describe the complex inner workings of the research project in order to establish a context for the students' work. I show how the students were able to conceptualize curriculum through being able to better see what and how to teach through creating art and making exemplars in a variety of media. Using the artists' work as a catalyst, the students worked in groups, selecting artists whose artwork spoke to them while creating exemplars and co-creating curricula that would be meaningful. The article concludes with student exemplars that offer insights into the value of focusing on local artists in order to better meet Art Education curriculum goals in Ontario and, by extension, elsewhere in Canada.

of due process in one's country with regard to suspected terrorists . The present research examines this phenomenon, and asks whether insights from work on collective action among the disadvantaged can be generalized to collective action among the advantaged. This is an important question because any action among the advantaged on behalf of the disadvantaged would appear to go against the advantaged group's objective self-interest to maintain the status quo. Indeed, such actions challenge the very social inequality that provides the basis for their beneficial position in society . This does not imply, however, that the advantaged never act against social inequality . In this article we explore a novel psychological mechanism that helps to explain how the advantaged come to challenge social inequality. Specifically, we propose that moral convictions against social inequality motivate the advantaged to challenge social inequality. Because moral convictions are experienced as strong and absolute stances that do not tolerate exceptions to the higher-order principle , any violation motivates individuals to actively change that situation . Importantly, we propose that seemingly individualistic moral convictions can have collective consequences because any violation increases identification with the victims of social inequality . Specifically, it is the absolute condemnation of social inequality that propels further actions on their behalf . Such identification with the disadvantaged group is the psychological basis for collective action, thus providing a conceptual bridge between seemingly individualistic moral convictions and group-based predictors of collective action identified by the Social Identity Model of Collective Action . According to this model, identification with a relevant group provides the psychological basis for the experience of group-based anger and group efficacy beliefs that motivate collective action. As such, violated moral convictions can powerfully motivate collective action among the advantaged. We tested this novel and integrative line of thought in two empirical studies. --- Motivations for collective action among the disadvantaged generalize to the advantaged Although theory and research on collective action are a multi-disciplinary enterprise , the past decades of research have converged on the conclusion that the psychology of collective action is crucial to its understanding. In fact, objective economic circumstances and societal events appear to be pretty poor predictors of collective action-such objective conditions are only one of several factors that determine how individuals become motivated to actually engage in such action . This implies that the study of social influences that propel individuals toward collective action is both important and consequential. In the psychological literature, collective action is typically defined as any action enacted as a representative of the group, aimed at improving the group's conditions . In keeping with this definition, very different types of action can be classified as collective action, ranging from participation in protest demonstrations and strikes to seemingly individualistic acts such as signing a petition . The definition also accommodates the possibility that advantaged group members may engage in collective action, as long as these individuals perceive themselves to be a representative of a particular group, and perceive collective action as aimed at improving that group's conditions . Further in line with the definition, theory and research suggest that identification with a group facilitates individuals' selfcategorization as a group member . For these reasons, the key variable in the psychology of collective action among the disadvantaged is the relevant group that individuals identify with . However, the "relevant group" here is not necessarily the in-group. For example, for disadvantaged group members, relevant groups may include the disadvantaged group but also more specific organizations that fight on their behalf . In the present article, we propose that, among the advantaged, identification may even be felt with an out-group, which enables collective action on their behalf. Indeed, SIMCA suggests a central role for group identification in the psychology of collective action. SIMCA predicts that such identification increases collective action directly, but also indirectly. It increases collective action directly because higher identifiers with the group are generally more committed than lower identifiers to achieve group goals, and conform more strongly to group norms about shared action to achieve them . Moreover, group identification predicts collective action indirectly because a shared identity validates and thus increases feelings of group-based anger and increases a sense of group efficacy . Can SIMCA be generalized to the advantaged? Some theory and research suggest that this might be problematic because members of advantaged groups tend to protect their objective group interests through their subjective motivation to maintain social inequality . However, theory and research in the social identity tradition suggest that the relationship between in-group identification and out-group discrimination is highly context-dependent, and thus one cannot speak of generic motivations to maintain or challenge the status quo . Either way, we propose that moral convictions against social inequality have the psychological power to motivate the advantaged to challenge social inequality. The key reason for this is that moral convictions are experienced as strong and absolute stances on moralized issues that tolerate no exceptions to the higher-order principle. As a consequence, any violation of a moral conviction motivates individuals to actively change that situation, which effectively overrides other concerns or motivations. It is for this reason that moral convictions can be extremely influential in motivating advantaged group members to challenge social inequality. --- Moral convictions motivate the advantaged to challenge social inequality Moral convictions are defined as strong attitudes that are experienced as absolute stances on moralized issues. Indeed, the aspect of moral absolutism has sometimes been referred to as one of the "hallmarks" of morality . Consistent with this line of thought, any violation of moral convictions leads individuals to experience strong feelings of anger towards the transgressors, seeking to punish and exclude them in order to defend one's conviction . Moreover, individuals may feel the need to reaffirm their moral stance by acting on it . This increased tendency to act is amplified because individuals' moral convictions legitimize and even necessitate action . However, this line of work has focused exclusively on individual behavior, and thus neglects how individuals come to act as group members on the basis of their group identities. This is precisely what we examine in this article. One of the reasons why the moral conviction and collective action literatures have largely remained disconnected from each other is that they differ in their conceptualization of identity . We believe that the two literatures can be integrated by considering that although moral convictions might develop on the basis of group identities and group norms, their acceptance as subjectively universal and thus as absolute standards transcends group boundaries . In this sense, moral convictions are extrapolated from the normative systems and codes of conduct within groups. They may arise out of, or are imbued with social meaning through, a process of consensualization . But the subject of these moral concerns is unique: They may develop within specific groups, but once they acquire a moral status, they become subjectively universal and thus transcend group boundaries. Similarly, the tendency to accept moral judgments as absolute is subject to the same social construction processes. However, once an individual has developed moral convictions, their violation overrides any "lower-order" concerns or motivations: Moral convictions demand adherence irrespective of the actor or subject that concerns them . The intriguing paradox here is that although moral judgments are no doubt constructed much like other norms, they carry the seeds of social change by virtue of being placed on a higher level of importance than personal identity, social identities, and any other relational process that may account for social order . Moral convictions against social inequality thus demand absolute adherence to this principle of equality. When advantaged group members who have such convictions are confronted with a disadvantaged group, this constitutes a violation of their moral conviction, which motivates them to change the situation. Indeed, because of their absolute condemnation of social inequality, individuals will increase their identification with that group, which enables collective action . According to SIMCA, identification with the relevant group increases group-based anger and group efficacy, and all three variables predict collective action . Thus, the advantaged can become motivated to challenge social inequality on the basis of their violated moral convictions against social inequality because they identify with its victims . --- Hypotheses Our line of thought can be summarized in three hypotheses. First, we predict that moral convictions against social inequality, at least when violated, increase the motivation to challenge social inequality , effectively overriding any other concerns or motivations . We refer to this hypothesis as the Moral Motivation Hypothesis, which we test in both studies. Second, we predict that the violation of moral convictions against social inequality leads to increased identification with the disadvantaged group . We refer to this hypothesis as the Identification Hypothesis, which we test in Study 2. Third, we predict that the same psychological processes that SIMCA predicts to explain collective action tendencies among the disadvantaged are also in play among the advantaged. Thus, on the basis of a relevant social identity, group identification, group-based anger and group efficacy predict collective action tendencies, while group identification also predicts group-based anger and efficacy. We refer to this pattern of predictions as the SIMCA Hypothesis, which we also test in Study 2. Together, these three hypotheses represent our predictive model . We tested our hypotheses and predictive model in two relatively similar studies that employed different contexts and populations from the Netherlands and Hong Kong . Both studies focused on advantaged group members' moral conviction against social inequality, their group identification, group-based anger, group efficacy beliefs, and their willingness to engage in collective action against social inequality. Because only Study 2 included identification with the disadvantaged group, Studies 1 and 2 test the Moral Motivation Hypothesis, whereas Study 2 tests the Identification Hypothesis and the SIMCA Hypothesis. In the Netherlands, we focused on how the non-Muslim Dutch responded to a situation about discrimination towards Dutch Muslims in the Netherlands . In Hong Kong, we focused on the salient intergroup relation between the Hong Kong Chinese and the Mainland Chinese . Finding support for our hypotheses across these quite different contexts would generalize support for our model, and for the general point that moral convictions motivate the advantaged to challenge social inequality because a violation thereof increases identification with the disadvantaged group. --- Study 1 --- Method Participants and procedure Eighty-one non-Muslim Dutch participants of non-immigrant descent were recruited from a university campus to participate in exchange for a chocolate bar. Participants were informed that the research was carried out by a Dutch university. The study began by asking participants to indicate their moral stance on the issue of discrimination against Dutch Muslims. Participants then read a newspaper article describing an instance of discrimination against Dutch Muslims. After reading the article, participants responded to a set of questions that included our dependent measures. All measures employed 7-point scales with two anchors . The newspaper article focused on an instance of discrimination against Dutch Muslims that occurred in 2007. The source was a respected Dutch newspaper, which reported that a Muslim woman who did cleaning work on a high school applied for a job at the same school as a canteen worker. She was not hired. The dean of the high school was quoted as saying that he was fine with the Muslim woman working at the school after hours , but that he was not fine with her working at times when students were present as this would lead to too much contact and "exposure" to her religion. The article reported that the woman had filed a discrimination complaint, and was awaiting the outcome. --- Measures Moral conviction All participants first indicated whether they were in favor of social inequality or against it; all participants were against it. Moral conviction was measured with three items . 1 These items reflect what we view as the essence of moral convictions, namely the combination of a strong and absolute stance on an issue . Principal axis factoring with oblique rotation extracted, as expected, one factor that explained 63.84% of the variance, with factor loadings > .74. --- Predictors of collective action tendencies Derived from previous work , we measured group-based anger with three items , and group efficacy beliefs with two items . We measured identification with the advantaged group with two items . Principal axis factoring with oblique rotation extracted, as expected, three factors that explained 62.68% of the variance, with factor loadings > .58. Collective action tendencies Derived from previous work , we measured collective action tendencies with seven items . Principal axis factoring with oblique rotation extracted, as expected, one factor that explained 63.68% of the variance, with factor loadings > .66. Thus, across the board the construct validity of our measures was adequate. --- Results We tested the Moral Motivation Hypothesis with a series of multiple regression analyses. In line with predictions, results showed that moral conviction strongly predicted collective action tendencies , group-based anger , and group efficacy . Also as expected, moral conviction did not predict identification with the advantaged group . In the next step, we regressed collective action tendencies onto moral conviction, group-based anger, group efficacy, and identification with the advantaged group . Results showed that although the effect of moral conviction was now considerably weaker , as expected group-based anger and group efficacy predicted collective action tendencies. Further in line with predictions, identification with the advantaged group did not predict collective action tendencies . Thus, individuals' identification with the advantaged group was completely unrelated to their moral conviction against social inequality and their collective action tendencies. Taken together, we found support for the Moral Motivation Hypothesis. We performed bootstrapping analyses to test for the simultaneous mediating roles of groupbased anger and group efficacy between moral conviction and collective action tendencies . Results showed that the total indirect effect was statistically significant , and that the unique contributions of group-based anger and group efficacy were statistically significant. Thus, both indirect paths were statistically significant. Because the above analysis does not explicitly test the relationships between identification with the advantaged group, group-based anger, and group efficacy, we tested two models through structural equation modelling . The first model represents a model that should not fit the data because it assumes that identification with the advantaged group is the psychological basis for the effects of moral conviction on group-based anger, group efficacy, and collective action tendencies. This model in fact did not fit the data well . Other fit indices corroborated this evaluation of the model: CFI = .79, GFI = .90, SRMR = .10, RMSEA = .37 . This evaluation was further supported by the fact that both the LaGrange Multiplier and Wald-tests for model modification suggested that paths could be added or removed to improve model fit. However, even adding the direct effect of moral conviction on collective action tendencies did not result in a fitting model, . The second model we tested represents a model that should fit the data because it assumes that identification with the advantaged group is completely unrelated to moral conviction, groupbased anger, group efficacy, and collective action tendencies, and that moral conviction predicts collective action tendencies directly. This model fits the data well . Other fit indices corroborated this evaluation of the model: CFI = 1.00, GFI = .98, SRMR = .06, RMSEA = .01. This evaluation was further supported by the fact that both the LaGrange Multiplier and Wald-tests for model modification suggested that no paths could be added or removed to improve model fit. This model thus shows that the relationships between identification with the advantaged group, on the one hand, and group-based anger and group efficacy, on the other, could be set to zero. --- Discussion The Study 1 results supported the Moral Motivation Hypothesis. Among the advantaged in Dutch society, moral convictions against social inequality predicted collective action tendencies through group-based anger and group efficacy. Importantly, moral conviction did not predict identification with the advantaged group, and this identification in turn predicted neither collective action tendencies, nor group-based anger, nor group efficacy. This is consistent with the idea that identification with the advantaged group is not the relevant group identity on which to challenge social inequality. This might also be indicative of the power of violated moral convictions to override other concerns or motivations. However, our results show a striking gap between identification with the advantaged group and the other SIMCA variables . It is also striking that moral conviction seems to easily fill this gap, and in fact shows the very same relationships with the SIMCA variables as a relevant social identity would . Yet, this is fully in line with our argument that moral convictions against social inequality, at least when violated, breach existing group boundaries and increase individuals' identification with the disadvantaged group . Study 1, however, did not include a measure of identification with the disadvantaged group. In Study 2, we therefore included such a measure, which enabled a test of the Identification Hypothesis and the SIMCA Hypothesis. These suggest that violated moral convictions increase identification with the disadvantaged group, and that such identification is the psychological basis for group-based anger, group efficacy beliefs, and collective action tendencies. Study 2 further As in Study 1, the newspaper article focused on a report about structural discrimination in society. In the Study 2 context, this represented discrimination against Mainland Chinese in Hong Kong society. The source of the article was a respected Hong Kong newspaper, which highlighted the case of a Mainland Chinese woman who was not hired for a job because of her Mainland Chinese background. Furthermore, the article reported an increasing number of such incidents and asked the Hong Kong government to intervene. --- Measures Moral conviction All participants first indicated whether they were in favor of or against social inequality . As in Study 1, moral conviction was measured with three items reflecting the strong and absolute stance that it represents . Principal axis factoring with oblique rotation extracted, as expected, one factor that explained 72.66% of the variance, with factor loadings > .74. --- Predictors of collective action tendencies As in Study 1, we measured group-based anger with three items , and group efficacy beliefs with two items . 2 We also measured identification with the advantaged group with four items , and, new as compared to Study 1, identification with the disadvantaged group with four items . Principal axis factoring with oblique rotation extracted, as expected, four factors that explained 73.63% of the variance, with factor loadings > .67. Collective action tendencies Finally, we measured collective action tendencies with seven items . Principal axis factoring with oblique rotation extracted, as expected, one factor that explained 64.95% of the variance, with factor loadings > .75. Thus, across the board the construct validity of our measures was again adequate. --- Results As in Study 1, we tested our predictions with a series of multiple regression analyses. In line with the Moral Motivation Hypothesis, results showed that moral conviction predicted collective action tendencies , group-based anger , and group efficacy . As in Study 1, moral conviction did not predict identification with the advantaged group . Moving beyond Study 1, and in line with the Identification Hypothesis, moral conviction predicted identification with the disadvantaged group . In the next step, we regressed collective action tendencies onto moral conviction, group-based anger, group efficacy, identification with the advantaged group, and identification with the disadvantaged group . In line with the SIMCA Hypothesis, results showed that the effect of moral conviction became non-significant , and that group-based anger , group efficacy , and identification with the disadvantaged group predicted collective action tendencies positively. By contrast, identification with the advantaged group did not predict collective action tendencies . We then performed bootstrapping analyses to test for the simultaneous influence of the three possible mediators of the link between moral conviction and collective action tendencies . Results showed that the total indirect effect was statistically significant , and that the unique contributions of identification with the disadvantaged group , group-based anger and group efficacy were all statistically significant. These results replicate Study 1 and provide more support for our hypotheses. In a final step, we used EQS 6.1 to test the fit of our integrative model . This model represents the most comprehensive test of our set of hypotheses by specifying that moral conviction predicts collective action tendencies through identification with the disadvantaged group, group-based anger, and group efficacy beliefs, whereas identification with the disadvantaged group, reflecting the relevant social identity, also predicts group-based anger and group efficacy. The model fit the data well, with a nonsignificant chi-squared statistic . Other fit indices corroborated the evaluation of the model as quite good: CFI = .99, GFI = .99, SRMR = .03, RMSEA = .08. This evaluation was also supported by the fact that the LaGrange Multiplier and Wald-tests for model modification suggested that no paths could be added or removed to improve model fit. All parameter estimates were significantly different from zero except for two . The first was the parameter estimating the predictive effect of moral conviction on group-based anger. This is consistent with our integrative analysis and more specifically with the idea that the predictive effect of moral conviction on groupbased anger is fully explained by identification with the disadvantaged group. This provides evidence for the idea that identification with the disadvantaged group is the psychological basis for group-based anger among the advantaged. The second non-significant parameter estimate in the model is the predictive effect of identification with the disadvantaged group on group efficacy. This finding is inconsistent with predictions and more specifically with the idea that a stronger group identification raises the efficacy of the group to achieve social change. We will return to this unexpected finding in the general discussion. To enable a comparison with Study 1, we tested a model with identification with the advantaged group at its heart . As expected, this model fit the data less well than our hypothesized model, with a marginally significant chi-squared statistic , indicating that the hypothesized covariance matrix differed somewhat from the actual covariance matrix. Other fit indices corroborated this evaluation of the model: CFI = .95, GFI = .98, SRMR = .04, RMSEA = .15. Both the LaGrange Multiplier and Wald-tests for model modification suggested that paths could be added or removed to improve model fit, which also suggests that this model is not the best fit to the data. Thus, a model with identification with the disadvantaged group at its core fit the data best. --- Discussion The results of Study 2 replicated support for the Moral Motivation Hypothesis, provided novel support for the Identification Hypothesis, and showed support for the SIMCA Hypothesis. Results suggest that, among advantaged group members in a different context than in Study 1, moral convictions against social inequality again predicted collective action tendencies through group-based anger and group efficacy. Study 2 also replicated Study 1 by showing that moral conviction was unrelated to identification with the advantaged group, and moved beyond Study 1 by showing that moral conviction was positively related to identification with the disadvantaged group. Indeed, together with groupbased anger and group efficacy, identification with the disadvantaged group fully explained the link between moral conviction and collective action tendencies. Structural equation modeling showed that, as predicted by SIMCA, groupbased anger was based in identification with the disadvantaged group, but, against predictions, group efficacy beliefs were not based in this group identity. The integrative model also showed a good fit to the data. Both Studies 1 and 2 thus show that the same psychological variables and processes that SIMCA identifies as key to collective action among the disadvantaged are also important in explaining the motivation to challenge social inequality among the advantaged. Moreover, Study 2 suggests that identification with the disadvantaged group is the relevant group identity on which to challenge social inequality in this context. --- General discussion Two studies supported SIMCA's extension to collective action against social inequality among the advantaged, and its integration with the power of moral convictions to motivate the advantaged to challenge social inequality. Both studies showed that moral convictions against social inequality, at least when violated, predict group-based anger, group efficacy beliefs and collective action tendencies on the basis of a relevant social identity. Results further showed that this relevant social identity was individuals' identification with the disadvantaged group . Our findings thus offer a strong pointer toward the importance of seemingly individualistic moral convictions in explaining collective action among the advantaged. Importantly, our results imply that individuals' moral convictions should be taken into account when thinking about social influence attempts to mobilize the advantaged to challenge social inequality. Below we discuss these and other implications of our findings, as well as limitations of the studies and directions for future research. --- Theoretical and practical implications Our findings support the general idea that there are no necessary qualitative differences between the disadvantaged and the advantaged in terms of the psychological variables and processes that predict their collective action against social inequality . Indeed, group-based anger, group efficacy beliefs, and identification with the relevant group all predicted collective action against social inequality . These results fit with an accumulating body of work on collective action among the disadvantaged , and suggests that integrative models such as SIMCA are appropriate frameworks to compare collective action against social inequality among the disadvantaged and the advantaged . However, one apparent difference concerns which social identity is the relevant psychological basis for challenging social inequality through collective action. For the disadvantaged group, the relevant social identity is the disadvantaged in-group identity, or the more specific social movement organization that fights for the group's interests . By contrast, for the advantaged group, the results of both studies show that it is not identification with the advantaged in-group, but with the disadvantaged out-group that is most relevant for predicting collective action. In this sense, the apparent difference between the advantaged and disadvantaged is overpowered by a strong commonality: For members of both groups, collective action against social inequality is predicted by their identification with the disadvantaged group. This is consistent with our argument that moral convictions transcend existing group boundaries to the extent that their violation increases identification with the disadvantaged group, which, according to SIMCA, enables collective action against it through group-based anger and group efficacy. It should be noted that our studies did not aim to uncover the exact psychological process that underpins advantaged group members' identification with the disadvantaged, and hence it is important to compare our line of thought on violated moral convictions with at least three other lines of work. 3 First, some may wonder how moral convictions are different from injunctive group norms . Although there are certainly commonalities between the constructs, the key difference in our view is that moral convictions proscribe standards for anyone, whereas injunctive group norms proscribe standards for in-group members in particular . In this sense we agree with and apply Turiel's distinction between moral judgments and social conventions . In sum, the element of moral absolutism is much more essential to the concept of moral conviction than to the concept of injunctive group norms. But despite this difference, it is also clear that the two are related: We believe that injunctive group norms may be an important step toward developing moral convictions. Such oughts may develop within specific groups, but as soon as they acquire the status of moral convictions, they transcend group boundaries. One of the major questions for future research therefore is when and how this transformation from injunctive group norm to moral conviction takes place in the context of collective action against collective disadvantage. Second, recent work on opinion-based groups, which are defined as groups that revolve around a shared opinion and develop through interaction and normative alignment , would suggest that the reason why the advantaged identify with the disadvantaged is that their moral convictions represent a "community of believers", or a moral community, that sympathizes with the victims of social inequality. In our view, the key question here is whether such a moral community is necessary to explain our current results. Our explanation that violated moral convictions increase identification with the relevant group does not require such a moral community and thus represents a more parsimonious account of our findings. The question of how moral convictions relate to opinion-based groups and moral communities is nevertheless an intriguing question for future research. Finally, recent work by Subasic and colleagues on political solidarity may suggest that the reason why the advantaged identify with the disadvantaged is that their moral convictions derive from the values and standards of a superordinate social category. In line with common in-group and dual identity approaches , Subasic and colleagues argue that the advantaged are more likely to display political solidarity with the disadvantaged when they categorize the outgroup as part of a superordinate category that also includes their own group. Admittedly, we did not measure identification with the superordinate category in either study , and we thus do not have the data to test the validity of these ideas. But a priori, moral convictions would not need to be embedded in a hypothetical superordinate category to enhance identification with the disadvantaged. Our explanation therefore again seems to be more parsimonious. Of course, future research is necessary to provide more conclusive evidence for these interesting ideas. Across the two studies, we encountered only one unpredicted finding. That is, Study 2 showed that identification with the disadvantaged was unrelated to group efficacy beliefs. In the light of the large number of correct predictions, we do not want to attach too much value to this finding. We note in this respect that recent research among the disadvantaged shows that the relationship between group identification and group efficacy may be more complicated than previously thought . This work shows that the relationship between these variables is likely due to the causal effect of group efficacy on group identification . This implies that this aspect of SIMCA might be in need of some revision, although we do not know at present whether these recent results generalize to the advantaged. Another possibility, however, is that the meaning of group efficacy beliefs in the context of collective action is even more complicated among the advantaged than among the disadvantaged. For the disadvantaged, group efficacy beliefs typically refer to the disadvantaged group. The advantaged, however, may be motivated to challenge social equality in part because they believe that the disadvantaged group`s efficacy is too low to achieve social change on their own. Thus, the group's efficacy for them might represent the joint forces of the advantaged and the disadvantaged. Future research can explore this interesting suggestion. Practical implications Practitioners of collective action against social inequality might find SIMCA a useful overarching structure that identifies the key psychological predictors of individuals' motivation to challenge social inequality. Indeed, the model suggests that they should try to socially influence individuals' sense of group identity, group-based anger, and group efficacy. This claim is validated by the accumulating evidence for its generalizability across different contexts as well as across disadvantaged and advantaged groups . SIMCA's first key recommendation to practitioners is that one needs to focus on individuals as group members. Indeed, increasing the self-relevance and salience of a social identity is a crucial start to any mobilization campaign, on which basis one can try to further increase individuals' group-based emotions and group efficacy beliefs. Moreover, previous and current findings suggest that it is very important to target the relevant group identity. As the current work shows, the relevant group is not necessarily the in-group. Van Zomeren, Postmes and Spears proposed in this respect that a strong normative fit between the moral conviction in question and the normative content of a social identity is what makes the identity become self-relevant and thus a basis for collective action. The second key recommendation to practitioners is that one should try to unleash the psychological power of moral convictions against social inequality by communicating the absolute immorality and thus the moral condemnation of their violation. Indeed, those who seek social change should target existing moral convictions about social inequality among the disadvantaged as well as the advantaged . This implies that making reference to the absolute nature of their moral convictions about social inequality and the zero-tolerance for violations thereof motivates both advantaged and disadvantaged group members to challenge social inequality. This might even lead to a coalition of members from both disadvantaged and advantaged groups that unite around a moral conviction against social inequality that increases identification with the disadvantaged group . --- Limitations and directions for future research One limitation of the current research is its relatively low internal validity due to the correlational nature of the two studies. Our theoretical rationale for the hypotheses and the model is based, however, on a synthesis of many primary studies that view social identity, group-based anger, and group efficacy as predictors of collective action. This is in part because there is very little evidence available on the consequences of collective action . Moreover, given that moral conviction is treated by definition as an individual difference measure , the specific limitation of the current studies is that we cannot be certain that moral conviction feeds into the identity, emotion, and efficacy variables, or vice versa, or both. This once more calls for future research on the question of how moral convictions develop . A second limitation of the current set of studies is that we did not measure actual behavior . However, there are two reasons to expect that this is not problematic for the interpretation of the results. First, Van Zomeren, Postmes and Spears employed such a measure and found that the SIMCA variables explained collective action through individuals' collective action tendencies . Second, Van Zomeren, Postmes and Spears's meta-analysis suggested that although the predictive effects of the SIMCA variables on collective action were smaller than on positive attitudes or intentions toward such behavior, these effects were still positive and significant . This suggests that using proxy measures such as action tendencies to some extent overestimates the size of the obtained effects, but does not invalidate their interpretation. We have already noted a number of interesting directions for future research that flow from our current work. Another promising avenue of research lies in experimentally manipulating moral conviction itself. Although one might believe that individual difference measures such as moral conviction are hard to manipulate in the laboratory, we see great promise in manipulating the absolutist mindset that is so central to the experience of moral conviction. Preliminary results from our lab suggest that inducing an absolutist mindset indeed increases identification with a relevant group . As far as we know, this constitutes the first experimental evidence that moral absolutism is directly related to group processes such as identification. As such, we believe that a more comprehensive and integrative understanding of how seemingly individualistic moral convictions can have collective consequences is within reach. In conclusion, we proposed in this article that moral convictions against social inequality motivate the advantaged to challenge social inequality because their violation increases identification with the disadvantaged group. As a consequence, and in line with SIMCA, such identification enables individuals from the advantaged group to engage in collective action against social inequality through group-based anger and group efficacy. Moral convictions against social inequality are therefore key to predicting and explaining collective action among the advantaged against social inequality. Notes 1. In both studies, we specified the relevant group in the items tapping moral convictions. This may constrain our claims about whether individuals' moral convictions tap universal beliefs. Nevertheless, at least two of the items focus on whether individuals believe that their opinion should apply anywhere, or at all times, which in our view is strongly suggestive of the moral absolutism so central to the concept of moral conviction. 2. In both studies, we decided not to operationalize group-based anger and group efficacy by referring to a particular group. We reasoned that if our argument about moral conviction's special link with individuals' identification with the disadvantaged group was correct, our measure of identification with the disadvantaged group would show a positive relationship with our measures of group-based anger, efficacy, and action tendencies. Results largely supported this line of thought. 3. We thank three anonymous reviewers and the guest editor for raising this important point. --- Biographical notes martijn van zomeren is Associate Professor of Social Psychology at the University of Groningen, the Netherlands. His research interests revolve around the psychology of collective action, including issues of morality, social identity, injustice, emotions, and efficacy. tom postmes is Professor of Social Psychology at the University of Groningen, the Netherlands. His research interests include intra-and intergroup processes, such as the formation of social identities. russell spears is Professor of Social Psychology at Groningen University, the Netherlands. His research interests fall broadly in the field of social identity and intergroup relations. karim bettache collected part of the data reported in this article in completing his Master's degree. His research interests include morality, intergroup relations, and cross-cultural psychology.

The literature on collective action mainly focuses on the protests, demonstrations and petitions of disadvantaged groups (Klandermans, 1997; Van Zomeren, Postmes, & Spears, 2008, in press). However, disadvantaged groups often attract considerable support from members of the advantaged group as well-a phenomenon that has only recently become the subject of systematic empirical research (e.g.

Introduction The concept of family functioning can be viewed as the general quality of the family environment and the relationships among its members . Different family theories, such as Beavers system theory , McMaster family functioning mode theory and family therapy theories have proposed different but conceptually related dimensions of family functioning. For example, Beavers system theory proposed six dimensions of family functioning, including family structure, mythology, goal-directed negotiation, autonomy, family affect, and global health pathology . Besides, the McMaster family functioning model theory proposes six dimensions of family functioning, such as effective communication, clear family roles, and appropriate affective responses. Studies have revealed the positive impact of positive family functioning on the developmental outcomes of children and adolescents such as engagement in learning, happiness, mental health, and proper behaviors . To assess family functioning, researchers have adopted different assessment methods such as direct observation , interviews , and self-reported instruments like Olson's Family Adaptability and Cohesion Evaluation and Epstein et al. 's McMaster Family Assessment Device. In fact, self-reported family functioning scales are commonly utilized to examine the perceived family functioning of people . As such, the development of family functioning measures with sound psychometric properties is of paramount importance for clinical and research purposes. However, most of the studies are WEIRD studies, with data collected from Western, educated, industrialized, rich, and democratic societies. As most of the family functioning measures have been developed in the West, researchers have translated and adapted these measures into their local languages like Portuguese and German . Nevertheless, other researchers have challenged cross-cultural adaptation of these measures because of cross-cultural differences, such as differences in individualistic versus collectivistic values in different cultures. In Sumari et al. 's study, the authors found that some factors of their indigenous family functioning scale were the same as those identified in the Family Assessment Device and Family Environment Scale. However, these factors had different meanings based on Malaysian local cultural understanding and interpretations. For instance, the communication and cohesion factors have the elements of courtesy and tolerance, respectively, and this reflects the importance of the preservation of family harmony in Malaysian collectivistic culture. Besides, other researchers have constructed indigenous measures to assess the perceptions of family functioning in their own countries, such as the Japanese version of Survey of Family Environment and Korean version of Family Dynamic Environment Scale . With specific reference to mainland China, there is rapid growth of family interventions in mainland China. The increase in the research on the importance of improving family functions for parents and children has called for the development of validated assessment tools to objectively examine family functioning in mainland China . Nevertheless, there are very few holistic, validated family functioning instruments despite the fact that Chinese people constitute roughly one-fifth of the world population. After checking with the PsycINFO database using "family assessment" in Abstract in November 2023, we found 27,967 records. However, we found only 32 records of family assessment using "family assessment" and "mainland China" and 121 records of family assessment using "family assessment" and "Hong Kong. " Besides, while there are validated translated instruments such as the Chinese version of Family Assessment Device , some important indigenous concepts of Chinese family functioning such as mutuality and avoidance of family conflict are lacking. Besides, although there are some existing Chinese family assessment tools, most of them are not comprehensive and only assess either family interaction or parenting of Chinese families . Furthermore, few studies have examined factorial validity of the different family functioning measures in China . Responding to this gap, based on focus group data and integration with the family science literature, Shek developed the Chinese Family Assessment Instrument to assess the perceived family functioning of Hong Kong adolescents. Specifically, the data gathered from focus groups with adolescents and their parents illustrated that the absence of conflict, family harmony, mutuality, sense of belonging, and good parent-child relationships were regarded as vital elements of a healthy family, whereas emotional expression and communication were least emphasized as important constituents of an optimal family. Past research has revealed that the C-FAI possesses good reliability and validity . In particular, the five dimensions of the C-FAI were validated by exploratory factor analysis and confirmatory factor analysis. There was also support for its convergent validity and reliability. However, the supporting evidence was confined to Hong Kong. In view of cultural disparities between Hong Kong and mainland China, the applicability of the C-FAI to assess the perceived family functioning of adolescents in mainland China deserves further exploration. Under the principle of "one country, two systems, " Hong Kong does not possess the same economic and social systems as those in mainland China. For example, children acting in a non-filial manner will be publicly sanctioned in mainland China. Substance abuse in young people is also unique in Hong Kong . Besides, there are other differences between Hong Kong and mainland China, including Hong Kong is more individualistic whereas mainland China is more collectivistic; Hong Kong is a Capitalistic society whereas mainland China is a Socialist society with Chinese characteristics; mainland China is still more susceptible to traditional Chinese values . As such, exploration of the psychometric properties of the C-FAI, which was originally developed and validated using Hong Kong adolescents as the sample, is warranted for preadolescents and adolescents in mainland China. Besides, there are several gaps in the existing literature in this field. First, validated family functioning measures in mainland China are very limited. Second, as mentioned above, compared to Hong Kong, research on family assessment is relatively inactive in mainland China. Third, there are very few family assessment --- Materials and methods --- Participants and procedures In this study, we conducted a 3-wave longitudinal research on the psychosocial adjustment of Chinese preadolescents and adolescents with data gathered at three different time points: a baseline , six months later , and one and a half years later from the baseline . In 2020, there were 623 elementary schools, 317 junior secondary schools, and 156 schools admitting both elementary and junior secondary students in Chengdu. All of them were public schools. Prior to the onset of the COVID-19 pandemic , a cluster sampling method was used to select five schools to participate in this study. Among these participating schools, two were situated in southern suburban areas, two were in northern suburban areas, and one was in the downtown area. In the scientific literature, there are studies in which data from elementary and secondary school students are collected . In sum, a total of 11,154 students from five selected schools participated in this study. Among them, 3,019 students completed the survey at either one wave, 2,008 students completed the survey at either two waves, and 6,127 students completed the survey at all three waves. Students were asked to answer an identical questionnaire containing a Chinese Family Assessment Instrument in class during the survey. For primary school students, the questions on the questionnaire were read aloud to the students, item by item, by the class teacher in each class. This practice is commonly used in similar studies in the field . As such, the class teacher could help clarify any misunderstandings when asked questions by students. For high school students, students read the questions and responded to the questions on their own. Before starting the survey, we got consent to take part in the survey from parents and students in addition to ethics permission for research from Sichuan University. Moreover, some vital principles such as anonymity and voluntary participation were told to students. After the survey, students' data at 3 waves were matched. To understand the research questions for students in the period of preadolescence and early adolescence, we primarily examined the responses given by students aged 10 and above . In the matched sample aged 10 and above , there were 1,938 primary school students at Wave 1 . There were 1,794 high school students at Wave 1 . --- Instrument The students responded to a questionnaire assessing psychosocial adjustment in children and adolescents. It contains a 33-item Chinese Family Assessment Instrument which has been employed to investigate the perceived family functioning of Chinese adolescents . It has five dimensions, including mutuality , communication , harmony and conflict , parental concern , and parental control . These five dimensions encompass the primary characteristics of positive family functioning in Chinese families, involving absence of conflict, mutuality, and effective communication among family members, in addition to favorable parent-child and spousal relationships. Students' responses were assessed using a 5-point scale . All positively worded items were reverse coded. As such, an item score and the level of functioning of Chinese families was positively correlated. C-FAI has been found to be a valid and reliable tool for assessing family functioning in past studies using Hong Kong adolescents . Besides the Chinese Family Assessment Scale, three additional items were employed to evaluate the convergent validity of the C-FAI: mutual support among family members ; degree of understanding of family members regarding the situations of each other , and relationship between the participant and his/her caregivers . Students were asked to respond to the first two questions along a 6-point scale and along a 10-point scale for the last question. Moreover, three additional items theoretically unrelated to family functioning were added to assess the discriminant validity of the C-FAI involving the items measuring the amount of time for sleeping and doing exercise , and the amount of sweet drink students take in per week/month . In the literature , researchers have used this approach to assess the discriminant validity of a measurement instrument. --- Data analysis In this study, we performed confirmatory factor analysis and measurement invariance tests to assess the factorial validity, convergent validity, discriminant validity, and reliability of the C-FAI, and its stability across groups and over time. CFA and MI tests were conducted using structural equation modeling techniques via Lisrel 8.54. Parameters were estimated by utilizing maximum likelihood estimation and robust maximum estimation methods. RML was chosen because it could reduce standard errors of the estimates caused by the violation of multivariate normality of the data. Convergent and discriminant validity of the C-FAI were assessed using Pearson correlation with the aid of SPSS 26.0. The present investigation implemented five sequential steps. First, CFA was performed to assess the factor structure of the C-FAI using three waves of data individually. As stated by Brown , the factor model of the C-FAI fits the data adequately when the values of the standardized root-mean-square residual and the root-mean-square error of approximation are less than 0.08 , and the values of the non-normed fit index and the comparative fit index are more than 0.90 . Second, after identifying the factor structure of the C-FAI and establishing its factorial validity, we assessed the stability of the factor structure of the C-FAI across groups. Initially, the total sample at each wave was randomly divided into two subsamples based on cases. Multigroup confirmatory factor analysis was then used to assess the measurement invariance of the C-FAI across subsamples at each wave. Following the steps outlined by Dimitrov , the levels of measurement invariance were assessed in the following order: separate groups, configural invariance, weak measurement invariance, strong measurement invariance, and strict measurement invariance. These steps are commonly followed when testing the measurement invariance of a scale . Hence, a series of models ranging from least restrictive to most restrictive models were compared. At the beginning, a five-factor model of the C-FAI was assessed separately for each group. Then, the five-factor structure of the C-FAI was evaluated simultaneously across groups to establish configural invariance in the analysis. The models were specified with no restriction in factor loadings, intercepts and uniqueness of the corresponding indicators between groups. Afterwards, weak measurement invariance was examined with the same models of configural invariance except the equality of factor loadings was imposed between the corresponding indicators of both groups. Later, strong measurement invariance was investigated with the same models of weak measurement invariance except the equalities of factor loadings and intercepts were imposed between the corresponding indicators of both groups. Finally, strict measurement invariance was examined with the same models of strong measurement invariance except the equalities of factor loadings, intercepts and uniqueness were imposed between the corresponding indicators of both groups. After establishing measurement invariance of the C-FAI, structural invariance of the 5-factor correlated model of the C-FAI was further explored by testing invariance in factor variances and factor covariances of the C-FAI model. Invariance in factor variances was examined with the same models of strict measurement invariance except the equalities of factor loadings, intercepts, and uniqueness were imposed between the corresponding indicators, and the equality of variances between corresponding factors was imposed between corresponding factors of both groups. Furthermore, invariance in factor covariances was assessed with the same models of factor variances invariance except the equalities of factor loadings, intercepts, and uniqueness were imposed between the corresponding indicators, and the equalities of variances and covariances were imposed between corresponding factors of both groups. For each form of factorial invariance, the model was compared with the model that preceded it. As chi-square difference tests tend to reject the null hypothesis of no difference between two nested models in large samples even though the difference is trivial , changes in CFI and RMSEA values were also commonly used to assess model fit for the factorial invariance of the C-FAI . An acceptable model fit for more restrictive invariant models is based on the change in CFI value that is not more than 0.002 , and the change in RMSEA value that is not more than 0.01 . Third, after confirming the stability of the factor structure of the C-FAI across groups, we further tested whether the factor structures were stable across time. Identical factor analytic procedures and criteria for the fit of invariant nested models mentioned above were conducted to assess the stability of the factor structure across three waves of data , with autocorrelation of uniqueness specified among same observable indicators in Wave 1, Wave 2 and Wave 3. Fourth, apart from investigating the factorial validity and invariant properties of the C-FAI, we also assessed the convergent and discriminant validity of the C-FAI. The convergent validity of the C-FAI is demonstrated when the "average variance extracted" for each factor at all waves was more than 0.50 . It means that each construct explained more than 50% of the total variance in their respective indicators, and hence the convergent validity of the 5-factor structure of the C-FAI was supported. Besides, the convergent validity Frontiers in Psychology 05 frontiersin.org of the C-FAI was illustrated when the total score of the C-FAI is correlated significantly and substantially with the scores of three conceptually related items in the questionnaire, including there is mutual support among family members, family members know to understand the situations of each other, and relationship between you and caregivers. On the other hand, the discriminant validity of the C-FAI was illustrated when the total score of C-FAI did not show any substantial correlation with those of items unrelated to the measurement of family constructs, such as the items tapping the amount of time for sleep and doing exercise, and the amount of sweet drink the participants take in per week and month. This approach was adopted in previous studies to examine the convergent and discriminant validity of a measure . Lastly, we examined the reliability of the C-FAI using composite reliability, in which the acceptable value for it is 0.70 and above . Moreover, we utilized Cronbach's alphas and mean inter-item correlations of the C-FAI to further examine the internal consistency reliability of the subscales and the total scale of the C-FAI . A value of Cronbach's alpha greater than 0.7 indicates acceptable reliability, while the value of mean inter-item correlations in-between 0.3 to 0.7 illustrates adequate internal consistency of the scale . --- Results --- Descriptive statistics Means, standard deviations, skewness, and kurtosis of each item of the C-FAI were assessed. The range of mean and standard deviation was 3.44-4.49 and 0.94-1.51, respectively. All items were normally distributed because the absolute values of univariate skewness and kurtosis values were not more than 2 and 7, respectively. --- Factorial validity of C-FAI Table 1 summarizes the results of CFA according to the sample at Wave 1, Wave 2, and Wave 3. The findings of this study illustrated that the five-factor correlated model of C-FAI, with four error covariances fitted the data of each wave adequately . Nevertheless, it is noteworthy that the RMSEA and SRMR values in the model of each wave represented fair fit only, although NNFI and CFI indices illustrated good fit. Apart from two items which had the loadings less than 0.34, factor loadings of all other items were higher than 0.40 and significant at 0.05 level. As such, Hypothesis 1 was supported. --- Multigroup invariance across subsamples A series of invariance tests were conducted across two subsamples at each wave to assess multigroup invariances of the C-FAI. As indicated in Table 2, the five-factor correlated model of the C-FAI showed an acceptable fit to the data of the subsamples at each wave, with NNFI and CFI values ranging from 0.93-0.96 and 0.94-0.97, respectively. As such, a series of factorial invariance tests were conducted across two subsamples in each wave of data subsequently. As the result of the chi-square difference test is too sensitive to large sample size , a practical approach was adopted for demonstrating the measurement invariance property of the C-FAI in the present study . The findings of this study revealed equivalent fit indices between all pairs of the more restrictive model and the comparison model since changes in CFI and RMSEA values were less than the cutoff values of 0.002 and 0.01, respectively. As such, C-FAI is measurement and structural invariant across subsamples of three waves of data. Multigroup invariance of the C-FAI was confirmed and Hypothesis 2 was supported. Specifically, the most restrictive model of the C-FAI supposing equality in factor loadings, intercepts, uniqueness of indicators, factor variances and covariances illustrated fair fit indices at Wave 1 to Wave 3 , in spite of good fit demonstrated by NNFI and CFI indices. --- Longitudinal invariance across time After confirming the multigroup invariant property of the C-FAI, its longitudinal invariance was further explored. As the five-factor correlated model of the C-FAI demonstrates an acceptable fit to the data of each wave , a series of measurement invariance tests were conducted over three waves of data subsequently to investigate the longitudinal invariance of the C-FAI. In Table 3, Model 1 demonstrated a good fit to the observed data , suggesting the generalizability of the factor structure of the C-FAI over time . Then, a more restricted model for assessing the weak measurement invariance of the C-FAI was performed. In Model 2, factor loadings were specified to be the same across three waves of data. As the change in both CFI and RMSEA values between Model 1 and Model 2 were less than 0.002, the weak measurement invariance of the C-FAI was supported. Given all factor loadings of items were invariant, strong measurement invariance of the C-FAI was examined. In this form of invariance test, factor loadings and intercepts were specified to be equal across three waves of data in Model 3. Since there was no change in CFI and RMSEA values between Model 2 and Model 3, the strong measurement invariance of the C-FAI was also supported. Given all factor loadings and intercepts of items were invariant, strict measurement invariance of the C-FAI was examined. In this form of invariance test, factor loadings, intercepts as well as uniqueness of indicators were constrained to be identical across three waves of data . As the change in CFI values between Model 3 and Model 4 was 0.003, which was greater than the cutoff value of 0.002, the strict measurement invariance of the C-FAI was not supported. In sum, the findings of this study indicate that the factor structure of the C-FAI remained consistent across time, demonstrating longitudinal invariance. Additionally, latent means could be compared without bias. This confirmed Hypothesis 3. In sum, C-FAI has good factorial --- Convergent and discriminant validity Regarding convergent and discriminant validity of the C-FAI, the findings revealed that the average values of AVE for all factors across three waves ranged from 0.53 to 0.61, which were higher than the cutoff value of 0.50 . In addition, the total score of family functioning correlated significantly and substantially with three conceptually related indicators in each wave of data, including there is mutual support among family members , family members know to understand the situations of each other , and relationship between you and caregivers . As 6. On average, how much sweet drink do you take in per week / month? -0.16 -0.12 -0.17 The correlation coefficient inside the bracket is insignificant . such, Hypothesis 4 was supported and the convergent validity of the C-FAI was demonstrated. Regarding discriminant validity of the C-FAI, the findings revealed that the total score of family functioning did not correlate substantially with other three conceptually unrelated indicators, including amount of sleep per day , amount of time for doing exercise per day , and on average, the amount of sweet drink which you take per week/ month . Consequently, Hypothesis 5 was supported and discriminant validity of the C-FAI was confirmed. --- Reliability Table 5 illustrates the reliability of five subscales and the total scale of the C-FAI. The findings of this study showed that the composite reliability of the subscales and the total scale ranged from 0.72-0.97 at Wave 1, 0.74-0.97 at Wave 2, and 0.75-0.97 at Wave 3. They illustrated that the C-FAI was reliable. The reliability of the C-FAI was further supported by Cronbach's alpha and mean inter-item correlations . As such, Hypothesis 6 was supported. In sum, the factorial, convergent and discriminant validity as well as the reliability of the C-FAI were confirmed. In addition, longitudinal and multigroup invariance of it were evident. As such, C-FAI is a psychometrically sound measure to investigate adolescents' perceived family functioning in mainland China. --- Discussion This study aimed to examine the factor structure, convergent validity, discriminant validity and reliability of the C-FAI as well as its invariance across subsamples and time, among children and adolescents residing in mainland China. One of the primary features of this work was its use of a longitudinal research approach with a large sample size to perform a construct validation study of the C-FAI. As such, the stability of the factor structure of the C-FAI over time was explored. It is important because the longitudinal invariant property of the C-FAI is largely neglected in previous studies using family functioning measures . Besides, apart from adopting RML estimation to address multivariate non-normality of the data, this study recruited a large sample for investigation. This would lower standard errors of the estimates and hence, enhance the accuracy and credibility of the findings. In addition, as most of the self-reported family functioning measures focus on adults instead of children and adolescents , this study provided empirical support for the usefulness of the C-FAI to assess subjective family functioning among preadolescents and adolescents in mainland China. In response to the question about the factor structure of the C-FAI among preadolescents and adolescents in mainland China , our findings offered empirical support for the five-factor structure of the C-FAI , hence supporting Hypothesis 1. It echoes the findings of Siu and Shek's and Shek and Ma's study, which revealed the same factor structure of the C-FAI among adolescents in Hong Kong. As stated by Cultural Atlas Editors , even though there are some social and cultural differences between people in Hong Kong and mainland China, Confucianism still serves as the foundation of the cultural roots of people in both places. Some important Confucian values, such as filial piety, are still prevalent among children and adolescents, which in turn determine their perceptions of a good and healthy family . For instance, under the filial piety tradition, children and adolescents will follow and respect their parents while parents will take care of and accept their children. As such, family harmony would be preserved by developing mutuality among family members. Moreover, as the dimensions of the C-FAI identified in this study have high similarity to three important dimensions of family functioning in Western studies, which are cohesiveness, communication, and flexibility, these three aspects of family functioning seem to be universal across both Western and Chinese cultural contexts. Nonetheless, similar to the findings using Hong Kong adolescents , the "conflict and harmony" dimension identified in this study reflects that the "absence of conflict" is also viewed as an important element of a good family for children and adolescents in mainland China. In addition, "parental concern" and "parental control" factors are associated with the functioning of parents, which in turn reflects the significant role of parents in determining the functioning of families in mainland China. In sum, as stated by Wong et al. , there are two perspectives to conceptualize family functioning, including process-oriented and result-oriented perspectives. The former perspective classifies families into different kinds based on the features of the family Annular Mode model of family functioning), while the latter perspective is mainly concerned with the essential components for the development of healthy families McMaster family functioning model). The dimensions of the C-FAI involve both result-oriented and process-oriented elements , which would offer holistic insights into the development of positive family functioning in mainland China. For the second research question, our findings supported Hypothesis 2 that the dimensions underlying the C-FAI were invariant across random subsamples. It is consistent with the findings of Shek and Ma's study, which illustrated strong measurement invariance of the C-FAI across subsamples based on case numbers . However, the results of this study offered additional empirical evidence in support of the strict measurement invariance and structural invariance of the C-FAI across random subsamples. These findings suggest two random subsamples have same interpretations of C-FAI items, and the factor and observable means of the level of family functioning between two subsamples could be compared without bias. Moreover, the relationships among the five factors of the C-FAI were equally applied to two subsamples. As such, two subsamples have the same conceptual understanding of the areas of functioning in Chinese families. For example, the "mutuality" and "communication" factors would be highly correlated because effective communication among family members would promote their mutuality . The findings of this study indicate that the factor structure of the C-FAI remained consistent throughout time, hence providing support for Hypothesis 3. This finding provides evidence for the long-term stability of the C-FAI. Please be advised that the use of C-FAI has been observed in longitudinal research conducted with teenagers in mainland China ), the longitudinal invariant property of the C-FAI has not been well addressed. The strict longitudinal invariance of the C-FAI found in this study adds to the extant literature and supports the fact that the C-FAI assesses the same family functioning construct at different points of time. As such, C-FAI could be used to assess age-varying changes in the subjective family functioning of Chinese people from childhood to adolescence to adulthood, especially during the period of adolescence in which teenagers may have negative relationships with parents . In addition, as mentioned in the review article by Dai and Wang , research on the development of family functions at different periods during the life of a family is very limited. C-FAI would be a promising family functioning measure to address this gap and assess changes in the functions of a family over the life course. Apart from supporting the factorial validity of the C-FAI, the construct validity of the C-FAI was further confirmed by establishing its convergent and discriminant validity. Regarding the fourth research question, the present results revealed substantial correlations between the total score of the C-FAI and the measures of family support, hence supporting Hypothesis 4. Convergent validity of the C-FAI was confirmed. The results of Gaspar et al. 's research align with the findings presented here, demonstrating a significant positive association between parental emotional support and family functioning among a sample of 1,757 parents from Portugal. 'Besides, the present results did not reveal substantial associations between the total score of C-FAI and theoretically unrelated constructs, and thus supported Hypothesis 5. As such, discriminant validity of the C-FAI was also confirmed. As stated by Strauss and Smith , construct validity of a measure is commonly regarded as a unifying form of validity for psychological measurements and hence encompasses cumulative sources of evidence supporting specific interpretations of a score from a measure. The establishment of the convergent validity Lastly, the findings of this study illustrated acceptable reliability of the total and subscale measures of the C-FAI, hence supporting Hypothesis 6. It is consistent with the findings of Hu et al. 's and Lam and Chen's study, which showed the total scale of the C-FAI and its subscales were reliable. In sum, C-FAI is a valid and reliable measure of perceived family functioning among children and adolescents in mainland China. It is a stable family functioning instrument that would be utilized to compare the latent means between groups and detect the changes of latent means across time. --- Implications Theoretically, this study provided empirical support to an indigenous conceptualization of family functioning in the Chinese context. As stated by Dai and Wang , theoretical models of family functioning in China are mainly focused on translated literature and the Western-developed models may not be culturally appropriate in the Chinese culture. Therefore, the development of unique Chinese family functioning models is of paramount importance. Hence, the study is an innovative attempt using rigorous conceptual arguments and research methods . This study also paves the way for the development of more sophisticated family functioning models for Chinese people. Basically, family functioning theory is classified into two categories in the West. The first one is result-oriented family functioning theory, which defines family functioning by special features of the family such as family intimacy and family communication styles. Another one is process-oriented family functioning theory, which describes family functioning in terms of tasks families need to complete, such as affective involvement and behavior control of the child in the family. Literature review has illustrated that a theoretical model of family functioning with both result-and process-oriented elements is very rare. However, the conceptual model underlying the C-FAI is composed of both resultoriented elements and process-oriented ones . This conceptual model of family functioning would add to the literature and serve as an innovative reference model to facilitate the cross-cultural examination of family functioning in different cultural contexts. Practically, C-FAI would serve as a psychometrically sound family functioning instrument to identify family problems and hence support clinical practices in mainland China and Hong Kong. In light of the increase in family problems, youth education problems and psychological problems in mainland China in recent years, the demand for family therapy and intervention has been raised by leaps and bounds . As such, the provision of family therapy and intervention has been greatly increased. Nevertheless, Quek and Chen commented on the applicability of Western-based family therapy approaches and screening instruments to the Chinese context. As C-FAI has been developed in the Chinese context, it could be utilized to conduct family functioning research in mainland China and Hong Kong appropriately. In fact, Hu et al. have already utilized the C-FAI to identify families with different levels of family environment dysfunction and subsequently explored the effects of the family environment on non-suicidal self-injury among secondary school students in mainland China. C-FAI would be used to help counselors and family therapists to identify the problematic areas of family functioning in an unhealthy family and subsequently provide appropriate intervention and treatment to clients. In addition, as the current findings illustrated that the C-FAI exhibited favorable psychometric properties, it could be utilized as an objective reference tool in future studies on family functioning within various Asian contexts, thereby contributing to the broader international research landscape. --- Limitations There are certain limitations of the study. First, we only used three-wave data to assess longitudinal invariance of the C-FAI. To delineate a holistic picture of measurement invariant property of the C-FAI over time, future research should aim to collect more waves of data over an extended period of time. Second, multigroup invariance of the C-FAI was assessed using random subsamples only. As family functioning has been found to be associated with gender and family SES of the participants , future research should explore whether the C-FAI is invariant across gender and family SES among children and adolescents in mainland China. Third, the study sample was limited to preadolescents and adolescents residing in Chengdu. Although studies focusing on a single province have been conducted , it is necessary to replicate the generalizability of the current findings across diverse populations in various regions of China. --- Conclusion This innovative study aimed to examine the factorial validity, convergent validity, discriminant validity, reliability and measurement invariance of the C-FAI in preadolescents and adolescents in mainland China. Based on rigorous conceptual arguments and utilizing advanced research design and methods, the results of this study provided support for all kinds of validity of the C-FAI and its multigroup and longitudinal invariance. As such, we conclude that C-FAI is a valid and reliable tool to assess perceived family functioning among children and adolescents in mainland China. The present findings provide support for an integrated indigenous Chinese model of family functioning. Besides, in view of its sound psychometric properties, the practical significance of the findings is that family practitioners and researchers can utilize the C-FAI to identify different problematic areas of the functioning in Chinese families and implement effective intervention and treatment to their clients. --- Data availability statement The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Shek et al. 10.3389/fpsyg.2023.1290224 Frontiers in Psychology 11 frontiersin.org --- Ethics statement The studies involving humans were approved by Ethics Research Committee of Sichuan University. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants' legal guardians/next of kin. --- --- Funding The author declare financial support was received for the research, authorship, and/or publication of this article. The study and this article are financially supported by Wofoo Endowed Professorship as well as the matching fund from The Hong Kong Polytechnic University and Research Grants Council . --- --- 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.

Regarding the assessment of family functioning in Chinese people, there are several research gaps. First, although there are some instruments in the field, there are very few validated instruments. Second, while some translated measures have been developed, there are very few assessment tools based on indigenous Chinese concepts. Third, compared to Hong Kong, research on family assessment is relatively inactive in mainland China. Fourth, there are very few family assessment tools to assess perceived family functioning in older children and early adolescents. Fifth, few studies used large samples to validate family assessment tools. Sixth, researchers seldom utilized longitudinal data to examine the psychometric properties of family assessment tools. Finally, few studies have examined factorial validity across samples and time to demonstrate the stability of Chinese family assessment measures. In Hong Kong, based on focus group data (i.e., indigenous concepts of family functioning) and an integration with the family science literature, we have developed the Chinese Family Assessment Instrument (C-FAI) to assess perceived family functioning according to the perception of adolescents. Results showed that the C-FAI possessed good reliability and validity. Specifically, five dimensions of the measure (mutuality, communication, conflict, parental concern and parental control) were supported via exploratory factor analysis and confirmatory factor analysis. Convergent validity and reliability of the C-FAI were illustrated. To understand the psychometric properties of the C-FAI in mainland China, we collected three waves of data from students in the period of preadolescence and early adolescence in mainland China (N = 3,732). Based on the data, we examined the psychometric properties of the measure, particularly factor invariance in different samples and at different times. Confirmatory factor analysis provided support for the five dimensions in C-FAI, including factorial invariance in terms of configuration, factor loading, intercepts, and over time. There was evidence for convergent validity and discriminant validity of the measure. Finally, reliability analyses showed that the total C-FAI scale and its subscales are internally consistent. The present findings suggest that family researchers and practitioners can use the C-FAI to objectively assess perceived family functioning in preadolescence and early adolescence in different Chinese communities.

Background Uganda is a low-income country with one of the highest prevalence rates of HIV worldwide [1]. It is estimated that 130,000 children under the age of 14 in Uganda were living with HIV in 2016 [2]. Although the development of antiretroviral therapy has made HIV a manageable chronic illness, [3] adherence to ART needs to reach 95% in order to reach the desired treatment outcomes [4,5]. However, research shows that ART adherence level in Uganda is still low among people living with HIV , with only 66% reporting the desired adherence outcomes [6]. Moreover, in rural areas, adherence rates are much lower, with only 55% adhering to their medication [7]. Furthermore, the ART coverage for children in Uganda is estimated to be only 47% of the target population [8]. Yet, low ART adherence can result in increased viral duplication, rapid disease progression, reduced life quality, and even premature mortality [9]. Therefore, suboptimal ART adherence among children in Uganda is an urgent health issue that needs to be addressed. Against this backdrop, this study examines family factors that impact ART adherence self-efficacy among perinatally HIV-infected adolescents in southern Uganda so that more targeted interventions can be put in place to improve ART adherence. --- Medication adherence and self-efficacy In the context of HIV, ART adherence is defined as the degree to which an individual adheres to taking the prescribed antiretroviral drugs [4]. Observable ART adherence levels depend on a range of factors, [10] including self-efficacy i.e. the person's perception of their own ability to accomplish a behavioral task, [11] which influences a person's development or maintenance of a health behavior at the affective, cognitive and motivational levels [12]. More specifically, adherence self-efficacy -defined as the confidence in one's ability to adhere to treatment plans, has been documented as an important predictor of medication adherence in the treatment of HIV and other medical conditions [13]. For example, an individual who feels able to successfully fulfill medication regimes as prescribed, in addition to following a specified diet, as well as executing recommended lifestyle changes, [14] will be more likely to achieve positive health outcomes. Moreover, individuals tend to be more motivated if they perceive that their actions can be completed [15]. Indeed, adherence self-efficacy has been linked to positive outcomes among patients with hypertension, [16] asthma, [17,18] diabetes [19,20] pain management [21] and depression [22]. Among PLWH, self-efficacy has been corelated with adherence outcomes [23][24][25][26][27][28][29]. For example, a meta-analysis examining the predictors and correlates of ART adherence found that adherence self-efficacy was positively associated with the initiation and maintenance of ART adherence [23]. In another study in South Africa, a strong association between self-efficacy and ART adherence was found in the nonadherent participants, explaining 9.8% of the variance [24]. In the United States and Puerto Rico, Nokes and colleagues [25] found adherence self-efficacy to be a robust predictor of ART adherence and a mediator between environmental influences and cognitive or personal factors. However, few of these studies have been conducted in SSA, and none have focused on children and adolescents living with HIV [24]. Yet, for children who depend on their caregivers to meet their adherence expectations, it is important to examine and understand their cognitive and motivational influences affecting medication adherence, including self-efficacy. --- Social support and adherence Several studies have documented the role of social support, especially from family members in influencing adherence outcomes [30][31][32][33][34][35][36][37][38]. For example, a meta-analysis of studies examining social support and patient adherence to medication showed that ART adherence was 1.74 times higher in patients from cohesive families and 1.53 times lower in patients from families experiencing conflict [30]. In Uganda, family cohesion and social support from caregivers/family were associated with self-reported adherence to ART among HIV-infected adolescents [31]. In another study examining the benefits of family and social relationships for health and mental health of PLWH, family functioning significantly contributed to ART adherence and quality of life [32]. Thus, strengthening positive family support and minimizing negative family interactions are crucial for increasing adherence rates [33]. Despite the unique developmental needs of children and adolescents, few studies have specifically focused on family systems among HIV-infected children and adolescents in SSA [31,34,35]. Moreover, these studies do not explicitly explore the relationship between family support and adherence self-efficacy -two factors that are critical to HIV management and adherence to treatment protocols among PLWH, including children and adolescents [36]. Thus, to bridge this gap, this study examines whether family factors, such as family cohesion, childcaregiver communication, and perceived child-caregiver support, are associated with ART adherence self-efficacy among HIV-infected adolescents in southern Uganda. We hypothesize that these family factors will be positively associated with positive ART adherence selfefficacy levels over time. --- Methods --- Study sample and context This study utilized data from the Suubi+Adherence study, a longitudinal randomized clinical trial funded by the National Institute for Child Health and Human Development . The Suubi+Adherence study examined an innovative family-based economic empowerment intervention on ART adherence among perinatally HIV-infected adolescents in southern Uganda, a region heavily affected by HIV/AIDS. Uganda has a national HIV prevalence rate of 7.3% among adults aged 15-49, with higher prevalence rates of 12% in the southern region where the study was implemented [1]. The Suubi+Adherence study followed 702 HIV-positive adolescents between 2012 and 2017. Participants were identified and recruited from health clinics in the greater Masaka region associated with Reach the Youth Uganda and the Masaka Diocese . All health clinics were accredited by the Uganda Ministry of Health to provide ART to all adolescents living with HIV in the region. The inclusion criteria for these adolescents were: 1) 10-16 years old, 2) HIV-positive and know their HIV status, 3) prescribed antiretroviral therapy, 4) living within a family, not an institution, and 5) enrolled in one of the 39 health centers or clinics in Rakai, Masaka, Lwengo, Lyantonde, Bukomasimbi, and Kalungu Districts in the study area. Detailed information on participants recruitment and selection process, as well as the study intervention is described in the study protocol and in our other publications [37,38]. --- Data collection Data were collected using a 90-min interviewer administered survey at baseline, 12, 24, 36 and 48-months post baseline. Survey instruments and all research related documents were translated into Lugandathe most widely spoken language in the study regionand back translated into English to ensure accuracy. This process was overseen by certified language experts at the Makerere University in Uganda. All interviewers completed the Collaborative Institutional Training Initiative certificate and NIH certificate for protection of research participants, prior to participant contact. In addition, the study team received training on Good Clinical Practices so that sensitive research activities were handled appropriately. Details on data protection are provided in the study protocol [37]. --- Measures The dependent variable in this study is adherence selfefficacy, assessed by the HIV Treatment Adherence Self-Efficacy Scale [13]. The scale measures adolescents' confidence in integrating prescribed ART plan into their routine life and maintaining optimal adherence levels. The scale was previously tested among people living with HIV in the southern region of Uganda, with a high reliability score [39]. There are nine integration questions, such as "In the past month, how confident have you been that you can stick to your treatment plan even when side effects begin to interference with daily activities?" and three perseverance questions, such as "In the past month, how confident have you been that you can continue with the treatment plan your physician prescribed even if your T-cells drop significantly in the next three months?" The rating range is between 1 and 10, with a higher rating representing higher levels of adherence self-efficacy. The scale has a high reliability . Family support factors were measured by three indicators: 1) family cohesion, 2) perceived child-caregiver support, and 3) child-caregiver communication, all adapted from the Family Environment Scale, [40] and the Family Assessment Measure [41]. All these measures were tested in our previous studies in Uganda among children affected by HIV/AIDS [31,[42][43][44]. Family cohesion was assessed by an 8-item scale that measures the degree of commitment, help and support family members provide for one another. Participants were asked to rate how often each item occur in their family, on a 5-point scale . Sample items include: "Family members ask each other for help before asking non-family members." and "Family members like to spend free time with each other." The scale had a strong internal consistency . Summary mean scores were created with higher scores indicating high levels of family cohesion. The perceived child-caregiver support scale assesses social support on two dimensions: acceptance and warmththe extent to which the child perceives the caregiver as involved in their life; and psychological autonomythe extent to which the caregiver employs a non-coercive, democratic discipline and encourages the child to express individuality within the family. Participants were asked to rate the adults they live with, on each of the 18 items , on a 5point scale . Sample items include: "Child can count on parent/guardian to help in case of a problem," and "Parent/guardian explains why they want the child to do something." Summary mean scores were created, with higher scores indicating high levels of perceived child-caregiver support. The child-caregiver communication scale assesses discussions between the child and the caregiver on 12 items related to issues such as puberty, cigarette smoking, sexual risk taking, puberty, HIV/AIDS, educational plans, etc. Participants were asked to indicate how often they discussed the specific topics with their caregivers, on a 5-point Likert scale . Summary mean scores were created with higher scores indicating high levels of child-caregiver communication . Control variables included in the analysis were: participants' gender, age, total number of people in the household, total number of children in the household, primary caregiver , school enrollment , HIV disclosure status to other individuals other than the primary caregiver, medication regimen and study condition . --- Analysis procedures All analyses were conducted using STATA version 15. Bivariate analyses were conducted on baseline sociodemographic and household characteristics, adherence self-efficacy and family support factors. Baseline results were compared between the control and treatment conditions . Multilevel analysis was used to examine the relationship between adherence self-efficacy and family support factors over time based on the formula: yij ¼ β0 þ β 1 X 1 ij þ β 2 X 2 ij þ β 3 X 3 ij⋯ þ β p X p ij þ ξij where β0 is intercept, X2ij through Xpij are covariates and ξij is a residual. The models were built with -mixed command using vce option in STATA, that has the advantage that the estimated standard errors are valid even if the level-1 errors are heteroskedastic or autocorrelated [45]. This method was used to study adherence self-efficacy over time , personlevel 2 characteristics that influence initial adherence self-efficacy and change over time . This approach did not require individuals to have equal numbers of measures and can handle both time invariant and time-varying covariates. First, the analysis started with building unconditional three-level model to determine between-person and within-person variability in adherence self-efficacy scores . Second, level-1 family factor variables were added to the unconditional model . Like for many other psychological constructs that lack a clearly interpretable or meaningful zero-point, [46] we used Centered Within Cluster variables to establish a useful zero point [47]. To accommodate possible endogenous time-varying covariates that are correlated with the random-intercept ζj, the model was fitted allowing for different within and between effects for time-varying covariates by including both subject-mean centered and the occasion-specific deviations from the subject means as the subject-mean centered covariates are uncorrelated with ζj by construction, and the corresponding coefficients could be consistently estimated [45]. Finally, we fitted the model with all the control variables . Statistical significance was determined at the 5% level. that they never keep their HIV status a secret. However, about the same number of adolescents reported that they always keep their HIV a secret. The majority of participants had to take their HIV medication at least twice a day. In terms of family support factors, participants reported moderate levels of communication with their caregivers , and perceived child-caregiver support . Higher levels of family cohesion were reported, with mean score of 31.8 . Adolescents reported higher levels of adherence self-efficacy, with an average score of 94.28 . No statistically significant differences were observed between the control and treatment conditions. Table 2 presents results from a multilevel unconditional model conducted to determine between-person and within-person variability in adherence self-efficacy scores. The variance in adherence self-efficacy over time for each child was 391.7 , explaining 83% of total variance. The variance of the true self-efficacy averaged over time was 79.3, while variability of clinic means around the grand mean was only 2.75 . The intraclass correlation for individual level was 0.173, and -0.006 at the clinic level . The likelihood ratio test indicated that there was evidence that using a random intercept model could explain the variance in adherence selfefficacy even in the absence of any covariates = 153.04, p = 0.000). Further analysis showed that there was no significant difference between 3-level and 2-level models =1.65, p = 0.198), thus analysis was continued with exploring 2-level models. Table 3 presents results from the multilevel model with socio-demographic and household characteristics. Participants' age was statistically associated with adherence self-efficacy . In addition, HIV status disclosure, whether sometimes or always , was also associated with adherence self-efficacy. Group assignment was not significant . The overall model was statistically significant = 84.2, p = 0.000). The variability of self-efficacy over time for each child slightly decreased to 389.8, from 391.1 and variance of the true self-efficacy averaged over time also slightly decreased to 62.7 from 64.3 . Table 4 presents results from the full multilevel analysis models conducted to determine the association between family factors and adherence self-efficacy, controlling for sociodemographic and household characteristics. Family cohesion and child-caregiver communication were both positively associated with adherence selfefficacy. Perceived child-caregiver support was not statistically significant . The entire model was statistically significant = 177.29, p = 0.000). In comparison to the previous model with sociodemographic and household characteristics only , the variability in adherence self-efficacy changed even more. Specifically, over time, self-efficacy for each child decreased even more to 384.3while variance of the true self-efficacy averaged over time decreased to 53.9 indicating that family factors can play significant role to define adolescents' adherence self-efficacy. --- Discussion This study examined the family factors associated with ART adherence selfefficacy among HIV-infected adolescents in southern Uganda. Findings from our study indicate that family cohesion and communication represent emotional support from family members towards HIV-infected adolescents and is felt by adolescents through daily communication and care expressed by family members. Although adolescence involves developing independence as a developmental stage, the supportive relationships and connections with family and caregivers continue to be protective factors. Specifically, for HIV-infected adolescents, family is the primary source of financial, physical, and emotional support. Moreover, most adolescents rely on their family members, especially caregivers, to access HIV care and help administer medication regimes [48,49]. As such, family members' assistance in helping with HIV-related concerns or problems encountered by adolescents can contribute to improving adolescents' self-efficacy in integrating treatment plans into their daily routines. This finding underscores the protective role of family and provides further evidence for transitioning from individual-based to family-focused health interventions. Orphanhood status was not associated with adherence self-efficacy. This finding somewhat deviates from past research in other sub-Saharan African countries, which showed that orphaned children were more likely to be ART nonadherent [50,51]. One possible explanation for this finding could be that given that all adolescents included in this study were living within a family , they were already being supported by family members to access and adhere to their medication, regardless of their biological relatedness. This finding also points to the fact that extended family networks in Uganda are very supportive, which is in line with the cultural norms where the extended family is expected to assume caregiving responsibilities following parental death [42]. Lastly, this study substantiates for the reasonable application of adherence self-efficacy concept and social cognitive theory in ART adherence. The study findings respond well to the reciprocal determinism of social cognitive theory and highlight family cohesion and childcaregiver communication as significant environments for improving ART adherence among HIV-infected adolescents in low-resource communities. Even with these findings, a few limitations are worth pointing out. With a general aim to explore the outcomes of the Suubi+Adherence study, this study examined adherence self-efficacy rather than participants' ART adherence. Theoretically, adherence self-efficacy is an important determinant of ART adherence behavior, however, it may not reflect the actual behavioral outcome [52]. In addition, family is an emotional unit that profoundly influences its members' thoughts and actions, but the dynamics between individuals and their family systems are complicated. Although we examined family cohesion and child-caregiver relationship in this study, further research using systems thinking to demonstrate how the Suubi+Adherence project can contribute to adherence self-efficacy improvement through enhancing protective functions of family is needed. --- Conclusion Study findings underscore family as a microsystem for HIV-infected adolescents in southern Uganda, that provides both tangible and emotional support to enhance adherence self-efficacy. Family cohesion, a composite concept representing family closeness and functioning, as well as communication, are both positively associated with adherence self-efficacy. Hence, our findings provide further evidence to consider including families-biological and extended-and targeting family cohesion in interventions aiming at increasing ART adherence among HIV-infected adolescents, especially in sub-Saharan Africa. --- --- Abbreviations ART: Antiretroviral therapy; PLWH: People living with HIV Ethical approval and consent to participate Participation in the Suubi + Adherence study was voluntary. All caregivers provided written consent for their children to participate in the study. Similarly, all adolescents provided written assent to participate -obtained separately from their caregivers to avoid coercion. The study received Institutional Review Board approval from Columbia University , from the Uganda National Council for Science and Technology , and from the Makerere University School of Public Health Higher Degrees Research Ethics Committee . The study is registered in the Clinical Trials database . --- Consort The study adheres to the CONSORT guidelines. Full study protocol https://doi.org/10.1016/j.conctc.2019.100463 Authors' contributions PN and BC wrote the manuscript. CD managed the study data and DD led the data analysis process. FMS wrote the grant and obtained funding for the study. OSB and FMS reviewed the manuscript for intellectual content and made significant additions to the manuscript. All authors read and approved the final manuscript. --- Funding The Suubi + Adherence study was funded by the Eunice Kennedy Shriver National Institute for Child Health and Human Development . NICHD had no role in the study design, data collection, analysis, interpretation of findings and preparing this manuscript. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the NICHD or NIH. --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Adolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence. Methods: Data from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy.The average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART.Findings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV. Trial registration: This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

direct engagement with communities is a vital learning experience for students. Students gain knowledge and learn skills relating to curricular objectives through community engagement . A social learning approach stresses facilitating opportunities for students to work with practitioners for learning the norms, routines and latest practices of a professional field . Some recent pedagogical studies in mass communications suggested that service learning could help develop future journalism curriculum . Madison applied social learning to journalism practicum pedagogy. This article argues that neither a service learning nor a social learning approach alone is adequate to encompass the complexity of journalism education, in which engagement with both citizens and professionals is important. The findings provide insights into why service learning in journalism succeeds when students get the opportunity of social learning and work with professional journalists. --- Collaboration for Journalism Education In an open letter to the U.S. university presidents in 2012, six foundations that provide funds to journalism schools called for massive and immediate changes in journalism curricula "to succeed in playing their vital roles as news creators and innovators" . Some warned that journalism schools, along with the industry, might face a dangerous fate if they don't change , as journalism education is up against a difficult future: "a future that is full of innovation and creative disruption" . Some scholars and professionals agree that collaboration among journalism educators, citizens and professionals is a key for journalism schools to tackling the upcoming challenges . The Accrediting Council on Education in Journalism and Mass Communications requires journalism schools to be "actively engaged with alumni, professionals and professional associations to keep curriculum and teaching, whether on site or online, current and to promote the exchange of ideas" for the council's accreditation. Journalism students are expected to develop an understanding of diversity of peoples and cultures as well as an understanding of best professional practices such as accuracy and fairness. The ACEJMC recommends that a journalism school contributes "to its communities through unit-based service projects and events, service learning of its students and civic engagement of its faculty" . Mensing noted that community-centered teaching could "provide a way to conceptualize a reconstitution of journalism education to match that taking place in journalism beyond the university" . Jarvis asked journalism educators to develop and encourage new thinking about the roles of journalists in the society, "Creating and partnering with new kinds of news ventures to not only teach but make more journalism." Jarvis also recommended that journalism schools create media outlets that would serve small communities. Bradshaw argued that discussion on journalism education often overlooks some significant areas. He claimed that this discussion revolves around the view of media industrialists who want changes in journalism education because the industry now requires a different set of skills. According to Bradshaw, what is often ignored are the way journalism education is organized; the information environment that students now operate in; and the relationship between media industry and academia. Giles suggested that students be trained to report on increasingly complex society: "Journalism schools should invest in their students a spirit of intellectual depth and versatility and a desire for continuous learning over a working lifetime." Overholser also put emphasis on stronger connection among scholars and practitioners. She also suggested that schools need to work as labs where students will experiment and test new techniques of journalism. Newton identified four trends in journalism schools across the U.S. First, journalism programs reach out to other departments and launch a team-teaching model. These programs are putting scholars and professionals together to work with new media. Second, journalism programs push for innovation-both technological innovation and entrepreneurial innovation. Third, journalism programs adapt a collaborative model of storytelling that focuses on increasing collaboration among journalists, businesspeople and programmers. Fourth, journalism schools use a "teaching hospital" model where students learn by doing in a newsroom. In these schools, students get real-life experience and get familiar with actual content from the industry. --- Theoretical Framework Scholars have applied several pedagogical approaches to examine collaborative projects at different universities. The prominent approaches include service learning or experiential learning , learner-centered teaching and social learning . This study has built a theoretical framework by combining the service learning and the social learning approaches. This framework allows researchers to examine student engagement with the communities they serve as well as the community of practice that they are members of. --- Service Learning: The service learning approach is rooted in the work of John Dewey , who proposed a multi-step process of learning, challenging the traditional approaches to education . Dewey described the learning process as a logical inquiry that starts with a learner experiencing a real-world problem and exerting efforts to solve it. To solve the problem, the learner formulates questions about the problem, gathers information, makes hypotheses and tests them, and draws conclusions. In other words, learning occurs within a meaningful context and matures through reflection . Later work of several notable scholars provided support for Dewey's approach. Lewin and Piaget believed that learning is an active process that occurs through one's interactions with the surrounding environment and reflection. These ideas have later been developed into the pedagogical approach known as service learning and applied across a variety of disciplines, including business , communication , journalism , sociology , and medicine . Despite disagreements over the definition of service learning, scholars across disciplines agreed that the key components of service learning were experience, reflection, and reciprocity . As service learning refers to a wide range of experiential education across disciplines, it is difficult to find a comprehensive definition of the term . Jacoby provided a definition that covered much of the literature on the topic: "Service-learning is a form of experiential education in which students engage in activities that address human and community needs together with structured opportunities intentionally designed to promote student learning and development" . Service learning is distinguished from other forms of learning and community service by its equal emphasis on both service and learning on one hand and reciprocity of benefits on the other . Moore , an advocate of a poststructuralist approach to education, suggested that service learning allows students to examine various systems of meaning and investigate critically the power relations among powerful social institutions. Kendall noted that service learning enables students to learn about the "historical, sociological, cultural, and political contexts of the need or issue being addressed" . The main objective of service learning is to boost critical thinking skills and enable students to integrate theory with practice through direct engagement with the communities . Service learning helps students better relate their knowledge to the world outside of classrooms . Widely accepted as a form of experiential learning, service learning "incorporates students' involvement into the dynamics of experiential learning and the rigors and structure of an academic curriculum" . Muturi et al. also noted, "Service-learning is viewed as a means to better citizenship and a greater understanding of community needs, and also exposes students to the problems facing their communities and encourages their involvement in finding solutions" . Previous pedagogical research found evidence that service learning helped students develop a sense of social responsibility , and become more tolerant towards diversity and able to relate learning experience to the community . Service learning was found to increase students' ability to analyze complex social problems . Einfeld and Collins found that participants in a service-learning project "developed several multicultural skills while interacting with their clients, such as empathy, patience, attachment, reciprocity, trust and respect" . Researchers found that service learning helps reduce negative stereotypes in the community and increase awareness among students about the complicated social issues . Boyle-Baise suggested that service-learning is "collaborative in intent," "responsive to local needs," and helps those who are marginalized in the society . Service learning was adopted widely across various disciplines as it empowered "students to bring about positive social change" . It does not only engage students and faculty members in meaningful dialogues around important community issues such as equity, tolerance and power , but also builds bridges between schools and communities . A Social Learning Approach. Lave and Wenger offered a theory of social learning that explains how old and new members co-construct professional communities. This framework, based on situated learning, suggested that learning is a social process and it is defined by "legitimate peripheral participation" that means drawing "attention to the point that learners inevitably participate in communities of practitioners and that the mastery of knowledge and skill requires newcomers to move toward full participation in the sociocultural practices of a community" . Lave and Wenger's approach is different from Albert Bandura's social learning theory that suggested individuals learn from observation of others' experience. Bandura's attention-retention-reproduction-motivation process applies to a broad range of people while Lave and Wenger's approach applies specifically to professional communities that may include students aiming to join a particular community. Bandura's theory provides an explanation of how individuals learn while Lave and Wenger explains how seniors in a professional community create and maintain standard practices-knowledge of which is essential for those who want to join that community. Lave and Wenger, an anthropologist and a computer scientist, noted that newcomers in a professional community must be introduced to, and become grounded in, the norms, routines and standard practices. Madison , who applied the theory to journalism education, suggested that professional communities create and maintain jargon to solidify their shared concepts . Elders in the community act as gatekeepers . Elders must grant access to newcomers. Newcomers may also need to "wage a campaign to gain the interest and acknowledgment of community elders" to gain access to the established community . According to Lave and Wenger , entry of interns or new graduates to a professional community is called peripheral participation. This participation comes to be called legitimate participation because senior members of the profession sanction the entry of newcomers and train them. A Combination of Service and Social Learning. The service learning and the social learning complement one another. A combination of these two approaches can provide a better framework to explain collaboration among educators, citizens, and journalists. For instance, the focus of service learning is on the community-the citizens. This approach helps students know the community better, encounter real life problems and find ways to solve them. But it is also important to note that most university graduates enter a community of practice and follow their established practices to serve citizens. Success often depends on how closely the new practitioners can follow the existing practices developed by the elder practitioners in the particular community of practice. The social learning approach helps explain this part. Journalism is considered a social practice. Journalists are members of a community of practice . Best journalistic practices in serving citizens are determined by participants in the practice pursuing excellence. Communities of practices have their own routines developed over time in relation to other practices . Initial success of newcomers in a community of social practice depends on how aware they are of existing best practices as well as routines. Therefore, this study combines service learning and social learning to analyze the case under study. Using this framework, this study asks the following research questions: RQ1: How did the collaborative project enhance students' understanding of communities? RQ2: How did the collaborative project enhance students' understanding of professional practices? --- Method This study uses case study method to analyze a collaborative project between the Gaylord College of Journalism and Mass Communication at the University of Oklahoma and a non-profit news organization in Oklahoma called Oklahoma Watch. The one-year project starting in summer 2014 had adopted elements of both service learning and social learning to give students an opportunity for in-depth public affairs coverage. Participating students, accompanied by professional journalists, visited three low-income neighborhoods in Oklahoma City, interviewed citizens about community problems and prepared multimedia stories that were later published on a publicly available website: http://talkwithus.net. The students were exposed to a large-scale effort to draw attention to a community issue involving numerous partners and means of engagement, including not only interviews with community residents but also interviews with officials in response to the problems they raised. Participating students included those enrolled in five journalism classes as well as students working as interns for Oklahoma Watch. Study Design. Case study is a form of empirical inquiry that "investigates a contemporary phenomenon in depth and within its real-life context" . It emphasizes "an understanding of people, events, and processes in their natural settings" . Case study researchers might examine documents, observe activities, and conduct interviews to answer research questions. The authors of the article had access to important project documents such as project proposal and list of participants. Both authors were directly involved with the project and, therefore, able to observe the activities of the project very closely. The authors also conducted 11 in-depth interviews with project participants including students, professors and professional journalists. A protocol was developed to analyze the interviews. Case study is a preferred method "when "how" or "why" questions are being posed, the investigator has little control over events, and the focus is on a contemporary phenomenon within a real-life context" . The first and third of these were true of this project, and the investigators -though involved in the project -did not have control over most details of how it was carried out. "Case studies have been done about decisions, programs, the implementation process, and organizational change" . As noted, this study seeks to answer the following research question: How did the collaborative project enhance students' understanding of communities and professional practices? Based on a preliminary analysis of the project, this study proposed that collaborative educational projects in journalism are more likely to succeed if two conditions are met: students are exposed to the communities they serve, and students are given an opportunity to work with professional journalists. These professionals guided students through the entire process from selecting a neighborhood to visit to publication of stories. Therefore, data collected by interviewing members of this project fit the proposition , and can appropriately answer the research question. The unit of analysis is the collaborative project described above. --- Results Two major themes emerged from the interviews based on literature on service learning and social learning: understanding of the community and understanding of journalism practices . Close reading of the transcripts based on knowledge from observation of the project and project documents led to identification of major categories within each theme. --- Understanding of the Community The interviews suggested that both students and professional journalists who participated in the project grew in their understanding of the communities from the perspective of citizens. There was also evidence that some students grew in their understanding of the community from the perspective of officials, while also encountering some roadblocks to their understanding. --- Perspective of citizens. Meeting and interviewing residents over their concerns about community problems helped to undo stereotypes and uncover blind spots about community needs and challenges. A reporter who worked as a liaison between the professional news organization and students and faculty noted that the areas where they did interviews have negative stereotypes connected with them. But we actually go out into these communities, you see that there is really, there is not a lot of truth to the stereotypes … Yeah, maybe there are some bad crimes that happened in the areas but that's not reflective of the entire community, that's not what this people…really not what this community wants. Similarly, one student said he learned that everyone doesn't fit neatly into a box. For example, he found college-educated people living in one low-income neighborhood because they wanted to and white families who loved living in the predominantly African-American neighborhood. Students also discovered neighborhood issues and challenges they would not have expected. One student from an affluent background was surprised that a resident raised lack of swimming pools as a concern and was happy to go on camera for about 45 minutes talking about it and its impact. Another student commenting on the same issue said, "That's not something you think would turn out to be an acute problem, but it really is because just for people's safety they should be learning how to swim." A third student said she learned about the difficulty of getting seemingly small problems such as street congestion fixed -problems that affect daily living. Residents' fear of raising problems publicly and lack of trust also came to light. One student said: They just don't trust us with the information. And a lot of people were afraid that if they would say something then it would get back to their community and it would reflect them in a bad light and then they would be in danger. --- Perspective of officials. Talking with officials, who were also interviewed in the project in connection with each resident's concern, provided some insight on community issues, one student said. The officials did provide a different perspective. However, she said it was difficult for a number of students to get officials to respond to them at all. Another student said she had to learn how to keep probing with questions once she had an opportunity to interview -an issue connected with the second category, understanding of journalism practices. --- Understanding of Journalism Practices The interviews also indicated that students gained a greater understanding of journalism practices. This finding was particularly evident in relation to interactions with people but also, to a lesser extent, in relation to understanding of technology. --- Interacting with people. A faculty member and the reporter for the professional news organization both commented on how students grew in their understanding of how to interact with people they didn't know. The professor noted that students were trying to interview residents who "were not used to dealing with the media." He pointed out that "there is a trust factor that you have to build as a journalist. They were able to do that." Another student also commented on the work involved in overcoming the trust barrier, trying to give residents "the confidence to go on camera and let them know that what they will be doing, we will be helping, not hurting." The reporter said he watched students develop in their interview skills, gaining comfort with talking to people. He mentioned the example of one rather shy student who "became a lot more outspoken" in the course of the project. That same student talked about speaking to people with different experiences and the benefit to them as well as to the journalist. "If you go out and you talk to people that aren't like you, you won't start writing stories and pieces that aren't true. You won't have headlines, you won't have stories that disenfranchise groups." Students also learned from the experience of interacting with officials they were interviewing for responses to concerns raised by neighborhood residents. They learned about the need for persistence and for building relationships with officials to enable access. One commented: You would ask something, and they have their script of what they want to say, and I was making sure to keep them on track and sometimes they would just talk so long. You don't get the chance to ask another question, and so I just kind of interrupt and make sure that they knew this is what I am trying to ask. Another student said they learned the value of thinking through questions and anticipating possible roadblocks to answers. Interacting with technology. In addition to understanding of journalism practices related to other people, some interviews suggested improvements in understanding of practices related to technology. One professor said the students "learned a new way to report a story" by using mobile devices for interviews. He said they also learned the value of using a less intrusive device than a large video camera or DSLR because they are "less intimidating" to interviewees. Some students reported gaining understanding of video editing. One of them commented on how helpful the professional reporter was in learning to edit to make a compelling story. A student also commented on learning how a tripod would have improved shooting of longer interviews because the video with a handheld camera would get shaky. --- Discussion This case study has examined how a collaborative project involving students, faculty and a nonprofit news organization on coverage of community problems enhanced students' understanding of communities and professional practices. Interviews with 11 participants suggested that students developed in their understanding of the communities primarily from the perspective of the residents who were interviewed on video, through insights that helped to undo stereotypes and identify community needs and challenges that were not obvious or expected. Interviews also pointed to learning about journalism practices. In particular, students learned the basic journalistic essential of talking with strangers, including people with backgrounds that contrasted with theirs, and building trust. From a practice standpoint, their interactions with officials taught them how to persevere, build relationships and get meaningful answers. In a project in which technology was central, it is notable that students talked most about what they learned about dealing with people. However, they also learned from interacting with technology -for example, the value of using mobile devices because they are less intrusive and the impact of video editing on the power of the story. The combination of learning about the communities and learning about professional practices places the project at the nexus of service learning and social learning. By experiencing the real problems of these low-income communities through interviews with residents, in the context of the communities themselves, and discussing possible solutions with officials, students engaged in the kind of learning process that scholars have identified with service learning . Students gained in critical thinking as they saw their preconceived notions about community residents and their needs challenged thanks to immersion in the world away from campus. Alongside this service learning, students were engaging in social learning by working under the guidance of faculty and an editor and particularly reporter from the nonprofit news organization, Oklahoma Watch, with which the school partnered. The faculty and journalists served as "elders" of the professional community by helping to describe and model professional-level practices for students . In the field, particularly those students who worked directly with the reporterwho proved to be the key figure on the ground in inculcating professional practices -learned norms of how to interact with community residents effectively and routines for approaching officials. They also had the opportunity to practice these themselves and get feedback in line with the expectation of professional practice. Notably, on the technology learning side, the engagement about norms and practices involved initial engagement of the reporter with news organization interns together to do preliminary test mobile video interviews over the summer before the classes started on the project. In this way, working with a technology that is relatively new to both professionals and students, the elders and learners worked together to lay a foundation that was crucial to subsequent student learning. They thus moved closer to leaving the peripheral participation stage to legitimate participation than the other students later. Unlike previous studies, this project brought together these two theories as a framework for discussing the implications of student, faculty and professional engagement in a collaborative journalism project. The study thus adds conceptually to previous work and suggests a dual lens for performing future studies of the burgeoning collaborative partnerships at journalism schools. Service learning provides a valuable grid for examining projects that involve intensive engagement with communities, but it does not emphasize the particulars of professionals and professional practices in this learning. Social learning complements service learning by providing a framework for considering the dynamics of interaction of professionals to be, working professionals and faculty members steeped in the profession and its norms. The focus of this case study was on a collaborative project at one school, and it is limited by this and the fact that the students interviewed were primarily those most highly engaged in the project. Less engaged students may have had a different experience of learning. Future research could address the service and social learning aspects of other cooperative projects that schools have undertaken across the country through case studies involving examination of the projects themselves, related documents and interviews with participants.

This study examined how a collaborative project involving students, faculty and a nonprofit news organization in Oklahoma on coverage of community problems enhanced students' understanding of communities and professional practices. It applied a theoretical framework that combines two pedagogical approaches-service learning and social learning-to analyze the case. In-depth interviews were conducted with 11 project participants including students, professors and journalists. The findings suggest that service learning in journalism succeeds when students get the opportunity of social learning and work with professional journalists.

Background Depression is one of the most common diseases worldwide, and has a heavy socioeconomic burden [1,2]. Depression has been ranked third on the World Health Organization's list of medical conditions with the greatest disease burden worldwide, and is expected to top that list by 2030. The 1-year prevalence of a major depressive disorder was reportedly 6.6% in the USA [3], 2.9% in Japan [4], and 2.5% in Korea [5]. An epidemiological study in Korea found that major depression had a high disease burden, with a disability-adjusted life years value of 1,287 years , representing 49% of the burden of all mental diseases [6]. Moreover, depression significantly influences health outcomes, such as disability, premature mortality, comorbidity with chronic disease, and decreased quality of life, in both Western countries [7] and Korea [8]. Despite the high prevalence and social burden of depression, only a small percentage of people with depression use psychiatric services [4,9]. Furthermore, the majority of adults with mental disorders, including depression, do not seek help from mental health services [10,11]. In order to provide effective treatment for people suffering from mental health problems, it is critical to identify the barriers that they face when accessing MHSs [12]. Previous studies have revealed that such barriers include structural factors and attitude factors [13,14]. These attitudes toward mental disorders differ according to sociodemographic characteristics such as age, gender, and education level [14,15]. Therefore, the individuals' sociodemographic characteristics may directly or indirectly influence their use of MHSs [16]. Several previous studies have found that men [16,17], adolescents, and seniors [10,12,16,18] with a low socioeconomic status [12,18,19] or living in rural areas [20] were less likely to access MHSs. Factors influencing the use of MHSs are various according to studies as mentioned above because each country has a unique healthcare delivery system. The Korean health insurance system is mainly run by the national government as in European countries, but most of health service providers are private hospitals. People pay the insurance dues differently in grade based on their income, and medical services for recipients of livelihood program are free of charge while medical care is equivalent [21]. Many studies have investigated the barriers to the use of MHSs in European Union countries and the USA; however, very little has been uncovered about the factors that affect MHS use for depression in Asian countries, and particularly in Korea. The aims of this study were to determine the use conditions of MHSs and to identify the sociodemographic factors associated with MHS use after considering the effect of mental health related factors among adults with a depressive mood, using a nationwide representative Korean sample. --- Methods --- Data source and study samples The data used in this study were obtained from the Fourth Korea National Health and Nutrition Examination Survey , which was conducted during 2007-2009 by the Korea Centers for Disease Control and Prevention . The KNHANES is a nationally representative and reliable study that assessed health status, health behaviors, and nutritional status. The survey used a stratified, multistage, probability-sampling design to represent the entire Korean population. The KNHANES is composed of the Health Interview Survey, the Health Examination Survey, and the Nutrition Survey. The Health Interview Survey was performed using self-administered structured questionnaires to obtain information regarding sociodemographic characteristics, health status, health service use, and health behaviors. Trained interviewers visited each household and assisted the participants with specific items in the self-administered tool. The KNHANES IV surveyed household members aged over 1 year from a total of 9421 households . All subjects in the survey participated voluntarily with informed consent, and the survey protocol was approved by the Institutional Review Board of the KCDC. This study is in compliance with the Helsinki Declaration, and was exempted from the evaluation of Seoul National Hospital Institutional Review Board in 2014. This study ultimately included 2735 subjects aged ≥19 years that had continuously experienced a depressive mood for more than 2 weeks within the previous year . --- Measurements Depressive mood was assessed by a "yes" or "no" answer to the question: "Have you felt sadness or despair affecting your daily life for more than 2 weeks over the past year?" [22]. The use of MHSs included subjects who had visited healthcare institutions or had received consulting services by phone or via the Internet for mental health problems. The questions were as follows: "Have you visited any healthcare institutions, or have you received consultation through the Internet, telephone, etc. due to your mental health problems during the past year?" "Have you experienced inpatient treatment for depression during the past year?" "Have you experienced outpatient treatment for depression during the past 2 weeks?" Sociodemographic factors included gender, age, region , education level , employment status , monthly household income , national health insurance type , and marital status . In addition, smoking status and alcohol consumption status were included, and the subjects' mental and physical health status were also assessed. Perceived usual stress was measured by the question, "How do you usually feel stress in your daily life?", with responses provided on a 4-point Likert scale . Subjective health status was measured by the question, "Generally, how is your subjective physical health status?", with responses provided on a 5-point Likert scale . Finally, chronic conditions such as arthritis, diabetes, hypertension, angina, and asthma were included. Each disease was organized into clinically diagnosed cases by self-reporting; for example, "Have you been diagnosed with diabetes by a physician?" was categorized into two groups: yes or no. --- Statistical analyses Given the complex sampling design of the KNHANES IV, weighted values were applied by using the surveyrelated procedure of SPSS software version 21 in all analyses. For variable selection, we included all sociodemographic variables as well as health-related variables associated with substance use, stress and chronic disease from the survey data. The general characteristics of the study sample were tabulated. A chi-square test was used to compare the differences in sociodemographic factors, health behaviors, and health-related factors between the two groups, according to the use of MHSs among the subjects with a depressive mood. Univariate and multivariate logistic regression were used to estimate the odds ratios and 95% confidence intervals of MHS use for each measure. Specifically, a multivariate logistic regression model was used to investigate sociodemographic factors associated with the use of MHSs after fully adjusting for all evaluated covariates such as sociodemographic and health-related factors. The level of statistical significance was set at P < 0.05. --- Results --- Characteristics of the subjects Of the 18,406 subjects aged ≥19 years who participated in the KNHANES IV, 2735 had experienced a depressive mood that hindered their daily life during the previous year. Among these subjects, 1953 were women, they were aged 48.00 ± 0.44 years , and elderly aged ≥65 years accounted for 20.4% of the sample. Of the 2735 subjects who had experienced a depressive mood, only 9.6% had used MHSs, 32.7% had an education level of ≤6 years, 18.8% were divorced or widowed, and 55.2% had the lowest monthly household income . Furthermore, 60.9% usually felt high or very high levels of stress in their daily life, 38.7% perceived that their health status was poor or very poor, and 35.3% had a diagnosis of at least one or more of five chronic diseases . --- Use of mental health services according to sociodemographic and health-related factors Table 2 lists the differences in the use of MHSs according to each sociodemographic or health-related factor among subjects with a depressive mood. Use of MHSs was significantly lower among men compared to women . Older subjects, those living rurally and those with a lower level of education appeared less likely to use MHSs, but these findings were not statistically significant. However, the use of MHSs was significantly higher among the unemployed compared to those who were in work , and among those with a poorer subjective health status and the highest perceived usual stress . --- Association between use of mental health services and sociodemographic factors The results of the multivariate logistic regression analyses are presented in Table 3. In the adjusted model, the OR for the use of MHSs by the elderly relative to subjects aged 19-34 years was 2.55 , but the difference was not found to be significant in the unadjusted model . Moreover, subjects with a lower education level were less likely to use MHSs compared to those with a higher education level . Conversely, the OR for the unemployed group relative to the employed group was 0.47 . There was a significant affect of gender in the unadjusted model , in that men were less likely to use MHSs; however, this result was not statistically significant after adjusting for all factors. Finally, being elderly , in the lower education group, and employed was strongly associated with a lower use of MHSs. --- Discussion People worldwide suffering from psychiatric diseases including depression exhibit a low rate of MHS use, as shown in the present study, in which only 9.8% of adults who experienced depressive moods for more than 2 weeks over the previous year had used MHSs. In the Epidemiological Survey of Mental Disorders in Korea, the prevalence of MHS use was 15.3% among people who had one or more psychiatric disease [5]. In the USA the prevalence was 13% for those reported with a depressive mood [23], 57.3% for major depression [3], and 19% for a substance use disorder [10], demonstrating a low treatment rate among psychiatric patients. However, Korean adults with psychiatric problems demonstrated a far lower usage rate than their counterparts in the USA, which suggests that the obstacles to MHSs accessibility are more serious in Korea than in the USA. Obstacles to the use of MHSs include lack of awareness of the necessity of MHSs [10], patients' attitudes regarding selftreatment, low recognition of their diseases, belief in natural recovery, negative perception and prejudice against the use of MHSs, and economic burden [11]. Using a nationwide representative Korean sample, the present study demonstrated an association between sociodemographic factors and MHS use in subjects aged over 19 years who had experienced a depressive mood. According to Andersen's model, the use of healthcare services is affected compositely by predisposing factors and promoting factors [24]. Variations in the sociodemographic characteristics of individuals create differences in the use of MHSs [16]. Furthermore, the severity of psychiatric disease is considered an important factor in MHS use [12,[25][26][27]. That is, the rate of MHS use increases with the disease severity. It is therefore important to consider the disease severity in order to clearly evaluate the effects of sociodemographic characteristics OR = odds ratio, CI = confidence interval, if OR > 1 then less use of mental health services, and OR < 1 then more use of mental health services. a Adjusted model: adjusted for sociodemographic and health-related factors . on service use [12,28]. In this sense, a major limitation of the present study was that the severity of the depressive mood could not be evaluated. The present findings show that after fully adjusting for all evaluated factors such as sociodemographic and healthrelated factors, age, education level, and employment status significantly influenced the use of MHSs. Previous studies have found that MHS use differs according to gender; specifically, that women use MHSs more than men [16,25]. However, in the present study, service use by women was only higher than that of their male counterparts in the unadjusted analysis. Regarding this gender difference, it has been acknowledged that women are more open about their psychiatric problems, and generally have a more positive attitude toward mental diseases [29]. In particular, there are fewer stigmas associated with depression among women than men [14]. Therefore, women are more likely to recognize the necessity of MHSs [10,17,18]. Prejudice and stigma toward MHSs are strongly correlated with actual service use [15]. The lower prejudice and more positive attitudes among women in this regard may explain their high MHS use. However, some researchers argue that the gender difference is mainly attributable to the exposure to depression being greater for women than for men [30], and that once socioeconomic variables are adjusted, the difference reduces or disappears [11]. Similarly, although in the present sample there were more women with a depressive mood than men, the gender difference disappeared after adjusting for sociodemographic factors. --- Differences in MHS use between the age group Regarding the difference in MHS use between the age groups, some previous studies have produced varying results among the adolescent, middle-aged, and elderly [10,11,16,18,20,31,32], while others have found that age was not associated with MHS use [27]. However, those aged over 65 years in the present study were less likely to use services than their younger counterparts. According to previous reports, the elderly are less sensitive to psychiatric symptoms and confuse such symptoms with those of the natural aging process, thus preferring treatment at general medical centers rather than at specialized MHS institutions [20]. In contrast, younger people are more aware of the necessity of MHSs, resulting in middle-aged people to use services more frequently [10]. An exception to this pattern was found in a study conducted in Iceland, in which the elderly were found to have visited more mental health institutions and sought help from psychiatrists more frequently. However, these results were explained by favorable conditions in Iceland, namely an increase in free time and a low-cost health insurance system available to those aged over 67 years [16]. On the other hand, while stigma against depression varies little with age, the effect of the stigma associated with mental illness has a stronger impact on certain age groups [14], and particularly among the elderly with depression, stigma is a significant obstacle to their use of MHSs [31]. The rapidly expanding aged population and depression-related suicide among the aged have recently emerged as growing social problems in Korea [33]. To effectively deal with these problems, greater public health strategies such as education, counseling, and campaigning for older people are required to promote their accessibility to MHSs. --- Differences in MHS use between the education levels Education level is an important indicator of an individual's socioeconomic status [12], and is considered one of the predisposing factors toward the use of healthcare services [24]. Many studies have found that those with a higher education level use MHSs more frequently [12,16,18,19,32]. The findings of the present study concur with that finding, in that the subjects with education that extended beyond the high school level were more likely to use such services than those who left the education system before high school. Furthermore, those with higher-level education preferred specialized MHS institutions to primary care centers [19,34]. In addition, one study found that patients with college degrees or higher who suffered from depression were more likely to receive care from a psychiatrist [16]. Thus, the type of MHS institution and service provider could vary according to education level. However, this factor could not be considered in the present study since the type of MHS used was unknown. It should be noted that higher education was found to be associated with low prejudice against mental diseases, and particularly depression [14]. Those with a higher level of education generally have a positive attitude toward the effectiveness of psychiatric treatment [15,34], which enhances their use of MHSs; conversely, the economic burden associated with service use is generally higher [15,19] and the level of awareness for psychiatric problems and treatment lower for those with less education, thus hindering MHS use in that group [12]. Therefore, in order to enhance the use of MHSs among relatively uneducated people suffering from depression, an education program that includes information on the detection of depression symptoms and MHS use should be provided to improve their mental health literacy. --- Differences in MHS use between income levels Income, which like education level is an indicator of socioeconomic status [12], is also a factor that promotes the use of healthcare services [24]. However, the present study found that the use of MHSs did not differ significantly with the monthly family income. Similar results have been reported elsewhere [11,12,35]. Like many European countries, Korea also has a comprehensive health insurance program that covers almost the entire population for mental healthcare. Thus, people with psychiatric diseases and a low income can use MHSs without suffering an excessive financial burden [11]. By contrast, the severity of psychiatric diseases was reported to be higher among those with a low socioeconomic status [11,28], leading to more frequent use of the MHSs [26,27]. As a result, MHS use is higher among the low-income population. --- Limitations This study was subject to a few limitations. First, the severity and the duration of a depressive mood and the presence of co-morbid mental health issues such as anxiety, which may act as strong confounders regarding the association between sociodemographic characteristics and MHS use, could not be considered. Also, the type of MHS institutions and service providers used were not determined. Second, the use of data from a national health survey may suffer from respondent bias. The use of self-report measures for both depressive mood and MHS use may lead to biases either due to recall or perceived stigma. There would be the discordance in time periods for outpatient use and the measure of a depressive mood. Third, these survey data prevented us from exploring important information on the use of pharmacotherapy such as antidepressants. Therefore, observed differences in the MHS use may not directly reflect differences in the need of MHS use. Fourth, subjects with a depressive mood were not screened using a standardized assessment tool since the data were collected from a general health survey and not a specialized mental health survey. Depressive moods were assessed by a single question in this study; previous studies have investigated the accuracy of such a single-question method, such as a Yale study measuring the accuracy of the following question: "Do you often feel sad or depressed?" The study showed that this question had a sensitivity of 86%, a specificity of 78%, a positive predictability of 82%, and a negative predictability of 82% in screening for depression in patients with recent stroke [36]. Thus, a single question has the potential to be a rapid and reasonable alternative to more lengthy questionnaires in surveys involving large samples [37]. Despite these limitations, this nationwide representative study provides detailed information on the current status of MHS use among subjects with a depressive mood according to their sociodemographic factors, and identified vulnerable social groups for MHS use in Korea. Furthermore, since the KNHANES is conducted every year, future studies will be able to monitor the trend of MHS use among subjects with a depressive mood. --- Conclusions The findings of this study suggest that the use of MHSs differs among Korean subjects with a depressive mood according to sociodemographic factors. The elderly, adults with a lower education level, and the employed were less likely to use MHSs. This study shows the relationship between sociodemographic factors and the MHS use in Korea by using a nationwide representative data, despite some strong limitations including recall bias and lack of measuring important confounders. The results in this study may be a useful data for policy makers and mental health professionals in improving the public strategy of the mental health delivery system. In order to enhance the use of MHSs, mental health promotion strategies, including community outreach service, campaigns and education programs, should be targeted according to the characteristics of the population. --- Competing interests The authors declare that they have no competing interests. Authors' contributions SJP initiated the collaborative project, designed data collection tools, collected data and monitored data collection, wrote the statistical analysis plan, cleaned, analysed, and interpreted the data, and drafted the paper. HJJ monitored data collection, analysed and interpreted the data, and critically revised the draft paper. JYK collected data and monitored data collection, analysed and interpreted the data, and critically revised the draft paper. SK collected data and monitored data collection, and critically revised the draft paper. SR initiated the collaborative project, monitored data collection, interpreted the data, and drafted and revised the paper. All authors read and approved the final manuscript.

The aims of this study were to determine the utilization of mental health services (MHSs) by adults with a depressive mood and to identify the influencing sociodemographic factors, using a nationwide representative Korean sample. Methods: The study included 2735 subjects, aged 19 years or older, who had experienced a depressive mood continuously for over 2 weeks within the previous year, using the data from the KNHANES IV (Fourth Korea National Health and Nutrition Examination Survey), which was performed between 2007 and 2009, and involved a nationally representative sample of the Korean community population who were visited at home. A multivariate logistic regression analysis was used to estimate the adjusted odd ratios (ORs) and 95% confidence intervals (CIs) for the use of MHSs, which was defined as using healthcare institutions, consulting services, and inpatient or outpatient treatments due to mental health problems. Results: MHSs had been used by 9.6% of the subjects with a depressive mood. The use of the MHSs was significantly associated with age, education level, and employment status, after adjusting for sociodemographic and health-related factors. Specifically, the OR for the nonuse of MHSs by the elderly (≥65 years) relative to subjects aged 19-34 years was 2.55 (95% CI = 1.13-5.76), subjects with a lower education level were less likely to use MHSs compared to those with a higher education level (7-9 years, OR = 2.35, 95% CI = 1.19-4.64; 10-12 years, OR = 1.66, 95% CI = 1.07-2.56; ≥13 years, reference), and the OR of unemployed relative to employed was 0.47 (95% CI = 0.32-0.67). Conclusions: Among Korean adults with a depressive mood, the elderly, those with a lower education level, and the employed are less likely to use MHSs. These findings suggest that mental health policies should be made based on the characteristics of the population in order to reduce untreated patients with depression. Greater resources and attention to identifying and treating depression in older, less educated, and employed adults are warranted.

is a well-established predictor of health . However, subjective social status has emerged as an appealing alternative measure because it captures cumulative influences of social position by accounting for past experiences and perceptions of future accomplishments . SSS is a particularly valuable measure in populations who do not have their own SES, for example, adolescents or when SES indicators change, as in retirement or unemployment. Like lower SES, lower subjective status is associated with negative mental and physical health outcomes . SSS assesses one's perceived position relative to others in the social hierarchy . The most common measures are the MacArthur Scales, which ask individuals to rate where they feel they stand relative to the nation and their community by marking the rung on a picture of a ladder where they feel they stand compared to the given reference group . SES and SSS are usually highly correlated and SES factors, specifically income and occupational position, seem to be the most powerful predictors of SSS . The way subjective status is assessed may directly cause this effect. The national ladder is anchored with objective SES markers, describing individuals at the bottom as having the least money, education, and least respected job or no job . National SSS may represent a more proximal influence on health compared to objective SES, while perceived status in the community may represent influences that are closer still than national SSS . However, fewer studies have used the community ladder and the links between community status and health outcomes are inconsistent . This may be due to a lack of understanding of exactly what the community ladder measures. Qualitative data from the MacArthur Network suggests variation in the way individuals define community, with responses falling generally into two categories: individuals close in physical proximity and close social contacts . These two categories may differ in the relevance of objective SES: comparing oneself to close social contacts may evoke more personal information than SES-related information. Thus, inconsistencies in definitions of community may contribute to the variation in health associations. --- Study aims To better understand the SSS relative to close social networks, this study aimed to separate the effects of more physical versus more social proximity by assessing their individual impact on chronic stress: a central underlying process for many negative health outcomes. We assessed self-reported psychological stress and basal cortisol functioning, specifically the cortisol awakening response . Employed and unemployed individuals were evaluated to investigate the effects of lacking SES indicators most strongly predictive of SSS . --- Method Participants Participants were 18 employed and 18 unemployed age and gender-matched German individuals . Unemployed participants were unemployed for at least 12 months in addition to looking for work and needing to generate income . --- Procedure The study was approved by the ethics board at the Technical University of Dresden. Unemployed participants were recruited through online and print advertisements in regional newspapers and employed participants through flyers and advertisements in the Technical University of Dresden and surrounding community. The experimenter visited participants' homes to obtain informed consent and provide questionnaires. Participants collected four saliva samples on each of two consecutive weekdays using the Salivette device and stored them in the freezer until the experimenter returned. --- Measures Participants provided demographic information. SSS was measured using two 10-rung ladder measures adapted from the MacArthur sociodemographic questionnaire . Participants rated their standing on the ladders with higher rungs indicating higher status. The instructions mimicked the original community ladder: "Please place a large 'X' on the rung where you think you stand at this time in your life, relative to other people in your neighborhood/relative to family members and friends." Perceived stress was assessed with the 14-item German translation of the Perceived Stress Scale . Saliva samples were stored at -30°C and after completion of the study, thawed, centrifuged, and assayed in duplicates using a cortisol chemiluminescence kit . Values from the two corresponding samples were averaged and two indices were computed. The maximum CAR increase was computed by subtracting the wake-up value from the individual's peak value . The CAR recovery was computed by subtracting the +60-minute value from the individual's maximum value . --- Results The employment groups did not differ in age, education, chronic diseases, medication use, smoking, or body mass index . Unemployed participants were more likely to be unmarried, reported poorer mental health, had lower monthly household income, and felt less secure in their current financial situation . Of note, controlling for any of these socioeconomic or health indicators did not change the pattern of results and thus findings are present without including them as covariates. However, for conceptual reasons, all subsequent analyses controlled for age and sex. --- Employment status differences in SSS The SSS ladders were positively correlated , with a trend for higher ratings relative to friends/family than neighborhood = 1.80, p = .08; friends/family: 7.31 ± 1.74; neighborhood: 6.69 ± 2.10). Analyses of covariance revealed that the unemployed reported lower neighborhood status = 6.05, p = .02, η p 2 = . 16) and no difference in friends and family status = 1.53, p = .23, η p 2 = . 05; see Figure 1). --- Employment status differences in stress measures Unemployed individuals reported more perceived stress than employed = 10.21, p = .003, η p 2 = . 24). Both groups further showed a lack of significant changes in cortisol across the four samples = 1.02, p = .35; group: F = 0.02, p = .87; group-by-time: F = 1.82, p = .18) and for CAR increase = .64, p = .43, η p 2 = . 02. However, unemployment was associated with a lack of CAR recovery = 6.92, p = .01, η p 2 = . 18 see Figure 1). --- Associations between SSS and stress measures A series of hierarchical regression models were tested with age and sex entered first as control variables, followed by employment status and subjective status ladder rating , and finally an interaction term for employment status-by-subjective status rating. These models were tested with self-reported perceived stress, CAR increase, and CAR recovery as outcome variables. Regression analyses revealed that lower perceived status among friends and family was associated with higher perceived stress, regardless of employment status . Neighborhood status was not linked to perceived stress . Neither of the cortisol indices were associated with SSS ratings. --- Discussion Our findings suggest that the impact of employment status on SSS may differ depending on who participants compare themselves to. Neighborhood status but not friend and family status was lower among the unemployed. Interestingly, it was specifically friend and family status that predicted chronic stress. However, these status-stress relationships were the same for employed and unemployed individuals, suggesting that SSS compared to more proximal groups, specifically family and friends, may offer an important extension to the study of SSS as a health predictor. Although not statistically significant, overall friends and family status trended toward being higher than status among neighborhood. However, unemployed individuals reported lower neighborhood status, a group close in physical proximity but not necessarily made up of close social contacts. Unemployed individuals may find that lack of income and job title are relevant factors in considering neighborhood standing. Although objective SES indicators have been identified as major SSS predictors , it appears that unemployed may not focus on SES indicators in determining status among friends and family, suggesting that future studies may benefit from assessing close social contacts as a distinct facet of SSS. Regardless of employment status, lower ratings among friends and family, but not neighborhood, were associated with more perceived stress. This study shows that even without explicitly describing the top of the ladder as those with the highest objective SES, subjective perception of having lower status than surrounding individuals is associated with elevated chronic stress. This link between stress and status among a previously untested group emphasizes the potential health impact of social standing among one's family and friends and demonstrates the value of a measure of very proximal SSS that captures influences of the closest people surrounding an individual. Unemployed and employed individuals had comparable CARs; however, for unemployed individuals, this was followed by a lack of CAR recovery. This observation is consistent with previous studies linking flatter cortisol slopes across the day and higher daily cortisol output with higher chronic stress . Similar to acute stress findings , lack of cortisol recovery in a basal context may lead to elevated cortisol exposure and health risks consistent with exposure to chronic stress associated with unemployment . --- Limitations A skewed gender distribution and differences in availability of government unemployment services reduce generalizability of the findings. Furthermore, associations between neighborhood status and perceived stress as well as subjective status and CAR recovery were not significant despite having medium effect sizes. Thus, it is too early to dismiss neighborhood SSS as a health-relevant domain of status. Finally, post hoc power analyses confirmed adequate power to detect large effects; however, the sample size does not allow for the detection of weaker relationships. Despite these limitations, the current findings provide promising first evidence that SSS differs in unemployed individuals and that it matters whom participants compare themselves to. --- Summary and outlook The current findings emphasize the health relevance of SSS among individuals in closer proximity-specifically friends and family. While unemployed individuals reported lower neighborhood status, there was no difference in status relative to family and friends, suggesting that lack of income and employment level may not be factors on which this type of status is based. Although SES plays some role in SSS ratings, these findings indicate that SES may not impact all domains of SSS equally. Past research has demonstrated a gradient relationship between health and perceptions of one's standing in broadly defined social hierarchies, for example, United States. By assessing status among a large, generalized social group, this measure may not have adequate resolution to detect which domains of status are most health relevant. Identifying specific components of SSS and their distinct associations with stress will enable future research to target the most health-relevant facets of SSS for different populations. Employment status differences in subjective social status ratings and cortisol awakening responses . Means ± standard deviations for subjective social status ratings for friends and family > employed: 7.67 ± 1.37 , unemployed: 6.94 ± 2.01 ; for neighborhood > employed: 7.39 ± 1.79 ; unemployed: 6.00 ± 2.20 . ---

Inconsistent associations between health and measures of subjective social status compared to one's community suggest that how people define community may matter. This study broke down community into status among neighborhood and friends/family to assess the impact of each domain on chronic stress in individuals differing in socioeconomic status (18 employed and 18 unemployed individuals). The findings suggest that for ratings of subjective social status, the social and physical proximity of the reference group matters. Specifically, neighborhood status was affected by unemployment, while friends/family status was associated with perceived stress, emphasizing the importance of the comparison group in assessing subjective status.

General Scientific Summary Using a large international dataset, this study finds that sexual minority men's risk of depression and suicidality is associated with the legal protections and social attitudes toward sexual minorities in the countries in which they live. Among sexual minority men who still live in their country of birth, structural stigma is related to depression and suicidality via two psychosocial risk factors: internalized homonegativity and social isolation. Sexual minority men who moved from higher-to lower-stigma countries, and who had longer exposure to these low-stigma contexts , experienced significantly less depression and suicidality as well as lower levels of psychosocial risk factors for psychopathology. --- Structural Stigma and Sexual Minority Men's Depression and Suicidality: A Multi-Level --- Examination of Mechanisms and Mobility Across 48 Countries Sexual minority men represent one of the highest-risk groups for depression and suicidality, with meta-analytic evidence consistently indicating that they are between 1.5-4 times more likely to experience internalizing psychopathology and associated comorbidity compared to heterosexuals . Recent evidence suggests that depression and suicide may have even surpassed HIV as a burden to sexual minority men's health in North America . Stigma-which occurs when labeling, stereotyping, status loss, and discrimination exist within a context of unequal power-compromises the mental health of disenfranchised groups worldwide , including sexual minorities . Although stigma manifests at structural , interpersonal , and individual levels , most research documents the mental health effects of interpersonal and individual stigma . For instance, interpersonal stigma, such as discrimination and other forms of status-based rejection, are consistently associated with poor mental health among sexual minority populations . Individual stigma manifests as the internalization of negative societal attitudes and chronic, anxious expectations of rejection. Sexual minorities who report more self-stigma and expectations of rejection have higher levels of adverse mental health outcomes. The dearth of research on the mental health consequences of structural stigma-defined as societal-level conditions, cultural norms, and institutional policies and practices that constrain the lives of the stigmatized -is partly due to methodological challenges. In particular, few datasets contain sufficient variation in structural stigma across geographical units from which to predict mental health. Despite these challenges, researchers have begun evaluating associations between structural stigma and mental health . This research has focused on sexual minorities, which represent one of the few stigmatized groups for whom structural stigma is heterogeneous and rapidly changing across geographies. This work has shown, for example, that lesbian, gay, and bisexual populations have lower life satisfaction, an indicator of mental health, if they live in European countries with high levels of structural stigma, measured as LGB-specific discriminatory country-level policies and population attitudes . Studies in the U.S. have similarly found that the sexual orientation disparity in psychiatric morbidity is significantly larger in high-structural stigma states, defined as states whose hate crime laws and employment non-discrimination acts lack protections based on sexual orientation . These observational studies have been complemented by quasi-experimental evidence showing that LGB populations' rates of psychological distress increase following increases in structural stigma , and decrease following decreases in structural stigma . This research has provided important insights, but a number of important questions remain. First, because most population-based mental health surveys do not measure respondents' geographic mobility, previous research has not been able to account for the possibility of differential mobility by mental health status, whereby people with better mental health are more likely to move in general or more likely to move to certain types of structural stigma environments, particularly to lower-stigma contexts. Differential mobility would confound associations between structural stigma and mental health. However, limiting analyses to nonmovers would rule out this confound and thereby strengthen evidence for the association between structural stigma and mental health. Second, with the exception of some quasi-experimental studies , most research treats exposure to structural stigma as a static experience. Thus, there is limited data on whether changes in structural stigma affect mental health. One way to approach this question is through studying stigmatized individuals who move to a different structural-stigma context. Such an opportunity would allow researchers to examine whether changes in exposure to environments diverse in terms of structural stigma are related to mental health, a particularly relevant question in light of widespread global geographic mobility . However, examining whether this change in the structural stigma context is associated with mental health requires a novel data structure that includes: 1) a large sample of respondents who have moved; 2) linkage to objective indicators of structural stigma in countries of origin and receiving countries; and 3) data on length of exposure to the receiving country and on mental health. Until recently, the lack of such data has precluded researchers from leveraging mobility patterns to examine life-course variations in structural stigma exposure as a predictor of mental health. Third, despite growing evidence that structural stigma is a risk indicator for adverse mental health outcomes , few studies have identified mediating pathways, given the relative lack of datasets spanning structurally diverse contexts that also include measures of potential psychosocial mechanisms. Minority stress theory and existing research on structural stigma suggest that several stigma-related psychosocial processes might explain the association between structural stigma and sexual minority mental health. Sexual orientation concealment represents one potential mechanism linking structural stigma to poor mental health. In fact, psychological theories of identity concealment suggest that concealment is context-dependent and largely a function of one's environment, with some environments being particularly threatening, and thereby strongly motivating concealment . However, most research into environmental determinants of concealment has focused on interpersonal stigma within the immediate social environment, such as from family , rather than on structural stigma. Nonetheless, a few studies have shown that individuals are more likely to conceal their stigmatized identities in more structurally stigmatizing environments . Yet, whether sexual orientation concealment mediates the association between structural stigma and poor mental health remains unknown. Internalized homonegativity refers to the incorporation of heteronormative societal bias into one's self concept and represents a second potential mechanism linking structural stigma to poor mental health . Inherent to the definition of internalized homonegativity is its primary source in structural stigma, including the assumption that internalized homonegativity "stem[s] from negative stereotypes and myths about homosexuality that permeate mainstream society and are absorbed from one's culture" . Still, most research has examined internalized homonegativity as a function of interpersonal factors, such as daily discrimination . Similar to the state of research on structural stigma and concealment, a few studies have found associations between structural stigma and internalized homonegativity , but none have examined whether internalized homonegativity mediates the association between structural stigma and poor mental health. Social isolation represents a final plausible mediator of the association between structural stigma and poor mental health. Sexual minorities experience more social isolation than heterosexuals across the lifespan; in turn, social isolation is associated with poor mental health outcomes among sexual minorities . Although stigma in the form of interpersonal discrimination is particularly likely to result in social isolation among sexual minorities, even more so than among racial/ethnic minorities , we are aware of only one study that has examined whether another source of social isolation among sexual minorities might lie in structural stigma . In that study, sexual minorities in Australia reported worse life satisfaction as well as poorer mental health in high structural stigma communities, which were defined as constituencies where the residents were more likely to have voted against same-sex marriage in a national plebiscite on proposed samesex marriage legislation; a lack of perceived social support mediated the association between structural stigma and mental health . Like concealment and internalized homonegativity, social isolation represents a plausible mediator of the link between structural stigma and mental health because it captures the ways in which societal norms and attitudes become enacted by the individual to shape their day-to-day cognitive, affective, and behavioral experience. Finding support for these three psychosocial mediators linking structural stigma and mental health would not only strengthen causal inference regarding this association, but also suggest potential intervention targets for reducing negative mental health sequelae of structural stigma. To address these outstanding questions in the emerging literature on structural stigma, we take advantage of a unique dataset called the European Men-who-have-sex-with-men Internet Survey , which includes a large number of sexual minority men living in 48 European and nearby countries. EMIS-2017 permits several strong tests of our research questions. First, from its inception, it has sought to capture the diverse structural contexts surrounding sexual minorities across Europe and includes valid mental health assessments. Because country-level structural stigma can be assessed objectively via laws, policies, and community attitudes, associations with mental health are not likely to be biased by self-reported stigma exposure . Second, EMIS-2017 includes measures of several plausible mechanisms linking structural stigma to mental health. Third, EMIS-2017 includes participants born in 179 countries; 11,831 of these participants had moved from higher-to-lower stigma contexts, thereby providing a unique opportunity to examine whether changes in exposure to structural stigma is associated with risk of poor mental health. Finally, EMIS-2017's assessment of movement away from one's country of birth allows us to rule out any influence of differential mobility by mental health by performing separate analyses for non-movers and movers. The present study takes advantage of these methodological strengths to test the following four hypotheses. First, based on evidence from prior studies within a single country , we hypothesize that greater country-level structural stigma toward sexual minorities will be associated with depression and suicidality among sexual minority men who continue to live in their country of birth . Second, we hypothesize that sexual orientation concealment, internalized homonegativity, and social isolation will mediate the association between structural stigma and depression and suicidality among non-movers. Third, among sexual minority men who have moved from higher-to-lower structural stigma countries, we predict that the association between country-of-origin structural stigma and mental health will be weaker with longer exposure to the lower-structural stigma receiving country, operationalized as greater number of years living in the receiving country. Fourth, among movers, we hypothesize that the indirect effect of country-of-origin structural stigma on depression and suicidality will be significantly smaller among those with longer exposure to the lower-structural stigma environments of their receiving countries. --- Method --- --- Measures Country-level structural stigma. Consistent with prior research , structural stigma was measured via an indicator of 15 laws and policies related to sexual orientation combined with countrylevel attitudes towards sexual minorities among each country's residents. Using this approach, we created a measure of structural stigma for the 48 current countries of residence represented in EMIS-2017 and the 178 countries of origin used in analyses restricted to movers. The measure of laws and policies included three areas of legislation: legal discrimination and criminalization; recognition; and protection . To create the index, negative scores were assigned for each form of protection and positive scores for each form of discrimination . The range across the 48 EMIS-2017 countries was +6 to -13 and, across the 178 countries of origin, +13 to -13 . The measure of population attitudes towards homosexuality was obtained from the Global Acceptance Index , which provides a country-aggregated score based on 5,236,837 responses to 67 questions about acceptance of LGBT people contained in 11 international surveys from the years 2014-2017 . For the 11 small-population countries not contained in the GAI, we imputed the score from the two most similar countries' score on the laws/policies index. The direction and magnitude of results remained the same when these countries were excluded. Because the index of laws and policies was highly correlated with the index of social attitudes , we combined them into one index and weighted them equally, consistent with prior work on this topic . Our combination of these two measures of structural stigma is further supported by existing research showing that legal policies and social attitudes often co-occur and recursively influence each other . Specifically, we combined these two measures for each country by standardizing each, summing them to create one index, and linking the resulting index to the EMIS-2017 dataset. The z-standardized scores, which ranged from -1.64 to 2.11 across the 48 EMIS-2017 countries, and from -2.22 to 1.91 across the 178 countries of origin, were used in all analyses; higher scores indicate higher levels of structural stigma. Supplementary Table 3 lists the score and rank of each country. Supporting the construct validity of our measurement of structural stigma, previous research has found this composite approach of combining laws and aggregated norms to be associated with sexual orientation concealment , internalized homonegativity , life satisfaction , and HIV prevention behaviors in predicted directions among international samples of sexual minorities. In addition to using these structural stigma indices as the primary study predictor, we also used them to characterize the sample of movers. Specifically, we classified movers from higherto-lower structural stigma countries as those who were born in a country of origin with a relatively higher structural stigma score than that of their current country. By controlling for structural stigma in participants' country of origin, all analyses involving the sample of movers adjusted for the magnitude of the difference between structural stigma in participants' country of origin and structural stigma in participants' current country. --- Mental health outcomes. Depression was assessed with the 2-item version of the Patient Health Questionnaire for depression, in which respondents indicate how often they had been bothered by depressed feelings and anhedonia during the past two weeks, with response options ranging from "not at all" to "nearly every day" . Responses were summed for the primary analyses and were dichotomized at ≥3 to illustrate between-country differences in the proportion of respondents exceeding this valid cutoff . A meta-analysis of 100 studies finds that the PHQ-2's sensitivity and specificity are comparable to the sensitivity and specificity of administering the PHQ-2 followed by the full PHQ-9, making the PHQ-2 suitable for use in studies such as the EMIS-2017 that seek to reduce participant burden. We use the term "depression" to refer to this outcome and are careful to note that the PHQ is not intended to diagnose major depressive disorder. Suicidality was measured by one item from the PHQ-9 concerning the frequency of experiencing "thoughts that you would be better off dead, or of hurting yourself in some way" during the past two weeks, with response options ranging from "not at all" to "nearly every day ." This variable was treated continuously and also dichotomized at "not at all" to illustrate between-country differences in the proportion of respondents exceeding this valid cutoff . Psychosocial mediators. We examined three mediators of the association between structural stigma and mental health: sexual orientation concealment, internalized homonegativity, and social isolation. Sexual orientation concealment was measured with the question: "Thinking about all the people who know you , what proportion know that you are attracted to men?" to "all or almost all" ). Respondents indicated their internalized homonegativity in response to seven statements about one's comfort with homosexuality assessed on a 7-point scale . Respondents indicated their perceived lack of access to tangible help from others in times of need in response to the 4-item "reliable alliance" subscale of the Social Provisions Scale using a 4-point scale . All mediators were examined continuously. Moderators. Among movers, we used number of years living in the receiving country as a continuous indicator of length of exposure to structural stigma. To illustrate moderation, we categorized this variable in terms of living in the receiving country for ≥15 vs. 5-14 vs. 0-4 years, based on the distribution of this variable. Covariates. We controlled for variables that could serve as confounders of the association between structural stigma and mental health and/or that improved model precision. At the individual level, we controlled for age, education, employment status, settlement size, and HIV diagnosis. Because some of these variables could conceivably be influenced by structural stigma , we additionally present results without control for these covariates in Supplemental Figure 2; the direction and magnitude remain similar in these supplemental analyses. At the country level, we controlled for each country's gross domestic product per capita to adjust for covariation between structural stigma and each country's living standard . We also controlled for each country's general mental health burden using each country's DALYs lost to mental disorders, which was also associated with structural stigma . --- Statistical Analysis Analyses were performed using multilevel regression, supported by the nesting of participants within countries and the intraclass correlations across countries on the main study variables: depression , suicidality , identity concealment , internalized homonegativity , and social isolation . All multilevel models included random country-level intercepts. All predictors were modeled as fixed effects except when testing the moderating effect of time since moving among movers. For the moderation analyses, the associations between time since moving and the outcomes were allowed to vary by levels of structural stigma using random slopes. We used the maximum likelihood parameter estimates with standard errors robust to non-normality and non-independence of observations. Analyses were performed in MPlus, using complete cases and unweighted data . Indirect effects were derived from bootstrapped estimates. First, among non-movers, we examined the association between country-level structural stigma and mental health . Second, also among non-movers, we performed three multilevel mediation models to estimate the indirect effect of our proposed psychosocial mediators on the association between structural stigma and mental health. These models were conducted separately because in EMIS-2017, participants were randomly assigned to receive either the internalized homonegativity or social isolation scale. In order to facilitate comparisons of effect sizes across levels of structural stigma and to illustrate country-level differences in the proportion of sexual minority men who reported elevated depression and suicidality, we also re-ran these models using the PHQ-2 cutoff. As a sensitivity analysis, we additionally re-ran these models removing all covariates that could be influenced by structural stigma in these models. Third, among movers from higher-to-lower structural stigma countries, we ran multilevel moderation models to examine whether number of years living in the receiving country moderated the association between country-of-origin structural stigma and mental health. Finally, among these movers, we ran multilevel moderated mediation models to examine if the indirect effect of country-of-origin structural stigma on mental health through our proposed mediators would be significantly smaller among those with longer exposure to the structural stigma environments of their receiving countries. --- Results --- Descriptive Statistics Table 1 presents sociodemographic characteristics by respondents' history of moving from their birth country. The majority of respondents were born in their current country of residence and identified as gay . Respondents with a history of moving were more likely to self-identify as gay, be single, have a high level of education, live in a large city, and be diagnosed with HIV compared to non-movers. --- Association between structural stigma and depression and suicidality among non-movers We first analyzed the association between country-level structural stigma and mental health among non-movers. Men who lived in countries with higher levels of structural stigma had significantly higher levels of depression and suicidality . Figure 1a-b presents the adjusted country-level proportions of depression and suicidality by countylevel structural stigma. --- Psychosocial mechanisms linking structural stigma to depression and suicidality among non-movers Country-level structural stigma was strongly and positively associated with all three mediators . In turn, internalized homonegativity and social isolation were associated with depression; all three mediators were associated with suicidality. There were significant indirect effects of the association between structural stigma and both depression and suicidality through internalized homonegativity and social isolation, and through sexual orientation concealment for suicidality. When re-running these analyses using the PHQ-2 cutoff, we found a near-identical pattern of results as when using the continuous scores of the PHQ-2 items . As a sensitivity analysis, we also re-ran analyses removing all covariates that could theoretically be associated with structural stigma. We found a near-identical pattern of results as with the fully adjusted analyses, with the exception that the indirect effect through concealment became significant for depression but non-significant for suicidality; further, the direct effects for depression and suicidality remained significant in the context of social isolation . --- Association between structural stigma and depression and suicidality among movers: Moderation by length of exposure to lower-structural stigma receiving countries Among respondents who moved from higher-to-lower structural stigma countries, there was a significant association between country-of-origin structural stigma and risk of depression and suicidality . However, as hypothesized, this main effect was significantly moderated by number of years living in the current country of residence . This interaction demonstrated that those with longer exposure to lower-structural stigma environments in their receiving countries have lower risk of depression and suicidality. Countryof-origin structural stigma was associated with depression and suicidality only for those who had recently moved from higher-to-lower structural stigma countries. There was no significant association between country-of-origin structural stigma and depression or suicidality among those who had lived in their lower-structural stigma receiving country for five years or more, and who thus had longer exposure to lower levels of structural stigma . --- Psychosocial mechanisms linking structural stigma to depression and suicidality among movers: Moderation by length of exposure to lower-structural stigma receiving countries We found significant indirect effects of all three mediators of the association between country-of-origin structural stigma and both depression and suicidality . However, as hypothesized, the indirect effects of the association between structural stigma and both depression and suicidality were moderated by number of years since arriving to the lower-structural stigma receiving country . Thus, stratified mediation analyses were conducted . These analyses show that the indirect effects of the association between country-of-origin structural stigma and mental health through the psychosocial mediators were smaller among those who have lived in their receiving country the longest . Supplemental Table 2 shows the associations between country-of-origin structural stigma and each mediator stratified by number of years since arriving to the lower-structural stigma receiving country. Associations between country-of-origin structural stigma and each mediator were smaller with longer exposure to the lower structural stigma environment of their receiving country. --- Discussion Stigma is increasingly recognized as a fundamental cause of poor mental health across stigmatized populations . However, psychological research into the association between stigma and mental health has tended to conceptualize stigma as residing within the individual or as limited to interpersonal discriminatory encounters between individuals . As an alternative approach, our study locates the ultimate source of stigma in societal structures that in turn generate downstream influences on mental health through psychosocial stigma processes, including identity concealment, internalized stigma, and social isolation. Such an approach has potentially important theoretical implications for the etiology of psychopathology among stigmatized populations. Specifically, although individual and interpersonal manifestations of stigma are related to mental health across stigmatized populations , stigma is a multilevel phenomenon , and failure to examine its broadest societal manifestations potentially obscures the identification of sociocultural risk factors for psychopathology among the stigmatized. Further, in documenting interrelationships between structural and individual forms of stigma, our study begins to link structural stigma theory to minority stress theory , which have previously been examined in isolation . This integrative approach provides psychologists with a more comprehensive conceptual framework for understanding the multilevel influences on the mental health of sexual minorities. This study advances research on structural stigma and mental health in three important respects. First, a growing body of evidence has established that structural stigma increases risk for adverse mental health outcomes among stigmatized populations , but few studies have been able to rule out differential mobility by mental health status, which would confound this association. While two studies have found limited evidence of such differential selection by health among sexual minorities and Black individuals , both were conducted at the U.S. state level and used measures of selfrated health, rather than specific mental health indicators. We extend this literature by documenting associations between country-level structural stigma and depression as well as suicidality among non-movers, thereby ruling out differential selection by health as an explanation for this association. Second, taking advantage of divergent geographic mobility patterns among EMIS-2017 respondents, this study explores whether changes in structural stigma exposures are related to mental health in ways that are consistent with structural stigma theory . We show that among movers from higher-to-lower structural stigma countries, those with longer exposure to lower-structural stigma environments in receiving countries-i.e., those who moved at least five years ago-have lower risk of depression and suicidality, and of experiencing the psychosocial mechanisms through which structural stigma might compromise mental health, compared to those who moved less than 5 years ago. This is one of the first studies, to our knowledge, to find support for structural stigma theory using differential mobility patterns, an approach that complements other methodological strategies employed to date, including quasi-experiments . The triangulation of evidence across different methods is an established procedure for causal inference . Notably, although we found that length of exposure to destination-country structural stigma moderated the association between country-of-origin structural stigma and mental health for movers from higher-to-lower stigma countries, we did not find such an effect for movers from lower-to-higher stigma countries, as reported in the Online Supplement. We suspect these divergent findings may be due, in part, to the fact that these two groups of movers differ in important respects that are likely related both to their timing of, and reasons for, moving. Specifically, movers from lower-to-higher structural stigma countries were more likely to have moved as adults and for opportunity rather than duress owing to lack of opportunity in their country-of-origin . These findings call for additional research to understand the reasons that the influence of earlier exposure to lower stigma contexts might not wane with greater exposure to a higher stigma context, particularly among those who spent longer periods of time in lowerstigma environments before moving to higher-stigma contexts, as was the case with our sample of movers. This research might consider a developmental hypothesis whereby growing up in more protective structural environments buffers sexual minority men from mental health problems upon moving to more stigmatizing environments, regardless of the length of time they spend in the new, more stigmatizing environment. This hypothesis would be consistent with research showing that protections at the interpersonal and individual levels can weaken the association between stigma exposure and mental health. By prospectively locating similarly protective features in the early structural environment that may buffer against later structural stigma exposure, this future research would begin to integrate structural stigma theory with developmental life course models of sexual minority mental health . Third, we documented several theory-driven psychosocial mechanisms linking structural stigma and mental health, including sexual orientation concealment, internalized homonegativity, and social isolation . The identification of these mechanisms expands previous research that has primarily focused on the role of discrimination as a mechanism linking structural stigma to mental health . Otherwise, very few studies have examined the ways in which structural stigma shapes the daily lives of sexual minorities. The present findings specifically suggest that hiding one's sexual orientation from others, internalizing negative societal messages about the inferiority of sexual minorities, and being isolated from reliable sources of social support represent ways in which structural stigma might "get under the skin" to generate adverse mental health. The percent reduction in the association between structural stigma and mental health was particularly strong in the context of internalized homonegativity and social isolation. These two pathways, therefore, represent potentially promising targets to address in structurally competent mental health care and for consideration in culturally responsive adaptations of evidence-based psychotherapeutic interventions for this population , in the absence of structural reform. The identification of plausible pathways through which structural stigma influences mental health also improves causal inferences because it establishes empirical relationships that are consistent with theoretical predictions. Effect sizes for the examined associations were small in magnitude, consistent with the fact that structural stigma represents a distal social factor that is expected to exert a smaller effect than more proximal factors, such as interpersonal discrimination, which have been the focus of most studies on sexual minority mental health . However, even small effects can be substantively meaningful, especially when they are related to factors whose influence is hypothesized to exert impact over a large population . For instance, we found that the odds of exceeding valid depression and suicidality cutoffs were approximately twice as high for sexual minority men living in the highest-stigma countries compared to the lowest , which likely represents a substantially elevated population burden of morbidity and mortality that could reasonably be expected to be reduced in high-stigma countries as the laws, policies, and national attitudes that inform our structural stigma index are improved. Our study had several methodological strengths, including being the largest dataset of sexual minority men in the world and the only dataset capable of examining the association between country-level structural stigma and mental health. We also note its limitations. While we used a large, diverse sample of sexual minority men, the data come from a non-probability sample, potentially limiting generalizability, especially to those who are older, have lower education, have fewer LGBT community attachments, and are more likely to conceal their orientations . Yet, our analyses assume that the distribution of variables in the EMIS-2017 sample matches the distribution of these variables in the population. Further, non-probability sampling can also lead to higher estimates of mental health concerns among sexual minorities. These concerns are somewhat attenuated given that the present study was not focused on establishing population estimates of mental health conditions, but instead sought to examine associations among variables, for which nonprobability sampling is more appropriate . Further, probability-based studies typically include relatively small numbers of sexual minorities in one country only, and thus would not have provided an adequate sample size across numerous countries with which to evaluate our research aims. Future efforts are needed to systematically assess sexual orientation in population-based research across countries . Future inclusion of a heterosexual comparison sample would permit establishing specificity of the associations found here, as has been observed in prior research on structural stigma and sexual minority mental health . Further, the EMIS-2017 dataset was not focused on mental health, and thus used brief, self-report items to assess mental health. Although these items have established psychometric properties and are associated with major depression and risk of suicide , future research should determine whether similar results are obtained with the use of diagnostic mental health assessments. Additionally, the suicidality item imprecisely assesses thoughts of both death and self-harm. Given the disproportionate risk of both suicidality and self-harm among sexual minorities, future research is needed to disentangle these distinct, yet related constructs . In addition, the data are cross-sectional. Because cross-sectional datasets can introduce the possibility that the outcome causes the predictor , we take two steps to rule out this possibility. First, we innovatively assess structural stigma exposure using an objective index of legal policies and aggregated country-level attitudes toward sexual minorities. Because it is not influenced by subjective perception, an objective index cannot be caused by participants' mental health status . One condition under which participants' mental health status would influence their structural context is if mentally unhealthier individuals differentially migrate to higher structural stigma countries. Therefore, we take a second step to rule out the possibility of differential migration by only including those participants who were born in the country in which they currently reside. This innovation in the structural stigma literature further removes the possibility that poorer mental health causes higher structural stigma. Together, these two steps address two primary limitations of cross-sectional data. At the same time, the present design cannot establish a causal direction between the mediators and outcomes, or any recursive impact between them. Future research would benefit from the examination of our research question in a longitudinal cohort, which would enable researchers to more systematically examine within-person change over time, including multiple moves to both higher and lower structural stigma contexts, while controlling for pre-move characteristics. Despite these limitations, our study has potentially important implications for both theory and intervention. With respect to theory, this study advances our understanding of the sociocultural determinants of sexual orientation-related disparities in depression and suicidality among men by providing additional evidence that structural stigma is associated with the mental health of sexual minority men, both through proximal experiences and as a function of length of exposure to structurally diverse contexts, at least for those who move higher-to-lower structural stigma contexts. Moreover, findings suggest the importance of routinely assessing life-course structural influences on mental health and deploying interventions to address those influences. In fact, multilevel interventions show promise for improving mental health in high-structural-stigma contexts, including through reducing stigma within institutions and improving personal coping through scalable behavioral treatments . This study suggests that such interventions may have powerful capacity to interfere with the mental health toll of structural stigma. , and country-of-origin GDP and country-of-origin DALYs lost due to mental disorders and current country-ofresidence structural stigma towards sexual minorities at Level 2 . These models are conducted only among sexual minority men with a history of moving from higher-to-lower structural stigma countries . --- Figure 1a-b Country proportion of self-reported depression and suicidality among non-movers by structural stigma in country of residence. * Includes microstates: Monaco , San Marino , Liechtenstein , and Andorra . † The designation of Kosovo is without prejudice to positions on status and is in line with UNSCR 1244/1999 and the International Court of Justice Opinion on the Kosovo declaration of independence. --- Supplemental Table 2 Multilevel-model estimates of the association between country-of-origin structural stigma and sexual orientation concealment, internalized homophobia, and social isolation stratified by years since arriving to current country of residence among movers from higher-to-lower structural stigma countries. --- Figure 2 Direct and indirect effects of sexual orientation concealment, internalized homonegativity, and social isolation as mediators of the association between country-level structural stigma and mental health. -Penal code -Morality code Maximum sentence in months and years: -1 month to 2 years -3 to 7 years -8 to 13 years -14 -years to life -Death --- Recognition Equal rights included in constitution Same-sex civil relationship recognition Same-sex marriage Joint adoption for same-sex couples Second parent adoption for same-sex couples --- Supplemental Figure 1 Direct and indirect effects of sexual orientation concealment, internalized homonegativity, and social isolation as mediators of the association between country-level structural stigma and depression and suicidality .

Sexual minority men are at greater risk of depression and suicidality than heterosexuals. Stigma, the most frequently hypothesized risk factor for this disparity, operates across socioecological levels-structural (e.g., laws), interpersonal (e.g., discrimination), and individual (e.g., self-stigma). Although the literature on stigma and mental health has focused on interpersonal and individual forms of stigma, emerging research has shown that structural stigma is also associated with adverse mental health outcomes. However, there is limited data on whether changes in structural stigma, such as when a stigmatized person moves to a lower stigma context, affect mental health, and on the mechanisms underlying this association. To address these questions, we use data from the 2017/18 European Men-who-have-sex-with-men Internet Survey (n=123,428), which assessed mental health (i.e., Patient Health Questionnaire) and psychosocial mediators (i.e., sexual orientation concealment, internalized homonegativity, and social isolation). We linked these data to an objective indicator of structural stigma related to sexual orientation-including 15 laws and policies as well as aggregated social attitudes-in respondents' countries of origin (N=178) and receiving (N=48) countries. Among respondents who moved from higher-to-lower structural stigma countries (n=11,831), longer exposure to the lower structural stigma environments of their receiving countries was associated with a significantly: 1) lower risk of depression and suicidality; 2) lower odds of concealment, internalized homonegativity, and social isolation; and 3) smaller indirect effect of structural stigma on mental health through these mediators. This study provides additional evidence that stigma is a sociocultural determinant of mental health.

Introduction This paper combines transitivity analysis with a social representations framework in order to examine the ways in which the issue of antimicrobial resistance is discussed in UK news publications . A more specific aim of the paper is to determine which social actors are presented as having agency in tackling this global issue. The concept of agency construction brings together the analysis of discourse through transitivity, with Social Representations Theory as a framework for understanding how a community comes to comprehend, discuss and behave in relation to a social object . In 2015 the issue of 'antibiotic resistance' , or, more generally, 'antimicrobial resistance' was widely discussed in the media. The year 2015 ended with reports that antibiotic resistant gonorrhoea is becoming untreatable and that scientists in China discovered a gene in E.Coli that makes it resistant to a class of 'last-resort' antibiotics and transfers resistance to other epidemic pathogens . It has become increasingly evident that "if we fail to find effective antibiotics and manufacture them at the scale needed, ten million people a year across the world will die by 2050" . Both DeSilva et al and Bohlin and Höst found that the most commonly reported cause of increasing antibiotic resistance was the unnecessary prescription of antibiotics. Patient expectation is one of several factors that underlie primary care physicians' decision-making regarding the prescription of antibiotics . In their survey of patients with upper respiratory tract infections, Linder and Singer found that physicians prescribed antibiotics to 46% of patients who requested them. Their multiple regression model demonstrated that patients asking for antibiotics was a significant independent predictor of physicians prescribing them. Nisbet and Markowitz have pointed out in a recent report for the American Association for the Advancement of Science that Despite the pervasive use of antibiotics and growing problems, research on public awareness, knowledge, and attitudes about antibiotic resistance is limited, as is research on communication and engagement strategies. McCulloch et al.'s systematic review of public knowledge and beliefs about antibiotic resistance found that people believed that others were largely responsible for the development of antibiotic resistance; they had a low personal risk from resistance; their risk increased if they were hospitalised or used prolonged courses of antibiotics; and causes of resistance included antibiotic use and overuse and not completing an antibiotic course. Most importantly, McCulloch et al. found that people believed that minimising antibiotic resistance was outside their control and, therefore, that strategies should be aimed at clinicians. This is consistent with Brooks et al.'s work, which found that patients generally viewed antibiotic resistance as a societal problem rather than as one that would affect them individually. Similarly, Wood found that "most people do not feel they have a personal role in either the problem of AMR or its solution". Nisbet and Markowitz found that members of the public put trust in science to find new antibiotics, thus distancing their own actions and responsibilities from this issue. They concluded that this "disconnect between science, knowledge, and patient expectations has led some scientists to argue that public health campaigns need to focus on bolstering public understanding of antibiotics" . Gill et al show that both patients and medical professionals have high levels of knowledge concerning MRSA , a particular hospital infection resistant to antibiotics. For both patients and visitors, general media constituted the most common source of information concerning MRSA, which is consistent with other studies of public understanding of science and medicine . It has been recognised that "[a]s a forum for the discourses of others and a speaker in their own right, the media have a key part in the production and transformation of meanings" . Although forms of social and digital media offer alternative sources and means through which such information is accessed by members of the public, research has shown that social media users rely just as much on local and national newspaper websites for information . --- Discussion of AMR in the media Given the prominence of the news media as a source of information concerning medicine, science and technology , it is important to explore existing research into media representations of antibiotic resistance. Across the globe, the news media have been shown to have an impact on public understanding of health issues , which contribute to the formation of social representations and, in turn, guide perceptions, attitudes and behaviour. DeSilva et al found that two key individual measures were not frequently reported in discussion of AMR in North American news articles . In the Swedish press, Bohlin and Höst found that reporting of these measures was even lower . Media coverage of antibiotic resistance goes back as far as 21 November 1969, when the New York Times published an article on the so-called Swann Report on the use of Antibiotics in Animal Husbandry and Veterinary Medicine . The article focused on the British Government's early efforts to restrict the use of antibiotics for farm livestock, as this can lead to the emergence of antibiotic-resistant bacterial strains in humans. 'Antimicrobial resistance' was discussed in the journal Chemical Week in 1984 in an article that focused on the use of antibiotics in animal feed and the dangers this poses to human health. Furthermore, the ESRC research brief states that: in order to develop effective patient education and health promotion materials to reduce inappropriate antibiotic use we need to understand how people talk about, and think about, antibiotics and infection. Possible approaches might include a discourse analysis of media reports . 'Discourse analysis' can be defined as: "the study of language above the level of a sentence, of the way sentences combine to create meaning, coherence and accomplish purposes", however, "even a single sentence or utterance can be analysed as a 'communication' or an 'action'" . In this work, we are concerned with how language constructs at the clausal level shape the broader news discourse around AMR 2010-2015 at the macro level, thereby creating the potential for the emergence of social representations about the issue and the role that individuals have in its development and possible mitigation. --- Theoretical and conceptual framework Theoretically, our study is grounded in social representations theory , offering a framework for understanding and exploring how scientific knowledge diffuses in society and informs thought and action at both social and individual levels. A social representation is defined as a system of values, ideas and practices regarding a given social object , as well as the elaboration of that object for the purpose of communicating and behaving in relation to it. The theory posits that social representations emerge when novelty is anchored to existing stimuli that are known about in a given social context and when it is objectified through the invocation of metaphors and images that can describe it . Accordingly, it can provide a shared social 'reality ' and 'common consciousness' vis-à-vis AMR. This study forms part of a growing tradition of SRTinformed research into science, technology and society . Social representations theory is combined with transitivity analysis as a means of offering an account of agency that is predicated on examining the 'choices' that speakers make when constructing sentences and making meaning. Transitivity analysis has offered a systematic method for examining how discourses at the macro level are formulated by language constructs at the clausal level, which has been influential in critical discourse analysis studies . The approach considers the clause in terms of the 'process' that is being described; the participants involved in the process; and the circumstances associated with the process. is characterised as having agency, with a particular focus on the degree of agency attributed to ordinary members of the public. --- Sample We searched the news database Nexis® using the search terms 'antibiotic resistance' OR 'antimicrobial resistance' , as well as 'superbug'. Given the discernible increase in the use of these terms , we restricted our search to 2010-2015. Nexis® allows users to search a database of UK National newspapers, which comprises 16 full-text national newspapers, including their online publications. Although there are of course alternative news sources in online and digital media, it has been shown that the credibility of national quality press is rated higher than news on the Internet and this database offered a sufficiently large dataset for our analysis. The distribution of the articles by publication and by year is shown in Table 1. [Insert table 1 here] At this point, our aim was to get a general sense of the ways in which the various social actors implicated in discussions of AMR are characterised before any breakdown of the dataset by publication type. The ideological standpoint and readership of the newspaper will have significance for how the material is presented and exploration of this would be a natural extension of our work, consistent with a critical discourse analysis approach . It is noteworthy, for example, that the dataset is heavily dominated by articles published in the Mail Online . However, in order to separate out those distinct voices we must first obtain a sense of the overall picture that cuts across publications. As such, the entire 627 articles were taken as a single dataset, although the analysis is presented year-on-year in order to facilitate discussion of any changes over time. --- Analysis The aim of the transitivity analysis was to identify the different social actors and their respective roles in the debate on AMR, focusing not only on their responses to the issue but also on their perspectives on its emergence. As such, we extracted all mentions of 'antibiotics' from the data and systematically assessed the clause construction to identify who and what was discussed in relation to 'antibiotics', as well as the process between them. Across the 627 articles this amounted to 2500 mentions of 'antibiotics' distributed as follows: 2010: 103; 2011: 288; 2012: 274; 2013: 525; 2014: 384; 2015: 926. The data show that, although there is an increase in the number of terms to refer to agents in the discussion of AMR, these terms generally relate to a small number of social actors. Thus we find 'antibiotics' and the 'infections' bugs', 'strains') that they are designed to treat across the dataset, with doctors/GPs and patients also at the heart of the discussion. Some nouns use)'), however, are more abstract and without a clear individual, or group of individuals, in the Subject position. This is one form of Exclusion that obscures the identity of the social actor. Similarly, it is not always clear to whom 'we' and 'you' refer. These are explored in turn below. Antibiotics Table 3 shows which are the most frequent verbs that are used when 'antibiotics' is in the Subject position. The most frequent processes attributed to 'antibiotics' are: the relational process indicated by 'are', which provide some form of identification or classification of 'antibiotics'; and the material process 'used' to indicate how and where antibiotics function. By positing 'antibiotics' in the Subject position the 'user' is given an indirect role or omitted altogether in a passive construction. This is observable in the following example: Antibiotics are used on farms, on livestock, under the prescription and care of a veterinary surgeon . The relevance of the farming context is relegated to a prepositional phrase and the role of the veterinary surgeon is given less prominence due to their position in the sentence. This is a common way of 'backgrounding' social acts and actors. It is 'antibiotics' that appears at the beginning and in the Subject position and so is the more obtrusive agent. Where 'prescribing' is the process of 'antibiotics' a passive construction is also often used, foregrounding what it is that is prescribed but providing only an allusion to the agent doing the 'prescribing' by relegating this to the prepositional phrase 'in GP surgeries'. As such, GPs are Suppressed as social actors with their involvement only implicit. The verbs 'losing' and 'becoming' indicate relational processes in the present continuous tense, demonstrating that this is an ongoing process. The use of 'losing' is generally in reference to the 'effectiveness' of antibiotics in treating bacterial infections. Similarly, antibiotics are reported to be 'becoming less effective'. The material process of 'working' works to the same effect in that references generally report that 'antibiotics are no longer working'. This is another series of examples where the factors causing the decreasing efficacy of antibiotics are not reported in a direct way. Rather, 'antibiotics' is reported to be the agent active in a process of 'losing' or 'becoming'. [Insert 'We' appears throughout and, although lacking specificity, contextual cues from the surrounding text suggest that it is generally used to refer to the general public. This indicates a focus on 'our' responsibility in the rise of AMR . This also allocates blame to 'us' in making AMR materially happen, most notably in the material process of 'using' antibiotics, the mental process of 'expect[ing]' and also the verbal processes of 'ask[ing]' and 'demand[ing]' antibiotic treatment. Subsequently, we are depicted as agents who potentially have some active role in 'preserving' existing antibiotics by 'reduc[ing]' our use of them. From 2013, this is formulated as a discussion of our 'need' for antibiotics, including some more instructive pieces offering advice as to when a patient might need antibiotics but equally, when they might not. The ambiguity afforded by this collectivisation means that there is no impetus on individual responsibility since there are no named individuals. There are some changes in the use of 'we' over time. In 2010 we can find, for example, a statement of the problem that we all face: Not so long ago, we imagined that antibiotics could cure all such infections 'Superbugs', 'infection ', 'bacteria' and 'strain' In the same way that 'antibiotics' are instilled with agency in 'becoming' less effective, the infections they treat are also depicted as being agentive. Infections, which had previously been 'defeated', 'treated', 'remedied', 'destroyed', 'beaten' by antibiotics are now 'developing' into forms that 'survive' and 'evade' antibiotic treatment. Representing the infections themselves as activeas agentivehelps to depict an opposing force: an 'enemy' that we as a society of patients, doctors, scientists etc. might collectively resist. However, this does generate a sense that the 'blame' for the symptoms of these illnesses lies with the bacteria themselves and thereby may detract from the sense of responsibility that we the public might assume. 'GPs', 'doctor ' and 'hospitals' In the corpus we find statistical reports that indicate, for example, that: "Some 74% of antibiotics are prescribed by GPs in the UK" . The medical domain is reported to be the disseminating source of antibiotics, which in turn implies that 'doctors', 'GPs', 'hospitals', 'medics' etc. are the ones with the capacity to inhibit their use. The distribution of antibiotics is reported in a handful of terms, from simply 'using' , 'dishing out', 'handing out', 'doling out', to the overwhelmingly most frequent: 'prescribing'. In terms of transitivity, the process of 'prescribing' has evoked some debate as it seems to originate from a verbal process, has been cited as a behavioural process but unarguably has more material consequences in terms of access to medications. Here, 'prescribing' is the process most frequently attributed to the various medical agents and is presented as a process central to the development of AMR. Phrases such as 'doling out' imply that there is little regard for the quantity of antibiotics being prescribed and that the 'prescribers' (i.e. doctors) are blithely doing so. Substantiating this more critical view of medical professionals is the oft-cited circumstance in which antibiotics are prescribed, such as 'when they are not needed', 'unnecessarily' or 'for coughs and colds'. However, this does not tell the full story in that there are instances where we find that GPs are 'pressured to prescribe' antibiotics. Thus, although GPs are the active agents in the prescribing of antibiotics, there is another force applying 'pressure' for them to do so. What we can surmise from this type of construction is that the writers may want to allude to the demands of patients, who are likely candidates for the source of this pressure, but do not cite them directly as the instigators of this process. It would be telling therefore, to look more closely at the patient-GP relationship as depicted in the data. We are told, for example, that GPs who refuse to give out antibiotics are 'less popular' . Furthermore, some texts directly instruct readers to 'Avoid your GP to slow rise of superbugs' . This example does highlight one of the potential oversights of the focus on grammatical agency employed here, where the imperative form omits the Subject for the verb/process and thereby the 'patient' is subject to exclusion. However, van Leeuwen cites the use of possessive pronouns in this way as a recognised strategy for indicating sociological agency and his expanded 'system network' offers some guidance on how to account for such examples. 'Use' The 'use' and 'overuse' of antibiotics is reported to 'lead to' the issues associated with AMR but once again, the 'users' undergo exclusion in this depiction. There is some sense in this: if we acknowledge that it is not patients/the public themselves that is the issue but rather their use of antibiotics then it seems reasonable to foreground this aspect. However, what this construct avoids is implicating agents such as the public, doctors and farmers in the 'overuse' of antibiotics. 'Farmers' as a group of social actors also experience exclusion when the discussion of the 'use' of antibiotics is situated in the 'livestock' domain. For example: "The routine preventative use in farming of colistin, and all antibiotics important in human medicine, needs to be banned immediately." . excludes those providing the chickens with antibiotics. The farming context itself is marginalised, appearing in prepositional phrases such as 'in the meat industry', or 'as medicated feedstuffs'. This practice then is not foregrounded as a focus of the discussion and thereby becomes incidental, which has the effect of normalising it. --- 'Farmers' and 'chicken' Where there are interventions or actions in this context for reducing the use of antibiotics, this is enacted not by farmers but rather the companies who trade with farmers for their livestock. For example, "McDonald's has also pledged to eliminate chickens fed on human antibiotics" . This does, however, only constitute a verbal process rather than any real transitive action. One of the contributing factors to the issue of AMR is that in the last 40 years, only two new classes of antibiotics have been developed 1 . There were only 37 references [2010: 4; 2011: 3; 2012: 6; 2013: 7; 2014: 5; 2015: 12] to social actors representing the industry of antibiotic production 2 , who were characterised as having 'lost interest in developing'/'not working hard to produce'/'reluctant to invest in developing' new biotics and as such, actors in the negation of material process pertaining to antibiotics. Thus while largely subject to exclusion , when mentioned, 'drug companies' are represented as being inactive. Furthermore, the use of passive constructions to report that 'the manufacture of antibiotics is not seen as profitable' offers another form of exclusion by omitting the actors who hold this profit-oriented perspective. Similarly, there are 44 references to the people and processes involved in the research behind antibiotics 3 , where scientists are discussed in terms of their ability to 'develop'/'produce'/'come up with' new antibiotics. However, this is presented in the context that 'microbes mutate faster than scientists can come up with new antibiotics' , demonstrating the inability to complete a material process quickly enough. Other processes are verbal: trials 'promote'; findings 'reveal'; research 'offers'; and scientists 'blame' and 'call for', so their role in the fight against AMR is not shown to be as impactful as transitive, material processes would be. --- Discussion In May 2016 the UK economist Jim O'Neill published a long-awaited report on how to tackle AMR , which recommended inter alia that "a massive global campaign should be launched to make the world more aware of the dangers of antimicrobial resistance" . Moreover, in September 2016 the General Assembly of the United 1 http://www.antibioticresearch.org.uk/about-antibiotic-resistance/ 2 Identified by the terms: 'drug companies'; 'pharmaceutical companies'; 'the pharmaceutical industry'; 'pharmaceutical firms'; 'Big pharma' and indirectly, 'manufacture of antibiotics' and 'the pipieline'. 3 Identified by the terms: 'research'; 'scientists'; 'microbiologists'; 'study'; 'trials'; and 'findings'. Nations held a special high-level meeting on AMR and committed to addressing the challenges posed by AMR to health, food security and development. 4 The growing problem of AMR can be attributed not only to biological and pharmacological causes but also to human action. Public perceptions of AMR play a fundamental role in how individuals engage with antibiotics and, consequently, in the progression of AMR. This ties in with existing research findings that patients may expect, and even demand, the prescription of antibiotics although they are not needed; that there is a tendency to misuse antibiotics; and that AMR is frequently attributed to external causes, such as to doctors, 'dirty hospitals', 'others' who overuse antibiotics, and society as a whole, rather than to one's own individual actions . An apparent disconnect between science, knowledge and patient expectations has led scientists and commentators to argue for greater public understanding of AMR. We strongly believe that the news media constitute an important starting-point for understanding the nature and structure of representations of AMR, which in turn inform thought and action vis-à-vis AMR. Attribution is a key component of social representations , and it can be regarded as a subprocess of anchoring . Indeed, problems need to be attributed to specific causes in order for them to be understood and discussed. In the data there was no sense of individual responsibility but rather AMR was attributed either to the bacteria themselves or to society as a whole. This could plausibly encourage the social representation that AMR is a biological and societal problem, over which individuals have no control, such as was found in reported studies. Patients tend to make "external attributions" and to perceive a lack of control over the development of AMR or its solutions . Chandler et al. have observed similar 'blame-games' in media and political discourse: framing doctors as over-prescribers and patients as misusers and over-consumers of antibiotics, with selective and/or limited attention, intentional or not, to contributions of socioeconomic inequalities and inequities, demographics and differences in exposures to infectious diseases, let alone the pharmaceutical industries role in the levels of antimicrobials sold. This highlights that the response to overuse of antibiotics needs to come at multiple levels and the media might have a role to play in promoting individual action among members of the public but there are also political and economic structures that will continue to determine who has access to antibiotics. Boyce, Murray and Holmes found that the British press often based antibiotic resistance reporting on governmental agency press releases rather than research reports, which will have consequences for the linguistic construction of this media discussion of the issue if the content is appropriated from reports or other documents that are written for a different purpose, in a different register. Potentially, studies that adopt a systematic linguistic approach as we have presented here can inform media practices as to how to incite individual action, if this is an accepted strategy for tackling AMR. Given the centrality of human action to the development of AMR, it is key that we understand the underpinnings of the social reality and public consciousness around AMR. Sources of societal information such as the media contribute to the development of social representations and yet the media can only possibly play a partial role in this developmental process, since individuals, groups and other channels of societal information function as co-constructors of social representations . Future research must explore how AMR is portrayed not only in the traditional mainstream media but also in social media, such as on websites, blogs and in political rhetoric. The Wellcome Trust, for instance, is doing an excellent job in disseminating information about AMR on social media platforms such as Twitter in order to enhance public understanding about it. An important next step in research into AMR would be to explore the impact of social media campaigns on the structure and quality of public understanding of AMR. Machin and Mayr have shown how transitivity analysis can be combined with a multimodal critical discourse analysis in their examination of the representation of criminals and crime fighters in the television show Crimewatch, which can offer some guidance as to how to extend this type of work into a multimedia/multimodal domain. In adopting a transitivity analysis we were able to identify those instances where the social actor was labelled in the process and thereby explore the more overt ways in which particular agents were implicated in the discussion of AMR. But as van Leeuwen observes, "sociological agency is not always realised by linguistic agency, by the grammatical role of Agent". Therefore, there may be other ways in which doctors, patients, drug companies etc. can be implicated with less overt naming strategies, such as the use of possessive pronouns . It is necessary to consider what effect these have too. Extending this research in the ways that van Leeuwen identifies in his 'system network' could offer a more comprehensive picture. Our findings provide some indications of emerging social representations of AMR. Bacteria, superbugs and infections are positioned as the enemy which needs to be beaten but there appeared to be little focus on solutions or on the tools that might be utilised in the fight against AMR. Adopting a 'solutions journalism' approach has been shown to improve readers' engagement with an issue as well as inspiring them to work towards a solution . Antibiotics are defined, categorised, but ultimately no longer responsive to bacterial infections. The agricultural dimension of AMR was largely marginalised, despite the central role that this domain also plays in the development of AMR . Thus, AMR was anchored principally to these entities: bacteria, superbugs and infections; and the war metaphors employed in relation to these entities objectified AMR as being driven by belligerent forces requiring action and mitigation . Research and manufacture of antibiotics were also subject to exclusion. Thus, a stable social representation of AMR in the news media concerns the anthropomorphic agency of bacteria, antibiotics and infections, which, despite the use of war metaphors, discursively attenuates the ability of human beings to engage successfully with the problem of AMR. It is easy to see how representations observed in the data might inhibit engagement with the problem of AMR by disempowering individuals who indeed could take action against its progression. Indeed, self-efficacy, which this representation may well inhibit, is a key predictor of behaviour change . Clearly, those social representations that empower people to engage with AMR should be encouraged and disseminated. Existing work on antibiotic resistance seems to suggest that there is a shortage of accurate and empowering information on the phenomenon. In other words, readers are not habitually exposed to representations that can inform them about the complexity of the problem or that can provide them with possible ways in which they as individuals may contribute to the prevention of antibiotic resistance. The findings from our media analysis seem to support this assessment. --- Tables and Figures

The increase of infections resistant to existing antimicrobial medicines has become a topic of concern for health professionals, policy makers and publics across the globe, however among the public there is a sense that this is an issue beyond their control. Research has shown that the news media can have a significant role to play in the public's understanding of science and medicine. In this article, we respond to a call by research councils in the UK to study antibiotic or antimicrobial resistance as a social phenomenon by providing a linguistic analysis of reporting on this issue in the UK press. We combine transitivity analysis with a Social Representations framework in order to determine who and what the social actors are in discussions of antimicrobial resistance (AMR) in the UK press (2010)(2011)(2012)(2013)(2014)(2015), as well as which of those social actors are characterised as having agency in the processes around AMR. Findings show that antibiotics and the infections they are designed to treat are instilled with agency; that there is a tension between allocating responsibility to either doctors-asprescribers or patients-as-users; and collectivisation of the general public as an unspecified 'we': marginalising live-stock farming and pharmaceutical industry responsibilities.

Distinctiveness of Aboriginal families As a population, Aboriginal men are arguably the most socially excluded in Canada, with higher unemployment, homelessness, injuries, incarceration, and suicide, and lower education and life expectancies than all other Canadians . While some Aboriginal families are typical of many non-Aboriginal families, population level findings indicate that many Aboriginal families are unique in a variety of ways. There is a higher rate of common law unions, higher levels of mobility and more children younger than 14 years of age within Aboriginal households compared with non-Aboriginal households . Aboriginal men are less likely to be coresident with their children; greater than one-quarter of Aboriginal children are living in lone mother headed households . At the same time, there are twice as many Aboriginal fathers shouldering the responsibility of raising children alone compared with non-Aboriginal fathers . With a higher rate of Aboriginal parents who live separately, there are more Aboriginal fathers who are the sole caregivers of their children when they take turns with their ex-partners in caring for children. It is more common for Aboriginal men to have children with several different partners, and for fathers to live in households and be partly responsible for the care of children to whom they are variously related, including children with different mothers, their current partner's children, children who spend part of each week or part of each year living with them, and so on . As well, continuing a culturally traditional pattern, many Aboriginal families do not conform to a typical Euro-Western nuclear family structure; children may be raised by their grandparents or by a number of different relatives in 'circles of care' . Thus, when practitioners want to engage a child's primary caregivers, it is important to ask who is involved in the child's direct care over a given period of time and to ask a father about his varying roles in a way that conveys assumed responsibility in which a biological connection may not be so important. It is also critical to be aware of the tremendous diversity among Aboriginal families, including the fact that some are thriving and some Aboriginal fathers are role models of positive father involvement. --- Using a sociohistorical lens A recent inaugural study of First Nations and Métis fathers of young children in Canada underscored the importance of understanding the historical conditions that account for challenges facing many Aboriginal families and fathers . Among the 80 fathers who came forward to be interviewed about their fatherhood journeys, virtually all pointed to the long series of colonial interventions, illustrated Commentary ©2012 Pulsus Group Inc. All rights reserved --- Figure 1) Evidence-based contributions of father involvement to child outcomes. IQ Intelligence quotient in Figure 2, which effectively disrupted Aboriginal family and community life and traditional modes of subsistence, child rearing and health promotion. The Indian residential schools delivered a final, devastating blow to Aboriginal peoples, causing a disruption in the intergenerational transmission of Indigenous cultural knowledge, languages, parenting and social care . Three-quarters of the fathers in the research study reported having to address mental health and substance abuse challenges related to developmental trauma -issues that interfered with their ability to remain in relationships with women with whom they have had children. While fathers who volunteered to participate in the study were not necessarily representative of all First Nations and Métis fathers, the healing process needed for many Aboriginal fathers to become positively involved in family life has been documented by First Nations scholars as part of the Aboriginal Health Foundation program of research and the First Nations Regional Health Survey . Fathers in the recent study emphasized the need for health care practitioners, social workers, and teachers to learn about colonial history, the Indian Act, and social policies that continue to affect many Aboriginal children and families and their access to services . Most fathers in the study described how they had no experience of a caring father figure in their lives. Many fathers who were involved with their children described having to 'pull out of thin air' an image of what it means to love and care for a child and to sustain a positive relationship with their child's mother and other family members. Yet virtually all of the fathers, including those who were very involved, described their commitment to 'learn fatherhood' as a lifelong journey of sustaining positive connections with their children and contributing to their well-being. Some fathers expressed their determination to find ways to be involved despite having few resources, such as a comfortable home, a vehicle, discretionary funds, or connections to social or recreational institutions. It is important for practitioners to consider the potential practical barriers to some fathers' participation in child health appointments, hospital care and follow-up routines, and to help fathers overcome these if possible, for example, by linking fathers with patient navigators or assisting fathers with procedures to obtain transportation vouchers. Social barriers may include fathers not knowing what is expected of them when entering a health care facility, visiting hours, meals, possible costs for medications, supplies, and specialist visits, and so on. As well, many Aboriginal people in Canada continue to experience racism and social discrimination; some fathers in the study described feeling unwelcome in off-reserve facilities such as well-baby clinics, child development centres, libraries and even playgrounds. Several fathers reported having been asked by practitioners whether they were related to the child they were with, as if their legitimate accompaniment of the child was in question. Significantly, Aboriginal children are more likely than non-Aboriginal children not to have their biological father identified on their birth record , and Aboriginal child welfare records are more likely not to include the father's name . Many Aboriginal fathers in the recent study perceived a mother-centric approach in mainstream health, social, education and child protection service systems. They identified a need for practitioners to be more vigilant in ensuring that fathers' identity and contact information is included in children's health, school and child welfare records, so that fathers can be notified about critical incidents, informed about care regimens and included in health care decision making, even if this requires extra --- Figure 2) Common impacts of colonial interventions Figure 3) Key strategies for supporting Aboriginal fathers' involvement effort on the parts of health care providers, because fathers may not be coresident with their children and their children's mother. 'We could be the turn-around generation'. This expression of hope was expressed by approximately 40% of the fathers in the research study and also by fathers who participated in a recent national event focused on Aboriginal fathers . Overall, the research study pointed to five avenues for supporting Aboriginal fathers to become the 'turn-around generation', illustrated in Figure 3. --- ConClUsion After so many decades of living in the shadows of Canada's colonial legacies, Aboriginal fathers are calling for more concerted efforts to include them in prenatal programs, decisions about their children's health care and education, and parenting education and support programs. Yet, support for father involvement falls between the cracks of government ministries at the federal, provincial and territorial levels. With no dedicated funding, there are few examples around the country of programs to support Aboriginal men's transition to fatherhood and to provide ongoing father education, encouragement and inclusion. However, more Aboriginal organizations such as Friendship Centres and First Nations communities are recognizing the need to promote fathers' involvement, and there is increasing interest in creating father support and education programs. Many fathers in the study noted, however, that fathers may be looking for different kinds of support than those that appeal to mothers. Rather than starting with peer support groups involving sharing personal stories, a majority of fathers identified the need for concrete information provided in plain language information handouts that could be available in clinic waiting rooms or handed to them by practitioners. Topics they suggested included information about child development milestones, oral health, how to make healthy, affordable meals and snacks, how to get children ready to learn in school, what to expect as children mature, how to support boys and girls through puberty, and where to take children for affordable recreation that can be accessed by public transit. Fathers emphasized that learning fatherhood takes time and, therefore, health care and other practitioners need to be persistent, patient and creative in their efforts to involve Aboriginal fathers. Practitioners need to recognize that some Aboriginal fathers are well prepared to become partners with professionals in supporting their children's optimal health and development, while others may be affected by sociohistorically conditioned socioeconomic, educational and personal limitations. Yet the resilience in the face of adversity demonstrated by Aboriginal Peoples as a whole , combined with Aboriginal fathers' desire to become the 'turn-around generation' by recreating positive roles for Aboriginal men in raising children, are assets that need to be capitalized on in policies and practices aimed at improving Aboriginal children's health and development outcomes.

L inks between children's well-being and their mothers' health, literacy, and behaviours are widely understood and accepted. Canada, similar to many other countries, has made longstanding investments in maternal and child health programs. Yet, both research evidence and conceptualization of the social determinants of health provide a solid rationale for securing fathers' involvement in their children's health and development. Research shows that although children can thrive without a father's involvement, regular contact with a positively involved father is strongly associated with good developmental and health outcomes (1), as shown in Figure 1. Practitioners may agree with the idea of involving fathers in prenatal education and children's health, development and education; however, there has been little policy support, public health program investment, or practitioner preparation to support fathers' transition to parenthood, or their positive involvement. Lack of effort, or success, is especially unfortunate in regard to Aboriginal fathers. There is evidence of poorer health outcomes among Aboriginal children compared with non-Aboriginal children on almost every health indicator (2) and poorer overall quality of life (3). As Grand Chief of the British Columbia First Nations Summit, Edward John has said, "Fathers and grandfathers may be the greatest untapped resource in the lives of Aboriginal children and youth" (4). The present article urges practitioners to recognize the contributions that fathers can make to children's well-being, and to tap into Aboriginal fathers' potential as contributors to the care and development of Aboriginal children. At the same time, the sociohistorically conditioned challenges facing many Aboriginal fathers must be recognized, so that efforts to harness their potential are understood as part of a long-term, multigenerational process of healing and strengthening Aboriginal families.

Introduction The modern world is dominated by digitization in several aspects. From developing countries to developed countries, this binary coding process contributes to the development of a variety of fields. When it comes to digital anthropology, a field of study that emerged during the latter part of the 19 th century focuses on understanding the behavior of mankind in the digital environment. Digital anthropology is a discipline that fits into the division of cultural anthropology. Considering cultural anthropology, religion plays one of the prominent roles. Buddhism is not only a religion but a unique cultural aspect in Sri Lankan social context. This paper is based on these two prominent factors and seeks to understand the evolutionary process in modern-day popular Buddhism, utilizing the characteristics of the era of 4.0. The main objective of this study is to introduce a new model for digital religious studies by utilizing digital anthropological knowledge to understand the digital behavior of Sri Lankan religious contexts. How to propose a model utilizing digital anthropological knowledge to understand the changes in popular Buddhism? is the existing problem of this research. To fulfill these objectives within a framework, the researcher applied one of the prominent factors in modern popular Buddhism, the propagation of Dhamma to examine the characteristics of the modern evolutionary process of Buddhism. Gananath Obeyesekere and Richard Gombrich play one of the leading roles when considering the early works which attended to understand the changes in Sri Lankan Buddhism. Their controversial ideas on "Protestant Buddhism" built novel dimensions in religious studies in Sri Lanka and their theoretical aspects are still utilized by scholars for their academic addresses. Obeyesekere and Gombrich pointed out the change in cosmology and the creation of new religious roles which interconnected matters based on gods and other figures. Although they argued that strictly Buddhist ideas, roles, and institutions have not remained unaffected by the new trends according to that period. Anyhow, their proposed concept called "Protestant Buddhism" caused novelty in the practices of Buddhism and prepared the field for a new term called "Applied Buddhism". Sri Lanka has been conventionally considered a fort of Theravada Buddhism. According to Tilakaratne the organizational aspect of modern Buddhism, the sasana, comprising the four groups of bhikkus, bhikkunis, and upasakas and upasikas, has changed. Pondering the new trends in Buddhism he highlighted concepts like Trans-yanic Buddhism, American Buddhism, and Eco Buddhism . Amunugama underscored the contribution of Anagarika Dharmapala, Piyadasa Sirisena, and John De Silva on the new trends of Sinhala Buddhism as well as the impact of the theosophical society of Olcott. Taking into consideration the main subject emphasized in this paper, Dhamma sermons played one of a significant roles in Buddhism. "He who acts according to the Dhamma is protected by the Dhamma itself" is a popular quote found in the Buddhist teachings of Buddha. Dhamma affects the transcendental life as well as the secular life of a person. According to Thalpavila Shilavansha Thero , there are seven types of Dhamma sermons such as wedding sermons , funeral sermons , title sermons , custom topic sermons , memorable sermons , demons-based sermons , nearby sermons . Other than these types he proposed more types of Dhamma sermons, sermons to monks, personal sermons, general sermons, sermons for girls, sermons to young people, sermons for the elderly, sermons to men, sermons to women, sermons to the learned, sermons to the ignorant, sermons to the urban people, sermons to the villagers, sermons to worshipers, marriage sermons, sermons to warlords, sermons to prisoners, sermons to patients, sermons on paganism, sermons to free thinkers, sermons to separatists, and missionary sermons. He proposed several factors for becoming a popular monk in Dhamma propagation such as ignoring party affiliation, ignoring highs and lows, ignoring self-interest, ignoring provincial divisions, general knowledge, abandonment of sectarianism, abandonment of caste, and compassion . When asserting the historical significance of Buddhist Dhamma sermons, Walpola Rahula Thero stated the importance of choosing "Chullahaththipadopama Sutta" by Mihindu Thero as the first propagation of Dhamma to King Devanampiyatissa, to explain the basis of Buddhist philosophy and religious background. In digital anthropology, there are six principles proposed by Daniel Miller and Heather Horst that underline the characteristics of the concept called digital. Dialectic nature of digital culture, human is not one iota, commitment to holism, cultural relativism and global nature, authenticity of ambivalence, and materiality of digital culture are the respective principles presented by them. As they stated the development of binary code radically simplified information and communication . Considering the development of the digitalization era 4.0 or the fourth industrial revolution is a prominent notion proposed by the works of the German government or on the other hand it is the ongoing automation of traditional manufacturing and industrial practices, using modern smart technology . Various components come under industry 4.0 such as: cyber security, augmented reality, big data, cloud computing, Internet of things etc. Digitalization is one of the key factors which effected the 4 th industrial revolution because when it comes to modern day, innovation has come to have an impact on the way of life of individuals of all ages, from children to working individuals to more experienced individuals . Campbell and Evolvi illustrate the theoretical background and the methodological aspect based on digital religion. They critically emphasize the how digital religion studies seek to investigates the spirituality religiosity in digital space. Sara Pink, Heather Horst and others proposing seven key concepts that can utilized to understand and conduct research on digital environment such as, through experiences, practices, things, relationships, social worlds, localities, and events. Considering the existing gap of this desk research, in Sri Lankan social context various studies on Buddhism were based according to vary of perspectives. Although various studies were conducted on Buddhism and digital era in various other countries, there is a huge lack of Sri Lankan academics in this field of study, especially in digital anthropology. This study aims to fill this gap based on a digital anthropological perspective and Buddhist practice known as Dhamma sermons and focuses on preparing a primary model to theoretically describe the modern evolutionary process of popular Buddhism from the real world to the virtual world utilizing propagation of Dhamma in the fourth industrial revolution. The researcher of this study mainly focused on the changes; and progression caused in traditional Dhamma sermons due to the development of digital technology in the fourth industrial revolution. The results of this study could be applied to other disciplines like sociology, digital studies, and media studies for their examinations on the mentioned aspects. As a theoretical analysis based on existing literature, the proposed model can applied to their studies too while understanding a characteristic of a particular religion in an existing culture. --- Materials and methods This research was based on one of the key principles in digital anthropology "authenticity of ambivalence" proposed by Daniel Miller and Heather Horst in 2012 in their paper titled, "The Digital and the Human: A Prospectus for Digital Anthropology". To examine the validity of this theoretical aspect this paper applies two cases regarding present-day Dhamma sermons based on digital platforms, especially social media which underlines the characteristics of popular Buddhism. These three cases were based on the sermons of Attaragama Pragyalankara Thero, also known as "Kotuwe Podi Hamuduruwo". Both posts were publicly uploaded by different Facebook pages, and they have been selected purposively to accomplish the objectives of the research. The main justification for applying this page was the widespread audience and the content of its posts, also they have a vast number of comments and reactions. The method used in this research was descriptive qualitative and to align with the research objectives, the researcher did not consider the comments of the public on these posts. Focus was regarded with the statements of the Thero and critically analyzed with the literature that was utilized for the research and compared the differentiations in these sermons and traditional Dhamma sermons. After collecting the underlined sayings of the respective monk, the researcher theoretically examined the validity of the previously mentioned principle of Digital anthropology and attended to highlight the evolutionary changes caused by traditional Dhamma sermons in the Sri Lankan popular Buddhism context. Qualitative data obtained from secondary sources were applied for this research. --- Results and discussion It is quite complicated to state precisely when and where the concept of popular Buddhism was established in Sri Lankan academic context. This concept can be assumed to be a residual concept that emerged from popular culture. Though, there is hardly any other religion in the Sri Lankan social structure that is as time and space shaped as Buddhism. Martin Wickramasinghe had mentioned about this cultural formation as, that the independence and spirituality of Sinhala culture was preserved due to Buddhism . According to Daya Amarasekara contemporary Sinhala Buddhism shows that it affects the coexistence as well as the conflict between social and worldly tendencies socially. That complex religious face can be identified only by popular Buddhism. Walpopla Rahula Thero once stated, from the time Buddhism became the state religion, it began to change and his statement indicated that since of that politicization, Buddhism achieved the perfect establishment for long period in Sri Lankan social context. There is no doubt to state that digitization is affecting every aspect of the world, including the cultural factors like religion. The study of pre-literature was a confirmation of the extent to which cultural diffusion has influenced the existing Sri Lankan cultural context. This study does not examine whether that socio-cultural change is good or not, although focuses on the impact of the diffuse influence of digital culture on Buddhism in the so-called era 4.0. which known as 4 th industrial revolution. --- Post 01: Fight like WWF to solve family problems This video has 55 minutes of duration, and more than thousands of audiences were engaged with it. In order to prove the trustworthiness of this post on existing research, the statements can be considered to the comparison of traditional Dhamma sermons and modern ones. Following table contains the statements which underlines the different aspects of modern Dhamma sermons, and the way digitalization affected. Relevant time in the video for these sayings is also mentioned here. Considering his propagation of Dhamma through a particular digital platform, the researcher underlined the significant features that describe the current objective of the study. Popular Buddhism, Dhamma sermons, impact of digital culture can be identified considerably through the following statements collected from the first post. Contemplating the selected sayings of him, researcher underline the different nature in Dhamma sermons comparing to early periods. Not only with his language, according to the content too there is a significant diversity. Comparing with the existing literature, a monk should not be considered about his self-interest. When it comes to the above-mentioned statements there is a quite different pattern in the sermon. Language is one of the prominent factors in traditional Dhamma sermons. Due to various changes in present society language also shifted to various aspects. According to Shilavansha Thero , a monk must advise his people on the importance of Dhamma sermons instead of conquering his own advantages. This phenomenon can be identified in 5.27-time duration, there is a huge variation displayed comparing to early doctrines of Dhamma sermons. When pondering the impact of digitalization to these types of Dhamma sermons, various terms and occasions can be recognized. Lankan political parties. This also a prominent shift compared to traditional Buddhist sermons. From digital anthropological perspective, this event can be examined applying the 5 th principle named authenticity of ambivalence or ambivalence and the principle of openness and closure. It emphasize the contradictions of openness and closure arise in digital domains. Considering Internet, there is a novel openness for the public as well as a limited freedom. This phenomenon can be identified in political as well as the religious context. Digital concept or the digital culture underlines the capacity of production through the openness and accessibility. On the other hand, there is a solid closure and restriction emerged as a tension in digital. Due to these characteristics more than idealized communities, there are cross-cutting affiliations of groups utilizing the internet to think through new opportunities. This new openness was significantly utilized by popular Buddhism, and the falseness or the idealized thinking are not considered as important conceptions due to these new groups which highlight different perspectives and ideas or opportunities of Buddhism. As highlighted early table particular monk's novel statements/ sayings are some of the characteristics that emphasize the tension of this so-called openness of digital. These sayings can be defined as unsuitable or inappropriate statements for a Buddhist monk according to someone's point of view. Although these types of things widely spread due to the support of digitalization and the considerable influence for this trend is the openness of the Internet. --- Post 02: people become couples at Dhamma sermons This video consisted with 14 minutes of duration and was found from a Facebook page which shares different types of posts and not considered as a religious page. Pondering the engagement of the audience clearly identify thousands of reactions and comments. As the first post selected earlier, following are the statements and sayings regarding this post align with the research. Dhamma sermons taking five percepts as example is a prominent custom. Considering the relevant monk's sayings there is a huge difference of explaining this third percept to Buddhist laymen. One of the significant characteristics identified in his sayings are the taking digital cultural terms and concepts. As he states about the mobile package of Hutch, a Sri Lankan telecommunication service provider, and the country's third largest mobile network operator during his Dhamma sermons while explaining five percepts, it clearly highlights the possible impact of digital culture. Likewise, the way he argues about a suicide case connected with Facebook, it comprehensively determines the effects of digital platforms to traditional Buddhist Dhamma sermons. In the principle of openness and closure of digital concept, underlines the capability and the capacity of the production in digital platforms. Since digitalization affects Buddhism, changes and evolutionary features arise and there is no limitation for new ideologies. On the other hand, closure, and restriction too discussed through the 5 th principle. When it comes to Buddhism in digital media there is clear negative and positive feedback from different audiences. This phenomenon is quite similar to the first principle of digital anthropology, the dialectic nature of digital culture. Wijayarathna, Abhayasundere, and Jayaweera stated this principle by utilizing the significant characteristics of Siri Sadaham Ashramaya and its teachings. The way people react to those sayings highlights the closure and restriction of digital. --- Conclusion and recommendations --- Sri --- Siriwattano, P.A., Phrakrukittipatananuyut, Phrakrupaladnattaphon, & Walker, T. . The method and process for establishing a centre for the production of Buddhist digital communication era 4.0 through the cooperation of a group network in Chiang Rai province. --- Proceedings of the

Along with era 4.0 digitalization involves several aspects of modern social context and religion is one of the prominent. When it comes to Sri Lankan popular Buddhism numerous changes can be identified through digital platforms like social media. This research attends to understand the evolutionary patterns of Buddhist Dhamma sermons by applying two cases selected from Facebook. Attaragama Pragyalankara Thero, also known as "Kotuwe Podi Hamuduruwo" is a key figure which emphasizes the characteristics of modern popular Buddhism. Two posts regarding his propagation of Dhamma browsed through random Facebook pages applied to understand the characteristics of the modern evolutionary process of Buddhism. The main objective of this study is to introduce a new-found model for digital religious studies by utilizing digital anthropological knowledge to understand the digital behavior of Sri Lankan religious contexts. For the analysis of this phenomenon, the researcher applied the 5th principle of digital anthropology named, ambivalence, and the principle of openness and closure, proposed by Daniel Miller and Heather Horst in 2012 through their work titled, "Digital Anthropology". Different patterns in language, as well as variations compared to traditional Dhamma sermons identified through literature, were identified from the data collected from the relevant posts. As an examination based on qualitative data, this research considered various literature to fulfill the research gap. One of the key conclusions that arise from the research is that digital anthropological knowledge is a way to understand modern popular Buddhism. Comparing traditional customs with modern-day and analyzing them utilizing digital anthropological principles emphasize the evolutionary patterns of contemporary Dhamma sermons.

| IMPACT OF COVID-19 ON INDIVIDUALS WITH EATING DISORDERS The novel coronavirus pandemic has far-reaching effects on both physical and mental health. Many aspects of the pandemic are already adversely influencing mental health-the disease itself, restrictive policies aimed at reducing the spread of COVID-19, economic consequences, and more. A third of Americans were showing signs of clinical anxiety or depression by late May 2020 . Addressing mental health needs is an integral part of the COVID-19 response . Factors related to COVID-19 will affect mental health in the general community , but may have greater adverse effects on individuals with pre-existing mental illnesses . Reports from China suggest that those with psychiatric illnesses before COVID-19 experienced a worsening in depression, anxiety, and post-traumatic stress symptoms during the peak of the outbreak . Individuals with eating disorders may face unique risks secondary to the pandemic. Public health measures designed to flatten the curve, and the impact of COVID-19 on food availability may directly and adversely affect the core symptoms of eating disorders, including dietary restriction, binge eating, and compensatory behaviors. Interviews with patients highlight issues such as intense urges to binge in those with binge-eating disorder when high-risk foods are being stockpiled to guard against disruptions to the food supply, anxiety about food availability for those with anorexia nervosa or avoidant/restrictive food intake disorder , and changes in the availability of treatment and social supports, isolation, and economic factors interfering with treatment progress or precipitating relapse . Specialist clinicians have highlighted the importance of attending to the unique needs of patients with eating disorders during this time and introduced potential adaptations to existing evidence-based interventions in inpatient and outpatient levels of care. However, the need for data-driven information from individuals with lived experience is urgent to guide clinicians in how best to deliver needed services. One study surveyed 32 patients with eating disorders in Spain about the impact of physical distancing measures during the first 2 weeks of confinement. They also reported qualitative data from a multifamily chat group in the United Kingdom consisting of eight patients with AN and their carers . Patients in both groups reported exacerbation of their eating disorder symptoms, increased anxiety, and challenges associated with reduced contact with their treatment teams, suggesting that patients with eating disorders may be at risk for symptom exacerbation and/or difficulty maintaining treatment progress during the global pandemic. The objective of this study was to characterize the impact of COVID-19 on patients with self-reported eating disorders and to describe their treatment needs. Resultant data will inform best practices for clinicians and caregivers and provide a roadmap for eating disorders care during the evolving pandemic as well as other catastrophic events that could interrupt direct service delivery. --- | METHODS --- | Participants and procedure Participants from the United States and the Netherlands were invited to take part in an online study. US participants were recruited via social media , or via emails to participants who consented to recontact from ongoing studies . NL participants were also recruited via social media and Involving Human Subjects Act did not apply to this study and official approval of this study by the METC was not required. --- | Measures The online survey addressed concerns and challenges participants are facing with regard to their eating disorder and general mental health during the COVID-19 global pandemic. The survey was developed in English, and translated to Dutch . The survey was administered using Qualtrics in the US and SurveyMonkey in NL. In the US, the Qualtrics survey options limiting responses to one per IP address and preventing indexing were enabled. --- | Sociodemographics and illness status Participants reported their age, sex, gender identity, and geographic location . Lifetime eating disorder diagnoses and current illness status were self-reported. --- | COVID-19 exposure and situational circumstances Several questions captured COVID-19 exposure and level of lockdown such as quarantine, physical distancing, voluntary or mandatory isolation, working from home, and shelter-in-place/stay-at-home orders. --- | Impact of COVID-19 on eating disorders Questions about COVID-19-related concerns on eating disorders captured the previous 2-week timeframe. A 4-point Likert-scale asked participants to rate their level of concern about access to and affordability of food and treatment, and worsening of eating disorder symptoms due to a lack of structure, changes in the social support environment, and time spent living in a triggering environment. The survey also assessed the impact of COVID-19 on specific eating disorder symptoms . These items were combined to create a mean impact score . Free-text items queried details on additional eating disorder-related concerns and any positive changes in their eating disorder or symptoms associated with the pandemic . --- | Impact of COVID-19 on general physical and mental well-being A 7-point Likert scale addressed the extent to which participants were worried about exposure to and/or contracting COVID-19. Relevant domains included: worry about self or others, worry about physical and/or mental health, and changes in overall anxiety levels since the start of the pandemic. Principal components analysis suggested these items loaded onto one component, so a total worry score was calculated . The Generalized Anxiety Disorder 7-Item Scale assessed anxiety symptoms, and has demonstrated excellent psychometric properties . A score ≥10 is a positive screen for GAD . The survey also assessed whether participants had experienced a change in their levels of anxiety since the end of 2019, whether this change was due to COVID-19, and any positive changes in their lives related to COVID-19 circumstances. --- | Impact of COVID-19 on eating disorder treatment We assessed COVID-19-related changes to eating disorder treatment modality, and for those currently receiving treatment, the frequency of sessions/contacts and perception of the quality of treatment. One free-text item inquired about the participants' perceived greatest treatment needs. --- | Statistical analysis Data from the US and NL were analyzed separately. We first report descriptives of the demographics, clinical characteristics, and COVID-19 exposure and situational circumstances. We assessed the different sections by a descriptive analysis of the quantitative survey items. We then conducted oneway analyses of covariance to explore differences between groups on continuous items from the various questionnaire sections, controlling for biological sex , age, and day of study enrollment. Logistic regression was used for nominal variables. We used the following category definitions for group comparisons: although individuals could indicate as many eating disorders as they have experienced in their life, in currently ill participants for the purposes of analysis we created hierarchical lifetime diagnostic categories (i.e., a person was only included in one category in the order of AN, BN, BED, other eating disorders As the a priori goals of the study were to conduct a broad analysis of areas of concern of patients with eating disorders in order to inform providers globally about healthcare service needs, we intentionally did not correct for multiple comparisons. The US and Dutch free text responses were coded independently . All responses to each free text question were reviewed, counted, and grouped into categories, which were then grouped in themes. Themes were then ranked based on the number of individuals providing comments in that theme. Given our goal of providing strictly descriptive results, we did not undertake formal efforts at establishing a coding scheme. --- | RESULTS --- | Quantitative results --- | Sociodemographic and illness characteristics Table 1 presents demographic information for the US and NL samples, which were very similar. The mean age was young adult, ranging from 16 to over 60, and participants were predominantly female, and currently ill or symptomatic. US participants were well-distributed from across the country . In both countries, the majority of participants reported a diagnosis of AN. The next most common lifetime diagnoses were BN, BED, atypical AN, and other specified feeding or eating disorder/eating disorder not otherwise specified , with different distributions between countries. Less common were ARFID, purging disorder, and night-eating syndrome. A full 56% of US and 34% of NL participants reported multiple lifetime eating disorder diagnoses, consistent with the known diagnostic fluctuation of these disorders . Slightly over half of participants in both samples reported being in treatment when COVID-19 struck. We excluded sex as a covariate for NL analyses, because of the small number male participants. --- | COVID-19 exposure Table 2 presents information on extent of exposure to COVID-19. In the US, virtually all participants had been impacted by COVID-19 with 99% reported practicing physical distancing. Only 1% reported having a COVID-19 diagnosis, but many more reported some degree of selfisolation, quarantine, or working from home. Seven percent of respondents reported family members who had been infected and 25% reported a family member having lost employment due to COVID-19. The Dutch sample showed a similar pattern-98% reported practicing physical distancing and between one third and half of the participants reported voluntary self-isolation or working from home. In NL, 2% of the respondents reported having a COVID-19 diagnosis, 13% reported family members who had become physically ill, and 6% reported a family member having lost employment. --- | COVID-19-related impact on eating disorder illness We describe the results for the whole sample combining those who endorsed "somewhat" or "very concerned" on items about eating disorder concerns and "frequently" or "daily or more" on items about eating disorder illness behaviors . The most prevalent concerns were parallel in both countries. Foremost, 79% and 66% of respondents were concerned about worsening of the eating disorder due to lack of structure. Furthermore, respondents were concerned about worsening of the eating disorder due to being in a triggering environment or lack of social support , and being unable to access food consistent with their meal plan . Concerns about having access to enough food or not being able to afford food or treatment were less commonly endorsed in both countries. T A B L E 1 Descriptive data showed that the greatest impact of COVID-19 on eating disorder behaviors for US participants was in the domain of feeling anxious about not being able to exercise . This question was not asked of NL participants. Over one third of participants in both countries reported worsening of dietary restriction and compensatory behaviors. Regular binge eating on stockpiled food was reported by 23% of respondents in the US and 14% in NL. Individuals with past eating disorders also expressed concerns. These --- Comparisons in lifetime diagnostic subgroups In both countries, many group differences emerged on the eating disorder concern and illness behavior questions that were generally consistent with diagnostic characteristics . For example, the AN group reported significantly greater concerns about accessing foods consistent with their meal plan and a greater worsening of dietary restriction. The BED and BN groups reported more frequent binge eating of stockpiled food. The results on the individual items are shown in Tables S2 andS3. --- Comparisons by treatment status Participants self-reported their treatment status and results are shown in Table 6. In the US, participants who reported difficulty accessing their treatment provider reported higher mean eating disorder impacts compared to those who reported that they had received face-to-face or online/tele-health treatment , F = 6.94, p = .01. In NL, there were no differences between these groups , F = 0.12, p = .91. Notably, 47% of patients in the US and 74% in NL rated their treatment in the last 2 weeks as somewhat or much worse than usual. --- Other comparisons Comparisons of eating disorder symptomatology by illness status and level of lockdown can be found in the Supporting Information. were 12.61 and 11.83 , respectively. The majority of participants reported an increase in anxiety levels since the end of 2019, and only 0.2% and 3% of this group reported that this change in anxiety was not at all due to COVID-19. --- | COVID-19-related impact on general physical and mental well-being --- | COVID-19-related impact on eating disorder treatment Table 6 presents treatment status over the past 2 weeks . Most respondents had transitioned to online/tele-health care , with smaller numbers still receiving face-to-face care , or not having been able to engage with their provider at all . Consistent with the literature, high numbers of respondents were not receiving any eating disorders treatment . Comparisons of the impact of COVID-19 on eating disorder treatment by diagnostic subgroup and level of lockdown can be found in the Supporting Information. --- Comparisons in currently ill versus past ill individuals In both countries, participants reporting a current eating disorder (US N --- Comparisons by treatment status Among those who were receiving treatment, there were no significant differences in mean worry score between those who reported that they had not been able to engage with their treatment provider at all Note: Percentages on available data are given. US missing data on the first item in the table was 1.4% ; the next two items were applicable to only those in treatment and were answered by 240 and 238 participants, respectively. NL missing data on the first item in the table was 4.3% ; and the next two items were both answered by 235 participants. Abbreviations: NL, Netherlands; US, United States. T A B L E 7 Summary of themes obtained from qualitative data : United States In the past 2 weeks, have you experienced any positive changes in your eating disorder symptoms? In Comparisons of the impact of COVID-19 on general physical and mental well-being by lifetime diagnostic subgroups and level of lockdown can be found in Supporting Information. --- | Qualitative results A series of open-ended survey questions asked participants to 7 and8). A positive consequence of the changes due to COVID-19 reported by respondents was a perceived increase in social support that helped challenge their eating disorder behaviors and increase motivation to recover. Their greatest treatment need was for more --- | DISCUSSION We describe the early impact of COVID-19 and treatment needs in patients with self-reported eating disorders in the US and NL. At the time of the study launch, the US had been in some degree of lockdown for approximately 3 to 5 weeks. In NL, restrictions had been underway for approximately 1 month. Although fairly few participants were directly affected by COVID-19, the overwhelming majority were indirectly affected, anxiety levels were elevated, and concerns were high regarding the impact of COVID-19-related factors on their eating disorder and on their mental health in general. Consequences of the lockdown measures-a lack of structure, increased time spent in a triggering environment, lack of social support-were common concerns. Additionally, worsening of eating disorder behaviors was broadly consistent with respondents' selfreported eating disorder diagnosis . US participants were particularly anxious about not being able to exercise. Of note, even those who were not currently symptomatic endorsed some degree of concern indicating a heightened vulnerability for relapse. Our results align with other studies showing worsening anxiety during COVID-19 . Mean GAD-7 scores were substantially higher than typical in the general population during nonpandemic circumstances , but on par with scores in both general psychiatric disorder and eating disorder samples . To our knowledge, GAD-7 has not been assessed in the general population in the US or NL during the COVID-19 pandemic for comparison. Encouragingly, more than one-third of participants identified that COVID-19 had led to positive changes in their life. Many reported a sense of connection with family and friends, an ability to focus on recovery-oriented goals, and engagement in adaptive coping skills. That respondents were able to name positive effects of this pandemic in addition to acknowledging the deleterious effects it has had on their eating disorder highlights the complex nature of individuals' experiences. We were particularly interested in ascertaining participants' perceptions of treatment during COVID-19. Unfortunately, nearly half of both samples reported not currently receiving treatment for their eating disorder . This is consistent with many previous reports indicating that eating disorders are often underdetected and undertreated . For those who were in care, most had transitioned to telehealth services at a similar frequency to previous face-to-face sessions. However, the transition was not without challenges. In our sample, 47% of US respondents and 74% of NL respondents reported that the quality of their treatment had been "somewhat" or "much" worse than usual. It is not clear what influenced this perception, and we underscore that the survey was deployed at a time when many clinicians were just making the transition to remote care. Follow-up surveys will allow us to address whether quality of remote care continues to be a concern. To our knowledge, this is the first large-scale study to capture concerns of individuals with eating disorders during COVID-19. Our rapid deployment had limitations. First, eating disorder diagnoses were self-reported as interviews were not feasible in the timeframe. Second, despite many striking similarities, differences between the US and NL emerged in terms of sample composition as well as the countries' approach to pandemic control-with the NL strategy being more comprehensive and uniform and the US being more fragmented. Moreover, differences in these strategies and stage of the pandemic at deployment could affect responses. Our use of convenience sampling could introduce bias, as individuals who were most worried/concerned might be more inclined to participate. Some of our questions may have used language that could be interpreted in multiple ways such as "triggering environment" and "lack of structure." We also mistakenly omitted the question on race/ethnicity, which we will critically include in subsequent waves, especially given the disparity in COVID-19 outcomes across racial and ethnic groups . Finally, our use of predetermined questions, did not allow for an unbiased survey of respondents' concerns; however, we hope that the inclusion of free text questions encouraged sharing of both negative and positive experiences. Although outside of the scope of the present study, given that many individuals with eating disorders returned to their families of origin during lockdown, it would be of value to document the impact of COVID-19 on carers' and family members' experiences particularly with relation to stress, burnout, mealtimes, and healthcare provider support. In summary, individuals with eating disorders may be experiencing a worsening of symptoms and those with past eating disorders may be vulnerable for relapse during COVID-19. Although these data are primarily descriptive, we aim to provide preliminary guidance to healthcare providers about ways in which --- DATA AVAILABILITY STATEMENT Data availability: Data will be made available at the end of the 12-month follow-up period via the Open Science Framework. --- CONFLICT OF INTEREST C. M. B. reports: Shire ; Idorsia ; Pearson ; C. M. P. reports: Sunovion . --- SUPPORTING INFORMATION Additional supporting information may be found online in the Supporting Information section at the end of this article.

Objective: We evaluated the early impact of COVID-19 on people with self-reported eating disorders. Method: Participants in the United States (US, N = 511) and the Netherlands (NL, N = 510), recruited through ongoing studies and social media, completed an online survey that included both quantitative measures and free-text responses assessing the impact of COVID-19 on situational circumstances, eating disorder symptoms, eating disorder treatment, and general well-being. Results: Results revealed strong and wide-ranging effects on eating disorder concerns and illness behaviors that were consistent with eating disorder type. Participants with anorexia nervosa (US 62% of sample; NL 69%) reported increased restriction and fears about being able to find foods consistent with their meal plan. Individuals with bulimia nervosa and binge-eating disorder (US 30% of sample; NL 15%) reported increases in their binge-eating episodes and urges to binge. Respondents noted marked increases in anxiety since 2019 and reported greater concerns about the impact of COVID-19 on their mental health than physical health. Although many participants acknowledged and appreciated the transition to telehealth, limitations of this treatment modality for this population were raised. Individuals with past histories of eating disorders noted concerns about relapse related to COVID-19 circumstances. Encouragingly, respondents also noted positive effects including greater connection with family, more time for self-care, and motivation to recover. Discussions: COVID-19 is associated with increased anxiety and poses specific disorder-related challenges for individuals with eating disorders that require attention by healthcare professionals and carers.

Introduction Technological innovations have changed domestic work dramatically since the beginning of the twentieth century in every country and context where these modern shifts applied. These have happened in tandem with changes in the position of women in society affecting relationships between women of different social classes and between women and men. These concerns are topical in view of discussions about migration movement of women informing current globalization debates. These movements have been partly fuelled by the employment by better off households in richer countries of women domestic workers from poorer countries. In Brazil, wealthy homes have always had large amounts of cheap domestic labour available to 'import' from poorer areas. How is this practice configured in relations of inequality in the country? What effects does it have on household technologies consumption? How are deeply entrenched social differences in the home lived with on a daily basis and justified? The exploration of these issues in this paper aims to contribute to further reflection about the 'global woman' debate. Bridget Anderson's study of the politics of domestic labour in contemporary Europe shows the predominance of racialized groups in paid work in the home and calls attention to the pernicious effects this employment has on relations between middle-class women and men who thus avoid both conflicts and challenges to their entrenched gendered positions of inequality. Anderson's perceptive study points to the gender and generational conflicts implicated in the employment of a person to do domestic tasks. She argues that the employment of paid work in the home creates particular sorts of relationships developing personhood, not just as a worker but also as an employer, and entailing particular sets of gender relations. Central to the construction of personhood is the consumption of care in the buying and selling relation. Anderson argues, following Arlie Hochschild , that as women flee from home into outside employment no one is left to care. The 'new' domestic workers thus fill this gap. Yet, while the argument for the centrality of the need of 'buying love' in the new domestic labour contracts is doubtless important, the material dimensions of this work, which remains arduous and lengthy, need to be kept in focus. There are many reasons for considering the emotional and the material dimensions together. One relates to how they both link with unequal relationships predicated on positions of class, gender and race. Another refers to cultural needs of material and emotional care, demanded within particular 'moral' environments justifying particular patterns of relationships in domestic life. One other salient reason refers to concrete material conditions related to demands of contemporary lifestyles. In this paper I focus specifically on the reasons I call 'ordinary morality', and on how housework technologies are deployed, as part of the materiality of ways of living. These are explored within the specific configuration of relationships of class, gender and race prevailing in Brazil. I argue that a major implication of the widespread use of paid domestic work is to hinder technological developments for housework. This crucial political outcome has been neglected in feminist debates about domestic labour. Women and homes remain marginal to technological innovation concerns . The cost of women's domestic labour is central to these developments. While technological modernization in machines for housework is uneven at a global scale, different levels of availability of domestic workers play a significant role in the differentiated patterns of innovation across regions. Yet, domestic labour availability is not simply a numerical concern. The ways in which the social relations implicated in its deployment are justified constitute the moral context enabling its use as resource for the social position of those able to pay. The material and the moral are interlinked. On the basis of participant observation, secondary data and a case study in the south of Brazil I discuss maids, machines and moralities in households. The ethnographic study was carried out in 1997 in the Southeast of Brazil, in the affluent region of Greater Campinas, in the State of São Paulo. The study centres on the differences between poor and middle-class homes regarding women's work and the gendered domestic divisions of labour, with a particular concern with how paid domestic work affects the division of labour in households and the consumption of household technologies . There was no intention to produce a representative sample of the population in statistical terms. But I wished to capture the relationships of women and men with domestic labour, and I wanted to include a wide range of social experiences of this kind. Families were selected according to their significance for theory, ideas and concepts. I carried out participant observation and 55 semistructured interviews in 30 families. All families had dependent children, 22 of them included children of school age . Women defined themselves as 'housewives' in 9 households. 21 families self-classified as white. The Brazilian case has some parallels with those in more developed countries. For instance, in Britain the growth of female employment, particularly that of married women, has, like in Brazil, been sharp since the 1970s. In a longer historical trend, UK consumption of technologies for the home grew enormously in the 1930 when domestic servants were fast disappearing . But does the Brazilian trend reflect a process towards greater equality between women and men, and among women, broadly similar to those in developed countries? How have women's jobs outside the home affected the patterns of domestic living? What has happened in Brazilian homes when women have in growing numbers taken on outside employment? As paid domestic labour becomes an increasingly significant feature of middle-class home life in contemporary Europe and North America through processes of the displacement of the poorer women across the globe, an exploration of the Brazilian case is illuminating. --- Contradictions of economic development within Brazil have resulted in great disparities of wealth which somewhat mirror the patterns of inequality in the context of home life of the international contexts involved in the domestic work world exchanges on a global scale. Brazilian specificities also remain. --- Maids In Rio de Janeiro, in the Southeast of Brazil, Maria, the maid, stepped out of the kitchen at 1pm bringing food to the table. Ronaldo, Anita, and their children, Fernando and Manuela , sat around it. So did I, as a friend of Anita. We had a salad for starter, four hot dishes to choose from, two desserts, and cold and hot drinks. It was a normal weekday. When the meal was finished, everyone moved on to their personal affairs and the table was left for Maria to clear. Maria lived in a small bedroom in a secluded part of the house adjacent to the kitchen. This was the 'service area' where laundry, ironing and cooking was done hidden away. Maria was only seen when she served water, coffee, at meal times, or while she quietly and unobtrusively made the beds, mopped the floors, and cleaned the bathrooms in the morning. Maria was up before 7am to serve breakfast, and she was still up at 9pm clearing the table after dinner. Maria came from the Northeast and had been working for Anita for about 10 years. Anita relied on Maria for all the housework. Anita was an academic, like me. She worked on poverty and land reform in the Northeast. She would never consider her everyday life without 'a' Maria. She did not engage with my attempts to converse about servants and their social inequalities. Anita was Brazilian. All the people in this scenario are white. In Recife, in the Northeast of Brazil, Vanya went shopping with Janice, her cook. Janice pushed the trolley, picked up the goods, and placed bags in the car. Vanya told Janice what to buy, paid and drove the car. At home Janice removed bags from the car and put the goods away. The living-in nanny, Teresa, looked after 5 year old Julian, keeping him out of the way so that Cida, the cleaner, could get on with her jobs. I was a friend of Vanya, staying for a few days. I could not even make myself a cup of tea or get a glass of water from the kitchen. Whenever I stepped in through the door a servant offered to attend to my needs. Vanya was an academic, like me, working on sexuality and 'race'. She could not imagine a life of looking after children, doing housework, relating to a partner and researching in 'culture' without 'a' Janice, 'a' Teresa and 'a' Cida. Vanya was English. Everyone in this scenario is black except for my friend and I. These are two stories of people with widely varying cultures and social positions. All were immersed in a world of deep social inequality. Anita alone earned ten times more than she paid Maria. Maria worked very long hours, had no pension, house or security. They were the same age. Vanya paid her three servants together in Recife as much as Anita paid Maria alone in Rio. This was why Northeastern Maria was grateful to have her Rio job. Both Anita and Vanya had husbands who earned quite a lot more than they did. The income of each one of the families was about 40 times higher than their servants' wages. The husbands were seen by Anita and Vanya as sensitive men, good providers, and supporters. They did no housework or childcare. But then… even I could not get myself a glass of water without having it offered to me on a tray! Why was it so easy for my well-off friends to live a 'comfortable' life with such social inequalities crying out from within their homes? The ease of access to the labour of others obviously derived from economic inequalities. But the moral issues also appeared significant. How was this seen as a 'proper' way of running homes? What political consequences did it have for wider economic and social contexts? Moreover, how could these practices coexist with contemporary transformations of women's position in the labour market and in society? One of the most significant changes in Brazil since the 1970s has been the increasing participation of women in the labour market. This is linked to economic necessities and employment demands, but also to demographic and cultural changes like a reduced fertility rate and increased education. Already in 1995 40 per cent of the Brazilian workforce was female. This rate was 45 per cent in the more developed São Paulo Metropolitan Region in 2001 . In 2005 there were 53 per cent of women in the economically active population . The increase has been greater in urban areas and in the most developed regions. Married, co-habiting and separated women have played a bigger part in the employment rise than single women. The proportion of married women working has been more than half since 1993 . Ethnicity has strongly shaped the place of women in the employment structure. A recent study by the International Labour Organization, based on data from Brazilian national statistics , shows that the difference between black and white women employed as 'domestics' is large: 24 per cent of blacks against 14 per cent of whites . Yet, the proportion of all women employed in domestic labour has decreased, particularly in the more developed urban areas, where this kind of employment has been more prominent . In a related development, the consumption of technologies for housework has grown since the 1960s . The consumption of these technologies relates to increased purchasing power, lower prices of goods, changes towards smaller family units, and also to different ways of dealing with housework demands. In terms of levels of wealth, colour of skin, and employment of domestic labour, the households in my study show a striking picture of inequality and subordination in the home. Skin colour grows whiter as the income level increases. The employment of paid domestic help increases with income and the whiteness of the skin. Figure 1 indicates that the place of individuals in society and their access to the labour of others appears firmly based on income class. The proportion of families in each level of income in this study is far from being statistically representative. There is a deliberate larger intake of higher incomes because of a concern with the effects of paid domestic service on the gender division of labour and on inequalities in the home. For Brazil as a whole at the time of my study, more than 50 per cent of the population earned below 2 minimum wages , with just 5 per cent earning more than 10 minimum wages . The region investigated is one of the most affluent in Brazil, with a population affording much higher incomes than for the country as a whole. Thus, it is to be expected that a statistical representation of these variables would show a staggering disparity of what is here qualitatively represented. I indicate five income categories to grasp the gradient of very high wealth disparity. All the paid domestic help were females. --- Figure 1 The majority of women in these households had employment outside of the home. Seven had no earnings and two earned only very small amounts, one from childminding and another from architectural design. All of them were mothers of small children and five of them were lone-mothers. They mostly had busy daily schedules. Women contributed half or more of the household income in over onethird of the families. There were only four women who were sole household earners , and they were all in the low-income group. Three of the women in the low-income group worked as maids in wealthier households. These were the only three maids included, in their home contexts, in this study. 1 Women's income was absolutely significant for the economy of their households when in the low-income group, but it was also important in the middle-high and upper-low income households. Despite this, the woman's income did not change her status in the home in any significant way. This is confirmed by Cynthia Sarti's , study of poor families in São Paulo, who argues that the distribution of 'authority' in the family was based on the different, and traditional, roles of men and women. However, in the families I studied, it was often the woman's income that objectively positioned the household in a higher income category. It was only in the middle- income households where women who did not earn any income were found. In the middle-low income group a more conservative household strategy of having a sole earner was stronger. Although women earned fairly well in the upper-high income group, their income did not make a great difference to the wealth of their homes. Men earned sufficiently high incomes by themselves in this group. Overall, the significant participation of women in the labour market did not reflect an equally important contribution to the financial resources of the household: women's earnings were most important when hardship was greatest, but it made no significant impact on overall wealth levels within the best off group. The everyday routines of the women in the wealthier households , that employ domestic labour, appeared fairly disengaged from their children's routines. Well-off mums' childcare activities involved taking to and picking up from school, feeding in the evening and putting into bed. Getting children out of bed, and feeding them breakfast and lunch was predominantly done by maids or nannies. In one of the homes the maid had to spoon-feed a pampered 4-year old, but the mother did not count this among the household caring activities. Children in upper-low and upper-high households ordered maids to do things for them, and expected their whims to be fully attended to, or they 'would tell off' the maid. For a group of privileged children a culture of expectation of being serviced by a lower class person has been part of their growing up. There are basically three ways in which women who do household work without pay can attempt to diminish their burden. One is by employing someone else to do the work, or some of it. Another is by putting pressure on the state for the provision of some public services to lessen this work. A third way is by deploying household technologies to facilitate the work. These three strategies can be combined. This paper considers the first and third, as the research found no evidence of housework burden issues being pressed upon governments either at a local or national level. However, I reflect about government intervention in domestic service in the conclusions. --- Machines Ownership of household technologies has increased sharply in Brazil. All the families I studied had cooker, fridge and washing machine or equivalent . However, there were estimates that in the mid-1990s, only 75 per cent of Brazilian homes had both fridges and cookers . These are universal household goods in countries such as Great Britain and the United States. The washing machine owned by 1/6 of the families was of the most basic kind, called tanquinho. This is a 4kg capacity washtub, which fills automatically with water, has a bleaching agent compartment, but no soap dispenser, and switches off automatically. It does not spin dry. Five of the six poorest families owned a tanquinho, while four more tanquinhos were owned by middle-low income households and another four by those of middlehigh income. However, the two later groups also owned older washing machines, which were used to spin dry clothes washed in the tanquinhos. Only the two upperincome groups did not own any tanquinho because they had access to better quality washing machines. Clearly the job of doing the laundry is more difficult with lower quality equipment. Wringing clothes by hand, or transferring from tanquinho to spin, increases labour considerably. But ownership of good quality technology did not necessarily mean ease the household tasks of all concerned. Figure 2 In two homes, two cookers were in use. In the Montes household the newer cooker had been a present from the man's mother. It was installed opposite the old cooker, which was used for frying and for making 'dirtier' or longer cooking foods. At the Oliveira's two kitchens were installed. A new fully fitted kitchen had been built and the old one had been transferred to an area of the 'service house', where the maid cooked. But the fridge had not yet been installed, and the maid needed to walk about 10 meters between the cooker, where she cooked in the 'service house', and the fridge, in the new kitchen inside the house. This had been her daily routine for six months. After washing up manually in the 'service house' the maid transported plates, pots and cutlery to the new kitchen where they were kept. The new kitchen was used only on weekends, by the woman of the house. While this use of two kitchens is exceptional, it has a curious historical counterpart. In colonial times, when slavery prevailed, in the better-off homes, it was common to have two kitchens. The 'clean' kitchen was located inside the house, the 'dirty' kitchen outside. In the 'dirty' one, laborious sweets and desserts were cooked, and the heaviest and less hygienic tasks were carried out. One explanation for this spatial division of cooking activities has emphasized that, contrary to Europe, where the heat of the hearth provided cosiness, the Brazilian climate made the range an object that was undesirable in the domestic space . However, there are references that even in the very cold South proper cooking was done in small tents built in the back yards of houses , an explanation that may suggest that external kitchens aimed to provide a spatial separation that reflected the social divisions between masters and slaves , which echoes maids and employers' relations nowadays. As Rita Oliveira says: 'I have built an outside kitchen for the maids to use because I got tired of having my kitchen scratched… They [the maids] wrecked it all.' The ways in which the performance of everyday domestic tasks is made easy or difficult, reflect unequal social divisions. For instance, it was accepted that electricity should not be used if it could be substituted by the labour of maids, and also it was widely perceived that maids could damage household technologies if they were allowed to use them. Many stories of damage, or of protective strategies by the mistresses, were told. From a sociological and economical point of view the rationality of such practices rests on both the low labour cost of maids and the relatively high cost of electricity and technologies. Underlying these reasons there were also the lack of skills to operate machines due to low literacy, and the absence of training in the operation of technologies for those very persons who should in fact be their main users: the maids. The women employed to do housework in homes with everything were unable to make use of the equipment designed to make housework easier, better, more efficient. This technology was predominantly used on weekends, when access to the labour of servants was not available. The current use of labour is careless and wasteful because it is cheap and abundant. Training is not provided, tasks are not made easier. These practices are informed by the social morality prevailing in the country. --- Morality How are people involved in, and how do they justify their practices, when they seem to be stuck in places of deep social differentiation? I explored the 'ordinary morality' of domestic labour through the application of a vignette to participants in my study. My concern was with a particular morality -or ethics of care. As defined by Tronto , this refers to moral sentiments, not to reason. It is a morality of the daily experiences and moral problems of real people in their everyday lives. In practical terms my method involved reading a vignette story to an interviewee, and asking their opinion about what the characters in the story should do. I applied four vignettes in this study. The moral reasoning portrayed by the one I present in this paper is mirrored in the other three, even though each of them addresses different dilemmas of everyday home life. I talked to each adult separately. The vignette explored here is a long one about a family's relationship with a maid. I used a method of building in a temporal dimension and altering the circumstances of the characters at a latter stage. Respondents were invited to make a choice about what 'ought to' happen in the first, second and third stages. This increased the complexity of my story. The vignette story usually triggered the telling of further related stories about the respondents, their friends and families. The assumption built into this method is that meanings are social and that the choice of a particular action brings out both the personal and the public morality of relationships . The story is a hypothetical situation based on real life occurrences. The context is typical of Brazil and the language reflects relationships and taken-for-granted assumptions about the roles of individuals. For instance, to address a maid by Dona before her name is often a sign of respect indicating that she is older, but it can also carry an idea of affection or mark a social distance. A man who looks after his son with the assistance of a full-time living-in maid is clearly not doing it on his own. When the story says he does do so, it colludes with the invisibility of the maid's job. Respondents can either remark on this or agree with it. Isabel and Sérgio had a 7-year old son, Pedro. They lived in a big and comfortable house. They both had full-time jobs and a maid, Dona Margarida, had been employed for 4 years. Dona Margarida looked after the house and Pedro, sending him daily to school; and she was an excellent cook. She lived in the house and had Saturdays and Sundays off. Isabel died suddenly and Sérgio had to look after Pedro on his own. Dona Margarida worked as before. Sérgio and Pedro never cleared the table, washed up, or made beds. They took a shower in the mornings and left their damp towels on the bathroom floor… It was always Dona Margarida who looked after everything. And now she looked after some of the things that Isabel used to do. Her work increased and she was tired. Do you think that Dona Margarida should: • Ask Sérgio for a wage increase. • Ask Sérgio to hire a helper for her. • Leave the job. • Ask Sérgio and Pedro to do some of the tasks that Isabel used to do before. Respondents who were poor tended to identify with the maid but feared that she should not leave the job, since jobs were difficult to find and the orphan boy was attached to her. Because she was clearly important to the family she should hint at a need for compensation for her increased effort. As a priority she should mention the need for a helper, but she should take what the boss would choose to give her: either help or wage. Better-off respondents tended to emphasize the emotional attachment. More than half of the respondents suggested that the maid should ask father and boy to do the tasks the late mother used to do, while nearly half of them did not remark on the fact that Sérgio and Pedro created some new tasks for Dona Margarida. However, the well-off were more likely to suggest that father and son should do some of the tasks, while most low-income women said Dona Margarida should have a helper. Perhaps these women believed that the practical 'help' the maid could get from Sérgio and Pedro was not going to be very effective. Only one person, a man, said the maid should leave the job. Independently of the respondent's choice, I carried on with the vignette, unfolding the story. Dona Margarida asked for nothing, and carried on doing her job and getting tired. One year later Sérgio got a girlfriend, Cléia, who came to live in the house. Dona Margarida's work increased because Cléia did the same as Sérgio and Pedro. And Cléia and Dona Margarida did not get on well. What do you think Dona Margarida should do? • Ask Sérgio for a wage increase. • Ask Sérgio to hire a helper for her. • Leave the job. • Ask Sérgio, Pedro and Cléia to collaborate by doing some tasks. In this second episode, I presented the situation unfolded one year later. This contradicted some respondents' previous opinions. I deliberately portrayed a maid of submissive character, in order to test the morality of the command -submission relationship since my key concern was with how relations of inequality were perceived and dealt with in the home. This does not imply that servants in Brazilian homes are all submissive like Dona Margarida appears in this vignette. Indeed, many practices of resistance are also found, described by Jurema Brites as subtle tactics of insubordination, which include 'borrowing' without permission clothes from employers and stealing food or objects. In the vignette, the maid carried on as before, never making any demands or letting her boss know that she felt overburdened. The new girlfriend, living in the house, acted just like father and boy. The maid's work increased. I invited respondents to say what Dona Margarida should do, repeating the same alternatives as before. The gender dimension became relevant this time. The most common reply now, mostly by women, was that the maid should leave the job. This was because a potential substitute mother had emerged, changing the situation and creating conflict. Dona Margarida was then freer of the inputed emotional ties. Interestingly, unlike in the first situation, now those with higher income predominantly said that Dona Margarida should leave the job, underlining the gender dimension of care in which the girlfriend could substitute for the emotional labour of the maid, and confirming the caution of poorer respondents about losing a job. I then carried the story further to a final episode where the maid chose not to ask for anything but one year later lost her job due to growing conflict with the girlfriend. However, Dona Margarida found another job at a neighbouring house. Six months later Sérgio got in touch asking her to return: he had broken up with his girlfriend. I did not offer any alternatives as answers, but asked again: What do you think Dona Margarida should do? Some respondents thought she should now remain where she was, but more than half, in similar proportions by gender, thought she should return to the old job because of the emotional ties with the boy and his father. 'She cannot abandon the child because she loves him. She should go back because of the boy -he's like a son… But ask for a helper.' 'She should go back because there was a friendship and this counts a lot.' 'In reality she helped bring up the child. She already had intimacy with the home. Return!' In a reversal of the pattern in the previous round, the suggestions that Dona Margarida should return to the old job predominated among those with higher income, while those with lower income tended to agree that the maid should not return to the old job. Resistance by the poor to being played off by the wealthy now surfaced. The fear of job loss no longer existed. But the richer felt the loss of care, and the emotional attachment by the maid was claimed back. Both submissive acceptance and resistance, as well as affective ties, are apparent in the reactions to this vignette, indicating a complex relationship between poverty and obedience, money and affect. With the important exception of this last moment in the story, when the poorer would choose the maid not to return to the old job, this vignette shows that respondents' choices were consistent with a prevailing morality prescribing the dedication of the dispossessed to the well-off. This reflects what Teresa Sales , in her study of northeast Brazil referred to as 'the political culture of the gift'. It implies passivity and gratitude of the receiver in face of the giver and relates to a history in which slaves were dispensable, depending on the 'gift' of their superiors for their very survival. From this context, as remarked various analysts , evolved a culture of social and political submission. Here the maid was not simply a worker but a devoted carer. However, the respondents' acceptance of men's detachment from housework and care did not equally apply to women. The late mother used to do some tasks like cleaning the table, washing-up in the evening, or making beds and picking up damp towels from the bathroom. This shows that welloff women can effectively have hands on light housework despite the colonial ideal portrayed in contemporary soap operas of 'madams' avoidance of all physical work. The girlfriend too was expected to do these household tasks and not to behave like the father and the boy did. As illustrated by Regina's comments: 'She should return… after so many years… what prevented her was the girlfriend.' Resistance was mainly from the poor. Some remarked that Dona Margarida had been mistreated and that leaving damp towels on the floor was unacceptable. Some criticized Sérgio for treating her as a 'change of clothes', 'in and out', 'depending on having a girlfriend'. It was clear for some that Dona Margarida deserved much better treatment. Also, she was the ideal caring maid of many people's dreams, as shows Dércio: 'If there is affection for the family she should go back. I would like my maid to have an emotional link with the family, or at least with Naomi'. Naomi was his 3year old daughter, and Dércio had complained of his maid's lack of emotional attachment to her. The pattern of gender relations in which most Brazilian domestic life is centred around the needs of men, where the woman services and the man provides, is socially pervasive, and it is the ideologically dominant pattern even where the woman is also a provider. In the vignette, or in accounts of real everyday life, triggered by the story of the vignette, it was not surprising that men did not do anything in the home. A particular sort of patriarchy supports these gender relations sustained by highly unequal relations of class, which affect inter-gender dynamics . More specifically, deep social differences based on class and 'race' appear to contribute to a reduction of domestic conflict in relationships between women and men in well-off homes. Julia Souza was one of the first to point out the paradox that some Brazilian women's liberation came at the cost of the subordination of inferior women. She focused on the economic implications of this labour relationship for capitalist development, and also reflected on the inconsistencies of Brazilian feminism. Following on from this, Suely Kofes , Sandra Azeredo and others have also argued that professional women may be able to progress in their careers because they can make use of the services of other women for domestic service. Moreover, Danielle Ardaillon has argued that the maid is the big problem of the professional woman: central to domestic life, their absence or disruption deeply affects the routine of the family, and Celma Vieira has emphasized the easier progress of white women in general at the expenses of black maids. Vieira has also observed how the living areas of maids in modern houses resemble the structure of colonial architecture which separated manor house and slave quarters. Although only a few families employ live in maids the little bedroom and bathroom designed for maids are revealing of the status of domestic servants, either employed everyday of occasional daily cleaners. As Donna Goldstein describes, the toilet normally has no seat, the shower has no curtain and water damps the whole room; the bedroom with a tiny bed is used to store all sorts of unwanted and des-used items in the household. At the end of the twentieth century, I still found evidence that the widespread use of domestic servants by the upper-and middle-classes had taken the edge off many conflicts about gendered domestic divisions of labour, since more menial domestic labour was given to poorer women. As reactions to the vignette showed, orders from middle-class men to lower-class women were perceived more strongly as 'a right' than the ordering to do that goes between women. This study has focused on the wealthier southeast of Brazil, but the social divisions between servants and better-off household members are even sharper in the North and Northeast regions. The value of domestic labour is lower, and the demands for care from the wealthy are greater, where poverty is higher. The price of Brazilian domestic labour increases considerably as one moves South and is highest in the big urban areas. But even in the economically affluent region of Greater Campinas, maids in middle-class households are rarely allowed to use all available household technologies. This is a consequence of the cheapness of domestic labour and it affects the patterns of development of household technologies. The good quality cookers and washing machines are very expensive, or imported, while the cheaper ones still demand considerable amounts of labour input for their operation . Although prices of technology have dropped overtime the cost of domestic labour has not increased sufficiently to make it attractive to replace maids with machines. The earnings by the poorer have not been sufficiently high to generate new waves of demand for technology in the home. In certain respects, this fits into the model of Brazilian society that some economists have called 'excluding modernity' . It has been based on income concentration and sophisticated consumption for a minority of the population, and exacerbates social differences. The fact that some better off women find that they need to have washing machines in order to keep their maids may be a small indicator of a trend towards less inequality. --- Conclusions Reminiscing about the feminist debates in the 1970s in the United States, Barbara Ehrenreich writes that '[t]he radical new idea was that housework was not only a relationship between a woman and a dusty bunny or an unmade bed: it also defined a relationship between human beings, typically husbands and wives.' She goes on to say that talking about housework was to talk about power. The degradation of housework was not derived from it being manual labour, but from the fact of the person who is cleaned up after being consistently male, while the person who cleans up is consistently female, rendering housework as a 'symbolic enactment of gender relations' . Analysing the contemporary servant economy, Ehrenreich remarks that '[i]ncreasingly often, the house cleaner is a woman of color and a recent arrival from the Third World' , bringing about the challenge of making this work visible again. If, as she argues, '[t]he growing servant economy… is largely a result of men's continuing abdication from their domestic responsibilities' , housework is not, however, the same sort of work that it was. The current context in developed countries is permeated by an array of machines, services and 'nearly ready products' as part of a new 'technological nexus' enabling a lifestyle less dependent on long domestic labour hours. Care of children and of other needed persons, and some household tasks do remain essential for quality daily living, but the context is different from that of the 1970s. In Brazil, however, continuities are stronger. Of course, a lot of feminist ideas have been debated in Brazil and many have been productive in bettering women's social stand. However, not much has yet affected domestic relations though. Women's paid Two different scenarios demand reflection from the case explored in this paper. In one Brazilian domestic service dwindles like it did in the UK in the 1930s and in the US after the Second World War . Would greater equality in the home and increasing modernization of household technology ensue? In the other current increasing use of immigrant women's domestic labour in Europe and the USA may come to affect the machines for housework and morality of everyday living in the home, slowing the pace of changes in gender relations. The challenges for feminist thinking posed by both scenarios are pressing. ---

This paper engages with debates about the increasing use of paid domestic labour in Europe and the USA contributing with a reflection about the case of Brazil. Relations of gender, class and race are considered in the deployment of maids for housework, the patterns of consumption of household technologies and the moral reasoning of daily living with hierarchical divisions within the home. The paper considers some parallels between the Brazilian context and that of more developed countries and also the specificity of Brazil. Based on participant observation, secondary data and an ethnographic study, rich empirical data are weaved through to discuss material and moral dimensions of domestic labour and care. How does the availability of cheap domestic labour configure relations of inequality? How are social differences in the home lived with and justified? The exploration of the Brazilian case illuminates some of the problems, contradictions and possible consequences of wealthier households benefitting from the displacement of poor women that is currently happening through international migration. The paper argues that in Brazil the deflecting of tensions in gender divisions of labour in households onto a subordinate person has affected relations of equality between women and men and also the patterns of technological innovation to facilitate housework. These are outcomes to be guarded against in Europe and the United States in face of the current trends in 'global woman' relations.

Introduction Perceived risk is related to judgments about susceptibility to disease as well as the probability of benefit from preventive actions and interventions [1]. The literature regarding risk perception in low income and underserved populations is still relatively undeveloped for several cancers, including cervical cancer, where there is a clear, relatively defined set of risk factors and preventive actions. In the U.S., disparities exist whereby Hispanics/Latinas have the highest incidence of cervical cancer and African Americans have the highest mortality [2]. This pattern may be explained in part by differences in screening utilization [3,4]. Lower screening rates may be attributed to low perceived risk of cancer and limited knowledge of cervical cancer risk factors [5][6][7][8]. which may mediate the relationship between risk perception and screening rates [9,10]. Women who smoke, are exposed to second-hand smoke [11,12], and who have been infected with particular HPV serotypes are at greater risk of cervical cancer [13]. Examining whether women who possess one or more of these known risk factors actually perceive greater disease risk remains an important question. Similarly, perceived test accuracy has also been found to be an influential factor on perceived risk of cervical cancer as many women have shown concern regarding the overall accuracy of their Pap test [14,15]. The objective of this study was to examine perceived risk of cervical cancer among a low income, diverse population of women by comparing self-assessed risk of cervical cancer, perceived prevalence of abnormal test results for others, and perceived Pap test accuracy by sociodemographic variables , and known risk factors . --- Methods and Materials --- Study Design and Sample Selection This investigation was part of a larger study that recruited women undergoing Pap testing at one of two University of Texas Medical Branch Regional Maternal & Child Health outpatient clinics between October 25, 2002 and June 1, 2003. Women were eligible for participation if they were between 18 and 55 years of age and self-identified as Hispanic/ Latina, White, or African American. Written, informed consent was obtained from all women prior to participation. Participation involved completing a self-administered questionnaire in English or Spanish. The study was approved by the UTMB institutional review board. --- Measures A short questionaire was used to gather data on age, race/ethnicity, marital status, education, household income , employment status, smoking status , and history of genital warts, HPV infection, and other sexually transmitted infections. Perceived risk of cervical cancer was assessed by asking: "What do you think is your risk of ever getting cervical cancer in your life time from 0% to 100%? where 100% meant you definitely would get cervical cancer, and 0% meant that you definitely would not." The questionnaire included the open-ended question: "Please write why you think this is your risk." Perceived prevalence of an abnormal result was measured by asking: "If you had to guess, what percent of women who come to the UTMB clinics have ever had an abnormal Pap smear?" using the same 0% to 100% metric. Estimates of Pap test accuracy were assessed by asking: "Out of 100 Pap test results, how many do you think are incorrect ?" In addition, we measured the expectancy of obtaining an inaccurate Pap test result with a likelihood statement: "If I came back for follow-up of an abnormal Pap smear, I might find out that the first result was wrong" and an evaluation statement:"Finding out my abnormal result was wrong and my Pap smear is normal would be the best thing I can imagine hearing from the clinic." A 6-point Likert-type scale ranging from "strongly agree" to "strongly disagree" was provided for each statement. For analysis, responses were recoded into "agree" and "disagree." --- Analysis Quantitative analyses were conducted using IBM SPSS Statistics . Analysis of variance was used to examine participants' estimates of their own lifetime risk of cervical cancer, prevalance estimates of abnormal results, and Pap test accuracy by participant characteristics . Bonferroni adjusted p values were examined for pairwise comparisons. Pearson correlation coefficients were computed to evaluate associations between continuous variables. A two-tailed alpha level of 0.05 was considered statistically significant. The open-ended responses were content analyzed and categorized. --- Results A total of 429 women met eligibility criteria; of these, 356 initially agreed to participate. Women who refused differed from those who initially agreed with respect to race/ethnicity, χ 2 =43.80, p<0.001 and insurance status, χ 2 =7.48, p<0.01. Disproportionately more Latinas refused the study, relative to White and African-American women , while women insured through Medicaid or indigent care had higher refusal rates than privately insured women . Of the 356 who initially agreed to participate, 338 women completed the survey while 18 women did not. A greater proportion of women who had accepted the survey but did not complete it were Hispanic/Latina relative to White or African American , χ 2 =17.56, p<0.001. The mean age of the sample was 29.9 ±8.6 years . Additional participant characteristics are shown in Table 1. One participant was excluded from further analyses due to inappropriate responses on focal survey questions, leaving a sample size of 337. --- Perceived risk of cervical cancer Women's assessments of their own lifetime risk of cervical cancer ranged from 0%-100% with a mean of 59.2 ±29.5 . Risk estimates were positively correlated with perceived prevalence of abnormal results, r=0.24, p<0.001, and perceptions regarding the accuracy of the Pap test, r=0.13, p<0.05. Perceived risk was not significantly associated with age, race/ ethnicity, education, income, smoking status, expectancies regarding an inaccurate Pap test result, or self-reported history of an abnormal Pap test result, HPV, genital warts, or STI's . The open-ended responses regarding risk estimate justification are shown in Table 3. Of twelve [2] cervical cancer risk factors recognized by the American Cancer Society , women in this study recognized eight risk factors: HPV infection, sexual behavior, smoking, STI's, family history, contraceptives, multiple pregnancies, and DES exposure. Women who reported having a family history of cervical cancer or other kinds of cancers and having a history of an abnormal Pap test primarily used the upper end of the rating scale to reflect their own risk . Most women who indicated lower percentages expressed that they do not have a family history of cancer, have regular check ups or have had a hysterectomy. It is important to note that while the lifetime risk of cervical cancer for the average woman is likely much lower than many of the risk estimates provided in this study, there were wide variations in the percentages offered for the same recognized risk factor. For instance, while a total of 10 women included smoking in their risk estimate justification, two current smokers reported highly discrepant lifetime risk estimates . --- Estimated prevalence of abnormal Pap test results for others On average, women estimated that nearly half of all women who receive Pap testing at the clinic have ever had an abnormal result ; these estimates were positively correlated with Pap test accuracy, r=0.32, p<0.001. Furthermore, the perceived prevalence of abnormal results for other women differed by race/ethnicity of the respondent, F=4.89, p<0.01 . Specifically, African-American women estimated a higher percentage of other women who have abnormal Pap test results, compared to Hispanic/Latina and White women. Women who experienced an abnormal Pap test result reported higher proportions of other women experiencing an abnormal result, t = -3.67, p<0.01 . --- Pap test accuracy Estimates of Pap test accuracy ranged from 0% to 100% . Women who agreed with the statement, "If I came back for follow-up of an abnormal Pap smear, I might find out that the first result was wrong" reported higher estimates of Pap test inaccuracy than women who disagreed with this statement, t=2.6, p< 0.05 . Estimates of Pap test inaccuracy were unassociated with participant age, race/ethnicity, education, income, smoking status, expectancy of an inaccurate Pap test result, or self-reported history of an abnormal Pap test result, HPV, genital warts, or STI's . --- Conclusions and Discussion This study contributes to women's health by focusing on quantitative and qualitative perceptions of risk, perceptions regarding how common an abnormal Pap test result is among women attending routine screening, and beliefs regarding the accuracy of the Pap test. No differences were observed in risk estimates based upon factors that would suggest higher risk, such as older age, smoking status, prior history of an abnormal Pap test result, or HPV infection. It is possible women do not recognize these factors as placing them at higher risk of cervical cancer. Indeed, a lack of knowledge about risk factors for cervical cancer is an explanation that is congruent with other findings [5][6][7][8] however qualitative data obtained in the present study suggest that women are not unaware of these risk factors. Other explanations exist beyond lack of knowledge, including optimistic bias, illusion of invulnerability or "wishful thinking." Importantly, if the current study stopped at examining quantitative risk estimates, a critical part of the story would have been missed. The qualitative data reflecting women's rationale behind their risk estimate are unique to this study and suggest that women do in fact recognize several key behavioral risk factors for cervical cancer. In the current study, women recognized eight out of twelve risks factors acknowledged by the American Cancer Society [2]. In several cases, women's answers were not technically correct , but they provided explanations that indicated an appreciation for risk and protective factors such as having an abnormal Pap result in the past, skipping exams, and delaying treatment of an abnormal result. In this study, African-American women reported higher proportions of other women experiencing an abnormal Pap test result relative to Hispanic/Latina and White women. It is possible that awareness of the higher death rate of cervical cancer among African Americans may contribute to this finding, although further work is needed to support this explanation. Historically lower participation rates in cervical cancer screening programs among African Americans may also provide insight into this finding [16,17] but the relationship is unclear. Cognitive constructs such as risk perception are not necessarily interpreted in the same way in different cultures [18] thus further research is needed to explore cultural nuances, recognizing that the racial/ethnic groups examined in this study are not monolithic. This study included a convenience sample of women within the southern region of the U.S. Latinas and women with public insurance were more likely to decline participation in the study therefore the conclusions that can be drawn are limited by these factors with regard to generalizability. Nevertheless, the geographic location is important for targeted education efforts, as Texas has one of the highest incidence rates for cervical cancer [2]. Similarly, this study included women already attending a clinic appointment for Pap testing, thus the findings may be biased toward those who have a greater awareness of cervical cancer and its prevention. However, our data suggest that education remains essential so that women who attend screening are fully informed about the limitations of Pap testing. Our results emphasize the importance of educating patients regarding cervical cancer screening, particularly given recent changes in recommended intervals. Screening intervals are now spaced out to 3-5 years. The change from annual or bi-annual screening to less frequent testing may be alarming to women who perceive an inflated personal risk of developing cervical cancer. Clearly communicating that the individual risk is low and that cervical cancer develops slowly from precursor lesions may help reduce patient anxiety while increasing acceptance of and adherence to the new testing intervals. Findings from this study provide further understanding of the perceived risk for cervical cancer among a diverse population of relative socioeconomic disadvantage and underscore the general inaccuracy of women's perceived risk or personal susceptibility regarding cervical cancer and the importance of addressing this issue in clinical practice. The findings elucidate the complexities surrounding how women perceive their own numerical risk of cervical cancer, and how they rationalize this estimate, which pose a challenge for health professionals. It seems particularly important for health care professionals to appropriately calibrate women's perceptions regarding their lifetime risk of cervical cancer as well as inform patients of the limitations and importance of the Pap test with or without HPV testing in light of currently changing screening guidelines. --- Précis This study advances our understanding of how women qualitatively view their risk of cervical cancer thus highlighting areas for practitioners to enhance patient education efforts. --- Themes Representative quotes

Background-Risk perception is an important predictor of cancer prevention behaviors. We examined perceived risk of cervical cancer among an ethnically diverse population of women of lower socioeconomic status. Materials and Methods-Females attending a women's health clinic were recruited for a study addressing cervical cancer prevention. Survey questions evaluated lifetime perceived risk of cervical cancer (0% to 100%), beliefs about the accuracy of the Pap test, and estimated incidence of abnormal Pap test results. Risk estimates for oneself were followed with an item seeking a brief, qualitative explanation of the risk estimate. Results-Surveys were completed by 338 women. The mean (M ±SD) age of respondents was 29.9 ±8.6 years. Women self-identified as Hispanic/Latina (32%, n=107), White (34%, n=116), and African American (34%, n=115). Estimated perceived lifetime risk of getting cervical cancer ranged from 0% to 100% (M=59.2 ±29.5). Risk estimates were associated with perceived prevalence of abnormal results, r=0.24, p<0.001, and perceptions regarding the accuracy of the Pap test, r=0.13, p<0.05. On average, women estimated that nearly half of all women have ever had an abnormal result (49.2 ± 26.9; n=335; range 0%-100%), with African-American women estimating a higher percentage compared to Hispanic/Latina and White women. Women who themselves experienced an abnormal Pap test result reported higher proportions of other women experiencing an abnormal result, t(333) = -3.67, p<0.01. Conclusions-This study advances our understanding of misperception of risk and how women qualitatively view their risk of cervical cancer. The findings underscore areas for practitioners to enhance patient education efforts.

Introduction Drug use is often associated with higher crime rates [1,2]. In France, studies estimate that 20% of inmates were convicted for crimes concerning illicit drug possession, use or sale [3,4]. Furthermore, between 60% and 80% of inmates report using drugs in the weeks prior to incarceration [4][5][6]. Even in prison, there are possibilities for substance use disorder treatment. In 1994, France inscribed in its laws that inmates should have access to the same standard of care as any other patient and shifted responsibility for prisoners' health from the Justice Ministry to the Health Ministry. Since then, usual care is performed by "Sanitary Units in Penitentiary Settings" . Those units are mostly composed of nursing and medical staff, but in order to deal with drug use care, help is enlisted from psychiatric hospitals and specialized institutions [7]. Doctors specialized in addictology and educators are then tasked to help ensure that prisoners benefit from the same standard of care as they would outside of prison. Since 2015, an alternative has been offered to inmates wanting to work on their social skills and drug use during incarceration. This socio-educational program, inspired by Spanish prisons, is called "Respect Module" . This program puts an emphasis on rehabilitation through work. Inmates sign a contract describing their objectives and their commitment to achieving them. By doing so, they agree to follow a well-defined code of conduct that also grants them more leeway during their personal time . They are then tasked to choose a personal activity plan and to respect a specific schedule throughout the day [8]. Finally, in 2017, a third type of care was introduced as an experimentation unit. The Rehabilitation Unit for Drug Users was created to try and apply the therapeutic community approach to drug use care in prison. The TC model consists of mediumto long-term accommodation structures that do not solely focus on addiction pathology but aim to rehabilitate patients so they can behave and live accordingly with social rules. To that end, patients are held accountable and are expected to become positive and reliable actors of the community. This "community as a method" approach [9] values one's personal involvement in the group dynamic in order to change oneself. This way, the individual will improve himself by appealing to the group's resources through the development of his own social skills [10]. Staff mainly play a role in promoting interactions among peers through educational activities and monitoring residents' and groups' statuses [11]. TC's effectiveness is already well described overseas in regular settings for its effect on drug use both during TC and after discharge [12,13]. These effects mainly consist of a reduction in drug episodes that can be reduced by 77% 3 months after discharge and sustained for a longer period. Prison-based TC programs also have an effect on drug use, notably on relapse [14,15], which can decrease by 15%. This effect on relapse can in turn diminish the likelihood of recidivism from 17% up to 39%, mainly by reducing drug-related offenses [15][16][17]. Prison-based TC was also shown to be effective in reducing rearrests [16], even if it has only been described as a small to moderate effect when aftercare is not involved after release. In RUDU, prisoners' days are organized with multiple group activities focused on resolving issues using communication skills, learning how to express their feelings when speaking with their peers or using arts and creations to do so. Expression groups help redefine their relation with the products of their addiction as well as their central role in the prisoners' problems. This unit was implanted in the Neuvic detention center thanks to the collaboration of penitentiary, associative and medical actors. RUDU is mostly composed of specialized educators as well as social workers, an addictologist, a psychologist, probation officers and even prison guards. RUDU staff often have interviews with prisoners to assess their progress, review recently encountered problems or talk about their near-term prospects . The TC model differs vastly from classic care in French prisons. The TC model focuses and relies on social rehabilitation to improve the overall state of the inmate, while classic care solely aims to work on the addiction pathology through medical interviews. The TC model gives structure to the inmates' stay in prison by encouraging them to participate in regular group activities and discussions. It is also important to note that the TC model allows for closer monitoring with regular interviews than classic care. This pilot study aimed to evaluate care based on the TC model in French prisons through the RUDU experimental unit and compare its effectiveness with other types of care available in French prisons such as classic care and socio-educational programs. To that end, a questionnaire was purposely built based on the fifth version of the Addiction Severity Index [18,19]. The primary objective was to evaluate the evolution of the overall addictive disorder, focused on the primary substance used or to be given up by the resident. The secondary objectives were to evaluate and compare effects on other factors linked with delinquency and addiction such as social interactions, self-esteem and reincarceration. --- Methods --- Study Design This retrospective study was conducted by the Esquirol Hospital Center of Limoges. This study was funded by the Regional Health Agency of the Nouvelle-Aquitaine region of France and was registered in the Health Data Hub . A letter was sent to the known addresses of all inmates whose files were to be included to inform them about the study and give them the opportunity to voice their opposition towards the use of their data. --- File Selection The study took place in two prisons in the Nouvelle-Aquitaine region of France. The first one, offering the three different types of care, was the Neuvic detention center. The second one was the Mont-de-Marsan penitentiary center, which offers both classic and socio-educational care for drug users. Socio-educational files were only selected in Mont-de-Marsan. TC files were only selected in Neuvic. Classic care files were selected in both centers. Files were selected if the inmate had spent at least 3 months in the studied unit's care and were meeting RUDU 's admission criteria, listed as follows: drug user seeking help and treatment, use of multiple substances and absence of heavy psychiatric comorbidities that would prevent group therapy. Some additional pairing criteria were required for the selection of files from other types of care in order to ensure comparability and prevent bias. The files were paired according to the duration of care, primary substance of the addiction pathology, age group and psychiatric comorbidities. --- Study Procedures The study started by including all adequate TC files from the 103 files available for the 2017 to 2020 period. Only 39 TC files were adequate and therefore included. These 39 files were used to build the pairing grid based on the criteria described above. Classic care and socio-educational files were then selected according to the pairing grid. For those, the end of treatment was arbitrarily defined to be similar to the original TC files they were to be paired with . In total, 23 classic care files and 13 socio-educational care files were included for a total of 75 files. A total of 16 of the 23 classic care files were from the Neuvic detention center, while 7 were from the Mont-de-Marsan detention center. After all the files were selected, a questionnaire based on the 5th version of the Addiction Severity Index [18][19][20] was filled out using the files as sources of information. The ASI is a hetero-questionnaire that takes interest in two periods: the lifetime and the last 30 days. It could not be used directly since it requires a dialogue with the patient to fill in the data corresponding to the last 30-day period. Therefore, our questionnaire was built by removing the family history domain from the ASI and replacing the two periods of interest for severity grades with the initiation of care studied and the end of said care. The questions relating to the last 30 days and self-evaluation were also removed from all the remaining domains. Severity grades were given to all the domains evaluated by our questionnaire, namely: medical status, employment and support, primary addiction status, legal status, social/familial status and psychiatric status. Grades were not reflective of a single questionnaire item but rather represented the global status of an explored domain. For example, primary addiction status incorporated items regarding abstinence, reduction in consumption, ability to feel, measure and voice craving, ability to ask for help, ability to refuse when the substance was offered by another inmate, compliance with treatment, etc. Similarly, psychiatric status was composed of psychiatric history, diagnosis, treatment for psychiatric or emotional problems, etc. Finally, along the same lines, employment and support status incorporated items regarding previous employment, education level and diploma or lack thereof, main source of income, training during incarceration, etc. Grades ranged from 0 to 9, with 0 being the lowest and describing the absence of problem, while 9 was the highest and described an extreme problem needing emergency care and treatment. Grades were given jointly after a full examination of all the files of each inmate by both investigators; one was a medical doctor specialized in addiction medicine and psychiatry who focused on medical status, primary addiction status and psychiatric status domains of our questionnaire, and the other was graduate in addiction medicine with a master's degree in biology who focused on employment and support, legal status and social/familial status of our questionnaire. This second investigator also selected and revised the files. Self-esteem scores presented in this study were self-reported and ranged from 1 to 5, with 5 being the highest. In this study, abstinence took into consideration the willingness aspect of undertaking a period without consumption as a step of recovery and not simply because the substance could not be procured. The duration of abstinence was measured in days. Multiple periods of abstinence were not taken into account . Abstinence data were centered on the main substance of choice for each inmate. The data were only taken into account if measured during in-prison care. Reincarceration rates were measured 90 and 180 days after release from the detention during which the studied care occurred. --- Statistical Analysis This study questionnaire provided both qualitative and quantitative data. Quantitative variables were described using means and standard deviation, and qualitative variables were expressed in numbers and percentages. To analyze this study's qualitative data, Chi 2 tests were used. If the sample size was deemed too small, Fisher's test was used. When paired , quantitative data were analyzed using Wilcoxon's test. Otherwise, Mann-Whitney's test was used. All statistical analyses were conducted on IBM SPSS Statistics version 26 with a statistically significant threshold set at 0.05. --- Results --- Study Population The study population age ranged from 20 years old to 59 years old = 37.7 ± 9.1 years). The mean duration of care was 175.8 ± 53.7 days. All inmates were male. In total, 79.5% of the TC population had benefited from care previously, while only 39.1% from the classic care and 46.2% from the socio-educational care population had . TC and classic care were compared in populations' prior access to substance use care . No significant difference was revealed when comparing TC and socio-educational care . --- Global Effectiveness of Care Regarding Addictive Disorder Evolutions of severity grades were used to compare the effectiveness of care. Admission scores corresponded to the severity grade awarded from the first interview with a professional involved in care. Similarly, the latest score was given according to the file's last interview, usually within a week of release. Delta represents the progress made during care. The higher the Delta value is, the more progress was made during care. When looking at primary addiction status, the comparability of the admission score ensured that the baseline was similar among the three types of care studied. The baseline showed tremendous problems for all the files included . The Delta values indicated that progress was made across all types of care studied . When comparing TC's and classic care's Delta, we found that TC's effect was significantly superior . However, the same could not be said when comparing TC and socio-educational care . This indicated that the global progress in the addiction pathology is higher with TC than with classic care but not higher than with socio-educational care. --- Comparing Care Effectiveness in Improvement of Psychiatric Status and Financial Situation For both psychiatric status and employment/support, the baselines indicated important issues requiring care for all populations studied . Similarly to primary addiction status, progress was achieved in both psychiatric status and employment/support across all three types of care studied . No significant difference was detected when comparing TC to the two other types of care studied . * Three files from classic care and two files from socio-educational care did not contain enough data to be graded. --- Possible Factors of Improvement Promoted by the Therapeutic Community Model Both TC and socio-educational care shared the same rate of abstinence at 84.62%. The classic care abstinence rate was at 69.57% and was not significantly different from TC . TC had the longest mean duration of abstinence followed by classic care . Socio-educational care had the shortest mean duration of abstinence . No differences were observed when comparing TC's duration of abstinence with the other populations . Self-reported self-esteem and social/familial status could only be found in TC's proprietary files, so we only took interest in progress being made during TC. When comparing admission scores to latest scores for both of these items , the significant improvement made during TC was revealed. --- Effects on Reincarceration Rates Finally, the reincarceration rates at 90 and 180 days after release were analyzed. The data could only be obtained for the former Neuvic detention center prisoners , while for both, the reincarceration rates were lower at 90 days after release than 180 days after release , and no significant difference was found between the two types of care studied . --- Discussion This study gives us the first data on the TC model's effectiveness on drug use disorder in French prisons. While this study did not allow us to establish profiles of prisoners most likely to respond to a particular type of care, we can still identify disparities between their populations. Indeed, our study showed that TC's population is more likely to have previously accessed professional help in substance use care than the population undergoing classic care. This could indicate that prisoners that have already encountered classic care in addiction, whether it was in prison or not, tend to be motivated to take part in more intensive type of care such as the one the TC model provides [9,16]. Our results point towards the TC model's superiority in its capacity to induce better improvement overall in addiction status when compared to classic care. These findings are consistent with previous studies in Europe and North America [21]. This result can be explained by the more intensive nature of TC, although it remains difficult to identify which components are the most beneficial [15]. Socio-educational care is also more intensive than classic care and relies on personal involvement, which could explain why the overall improvement in addiction status is similar for socio-educational care and TC. When comparing other aspects of care such as psychiatric status and employment/ support, we were not able to detect differences between the three units. The lack of significant improvement in psychiatric status is consistent with the limited effect on mental health in the TC literature [22]. This means that the TC model could benefit from stronger psychotherapy components in order to broaden the range of its benefits to inmates. The addiction pathology and its treatment are complex and involve multiple factors. Self-esteem is described as one of these factors, as lower self-esteem is correlated to more substance use [23,24]. The TC model allows residents to work on this personality trait as it is also linked with group membership and belongingness [25]. De Leon suggests that group membership can constitute a replacement for the bond with the object of addiction [9]. Belongingness is also known to be a crucial part of TC used in order to promote change and in turn improve self-esteem [26]. Therefore, TC's positive effects on self-esteem could be linked to belongingness, and both of them might play an important role on the overall progress made by the inmates on their addictive disorder. In that sense, they could constitute a secondary index of this criteria of effectiveness. Familial/social status is also an important factor in addiction status improvement that is worked on with the TC model used in RUDU [27]. In this unit, prisoners learn to improve their communication skills in expression groups with the help of other residents, care professionals and even prison guards. Our findings indicate no significant differences, neither in terms of promoting attempts of abstinence nor in the duration of such endeavors. Our results were unexpected, as TC's positive effects on relapse have been described [14] and could be expected to translate into a positive effect on abstinence. However, abstinence is not the main purpose of the TC model because the recovery process and goals are not solely based on the addictive disorder but instead on a "whole person" approach, which could explain the absence of a significant effect on this criterion [9]. Still, it could be a meaningful indicator for some prisoners' progress with their addictive disorder that should not be dismissed. It also means that future studies should strongly consider other criteria to measure addiction status, such as craving frequency and intensity or reductions in drugs consumed both in nature and quantity, in addition to abstinence. Reincarceration rates were of particular interest, as prison-based TC has shown effectiveness in reducing reincarceration [14] and recidivism [28,29]. We were not able to detect any significant differences in our study, probably due to the low number of files containing data on this subject. Indeed, data could only be obtained for 39 TC files and 16 files for classic care. The short time period with up-to-date information could also have played a role in those results. Studying reincarceration rates for a longer period after release could allow a significant difference to emerge. Other items could also be studied, such as recidivism, which was considered by O. Mitchell and colleagues as the most reliable and comparable outcome criterion [15,17]. Finally, RUDU allows for care professionals to systematically search for adequate aftercare in the couple of weeks leading to release. It is well described that aftercare is one of the most important components for substance use treatment success and for preventing relapse, recidivism [1,16,17] and reincarceration [14,30,31]. Similarly, the study period being focused on in-prison care and therefore not allowing us to measure the progress retained after could have deprived us of meaningful indicators of effectiveness [32]. Hence, the TC model represented by RUDU might offer much more societal advantages and rehabilitation capabilities than our study is able to reveal. --- Limitations This retrospective study encountered two main limitations while comparing the different options of addiction care in French prisons. Firstly, the files' content is highly dependent, not only on the detention center, but also on the specific type of care received by the prisoner. This disparity in files' content and the lack of standardized tools for evaluation could have hindered the comparison by misrepresenting both the progress and the difficulties encountered by prisoners and fields teams alike. Secondly, a robust cost analysis of the three types of care studied is also missing from this study. Although we originally aimed to include a cost-effectiveness analysis, we were prevented from producing such an analysis by the lack of available data and the poor comparability of those obtained. Despite these shortcomings, the economic data retrieved could help design a more robust analysis that could be used in a future prospective study. Such a prospective study should be focused on inmates' fates after release from the three different programs studied here. Follow-up would be crucial to assess how much of the progress, both in the addiction pathology and in social rehabilitation, made in prison is retained when inmates are no longer in a secure environment. Particular attention should be given to aftercare and whether or not inmates return to a known problematic social environment or rather choose to start anew to avoid the repetition of criminal behavior. Finally, the long-term economic impact should be assessed to help policy makers decide how to help develop and fund such care programs. --- Conclusions This study represents a first look into the TC model in French prisons through the special unit that is RUDU. Although TC's effectiveness has already been demonstrated in reducing substance use and criminality in conventional settings and in prisons overseas, such data are lacking in France [21]. This study points towards stronger improvement in the addiction pathology granted by the TC model than by classic care in prison. It also shows that the TC model is not solely focused on the addiction pathology but rather on social rehabilitation and can significantly improve other characteristics such as social/familial status and self-esteem. More studies are required on the subject, particularly when it comes to follow up and the fates of inmates after release. To that end, it is important to implement standardized tools to monitor, evaluate and improve such treatments, as TC's more intensive care can be more beneficial for some inmates than the classic procedure available. The clear identification of the most efficient components of the TC model and the profiles of prisoners most likely to stay in care and take advantage of it is crucial to ensure its efficiency [9,15,21,25,28]. It could also be interesting to evaluate the benefits of RUDU and the TC model on an economic scale to see if it is compatible with healthcare and the justice system in France. To that end, cost-benefit analyses relying on standardized tools such as ASI or the Drug Abuse Treatment Cost Analysis Program [33,34] could provide interesting insights to both field teams and policy makers. --- Data Availability Statement: The data presented in this study are available on request from the corresponding author. The data are not publicly available because it is derived from a sensitive and protected sample of the population. --- Author Contributions: T.V.: validation, investigation, formal analysis and writing-original draft. A.L.: methodology and writing-review and editing. T.G.: methodology, validation and writingreview and editing. P.N.: conceptualization, validation, investigation and writing-review and editing. All authors have read and agreed to the published version of the manuscript. Funding: This work was supported by the Regional Health Agency of the Nouvelle-Aquitaine region of France. The ARS had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. --- Informed Consent Statement: Patient consent was waived due to the study not involving human directly but focusing on the data recorded in their files. However, they were informed of the intended use of their data and could voice their opposition towards the use of their data. ---

Background: In France, addiction care in prison usually consists of nurses' interventions, medical care and socio-educational programs, but new alternatives have arisen, namely the therapeutic community (TC) model. This pilot study aims to evaluate the effectiveness of this prison-based TC in comparison with classic and socio-educational care offered in French prisons. Methods: To compare these three types of prison-based care, two detention centers' files were screened for use of multiple drugs, willingness to participate and absence of psychiatric comorbidities incompatible with group therapy. A custom questionnaire was built based on the fifth version of the Addiction Severity Index. It investigates medical status, employment and support, primary addiction status, legal status, social/familial status and psychiatric status through various items. Results: Our sample only consisted of male repeat offenders with a mean age of 37.7 ± (9.1) years. Primary addiction status improvement was observed for all care studied but was more important in TC than in classic care. Self-esteem and social/familial status saw significant improvement throughout TC care. Conclusions: The TC model represents an alternative to classic and socio-educational care in French prisons. More studies are needed to assess the extent of the benefits provided on both the medical side and economic side.

Introduction Onchocerciasis is a neglected tropical disease caused by the nematode Onchocerca volvulus. Onchocerca volvulus is transmitted through the bites of blackflies of the genus Similium that breed near rivers and streams in regions with constantly moving water [1]. S. damnosum complex and S. neavei found in Africa and the Middle East and in parts of East Africa respectively are the most important vectors. However, in America, the most important vectors are S. ochraceum, S. metallicum, S. oyapockense, S. guianense, and S. exiguum [2]. Although this disease occurs mostly in warm tropical settings, its parasitic flies survive under environments favourable for their growth all year round [3]. The disease is known to affect rural populations and is a major cause of blindness and Onchocercal skin disease in endemic areas with severe socioeconomic outcomes [4]. Symptoms include severe itching, disfiguring skin conditions, and visual impairment [5]. Globally, it is estimated that about 90 million people are at risk of being infected with Onchocerca volvulus in endemic areas mostly in sub-Saharan Africa , and out of which about 37 million are infected and 300, 000 are permanently blind as a result of onchocerciasis [1]. However, 1 to 5 percent of the population in onchocerciasisendemic areas who are exposed to a high rate of infection transmission do not exhibit any clinical signs of the disease and are thus considered putatively immune individuals [6]. It is known that onchocerciasis is a chronic, slowly progressive, parasitic disease that has been regarded as the second-leading communicable cause of blindness globally with around 500,000 persons blind yearly [7]. A study by Crump, Morel, and Omura [8] revealed that, out of approximately 123 million persons who are at risk for infection in 38 endemic countries, 25.7 million are infected and 1 million are blinded or have a serious visual impairment. Onchocerciasis is endemic in SSA countries causing partial or total loss of sight and extreme itching with skin conditions [9] as a result of high infection load [10]. Study shows that onchocerciasis is the second most common infectious cause of avoidable blindness [11]. These have a significant impact on people's social and economic lives, which lead to poverty and impede their development [11]. All because, they become unproductive, and those who are badly afflicted spend all of their time and money roughly $20 per year, or 15% of their yearly income on their health and medical treatment [12]. It was estimated in 2017 that 99 percent out of the estimated 20.8 million onchocerciasis cases came from the poorest and most vulnerable populations of SSA [13]. Out of the 218 million people, about 25 million people are infected globally and 90 million people are highly at risk of the disease with more than 99% of the cases coming from 31 countries in the SSA [14]. Of those who are infected, 14.6 million suffer from skin disease and 1.15 million population has been estimated to experience loss of sight while 220,000 are confirmed to be completely blind which caused 1, 136,000 Disability Adjusted Life Years in 2015 [14][15][16][17] and 1.23 million DALYs in [17]. The WHO's Onchocerciasis Control Program has effectively reduced the prevalence of onchocerciasis by interrupting the transmission of the parasite and by mass population treatment in the regions at risk of the disease [7]. The widespread use of ivermectin therapy is essential for managing and eradicating onchocerciasis as a public health issue, which will help to stop the pandemic of neglected tropical diseases by 2030 [15]. From WHO report, efforts to stop the spread of the disease have improved as of 2020, but six countries saw a 27% reduction in coverage as a result of their inability to carry out large-scale treatment plans, which was made worse when the covid pandemic first appeared [15]. In response, several studies contend that community involvement is essential for managing and eradicating onchocerciasis or even all NTDs, particularly in areas with limited resources [18]. Additionally, the health system has implemented test-and-treat procedures, which are meant to identify patients who require therapy, need to stop receiving it due to side effects, or do not require it [19]. Ivermectin Mass Drug Administration remains the primary method for controlling with effort of eradicating onchocerciasis in Ghana [20]. Despite several years of MDA with ivermectin, infection with onchocerciasis and the commonly associated clinical manifestations of the disease still persist in many regions and districts across Ghana [20]. Despite the significant reduction in the prevalence of onchocerciasis in Ghana, there are still communities with positive microfilaria prevalence above 1% [21]. For instance, a study carried out in three communities in Ghana showed that the prevalence of microfilaria in the communities were 13.2, 2.4, and 2.9%, respectively [20]. Adolescents are among the school-going children that are targeted by the Ghana Health Service for MDA program and other interventions that are targeted toward the elimination of onchocerciasis in Ghana because adolescents are among the highest group at risk of onchocerciasis in the Nkwanta North District of Oti region. Despite these efforts, recent observations within the district show that more and more adolescents are diagnosed and treated for --- PLOS NEGLECTED TROPICAL DISEASES onchocerciasis. There are limited scientific studies documenting adolescents'perceptions regarding the management of onchocerciasis and the support that is available to them. In this view this study sought to explore the adolescents' perception regarding the management of onchocerciasis, community and health system support in Nkwanta North District of Ghana. --- Methods --- Ethical approval and consent to participate This study was approved by the University of Health and Allied Sciences Review Committee . Consent to participate in the study was also obtained through written informed consent forms and parental assent forms from the participants and their parents. All methods were carried out following relevant guidelines and regulations. The reporting of this study is guided by the consolidated criteria for reporting qualitative research [20]. --- Setting The study was conducted in Nkwanta North District of the Oti Region, Ghana. The district is located in the north-eastern part of Ghana. The district is located between Latitude 7˚30'N and 8˚45'N and Longitude 0˚10'W and 045'E [22]. The District Capital, Kpassa is located 270 km to the South of Ho . The population of Nkwanta North District, according to the 2010 Population and Housing Census, is 64,553 representing 3.0 percent of the region's total population [22]. The Nkwanta North District is one of the districts in the Oti Region with the highest level of onchocerciasis prevalence and adolescents are most at risk of the infection [23]. --- Design This study adopted a qualitative phenomenological design and exploratory descriptive qualitative approach. This design and approach were adopted in this stusy to facilitate an in-depth exploration of adolescents' illness experiences of onchocerciasis. The phenomenological design was used in this study because we sought to hear adolescents affected by onchocerciasis tell their experiences about living with onchocerciasis. This gave us an in-depth understanding of their perceptions of the condition and its management using both routine MDA and TNT procedures [24] using in-depth interviews. --- Study population The main target population for the study was adolescents between 10 and 19 years old who were affected by onchocerciasis in the Nkwanta North District at the time of data collection for the study. --- Sampling The purposive and snowball sampling strategies were used in selecting participants for this study. The adolescents were selected based on whether they still have the disease and are on treatment or have just completed treatment. The adolescents who have completed their treatment within one year of the time of this study were selected because they can provide rich information on the issues being studied. They were chosen on the basis that they represent a specific perspective on the phenomenon rather than a population [25]. Gatekeepers and key informants such as chiefs, queen mothers, assembly members, Nurses, and public health officers were used as a means of gaining access to the adolescents. --- Sample size We sampled 16 adolescents for the conduct of this study. Our sample size was based on data saturation. --- Data collection Data were collected using in-depth interviews in collecting data from the participants through face-to-face interactions. Data for this study were collected using an in-depth interview guide. A structured data collection tool was used to collect data on the socio-demographic characteristics of the participants. The interviews were conducted in the homes of the participants. The interviews were conducted in English and Ghanaian languages . The choice of local language for the conduct of the interviews was to ensure that we have in-depth information without any language barrier challenges. To ensure that the use of the local languages did not affect the quality of data collected, the researchers who could not speak the local language were assisted by interpreters that speak the local language fluently. All interviews were recorded using a digital audio recording device, permission was obtained from all participants to record each interview. Hand-written notes were taken during the interview process to record responses given by the participants. The purpose of using both the audio recorder and hand-written notes is to ensure that the interview process is not halted should any of the equipment breakdowns during the interview process. To ensure the trustworthiness of the instrument, interview guides were given to experts in qualitative research to peruse the appropriateness of the questions before we used them. --- Ethical considerations Ethical clearance was obtained from the University of Health and Allied Sciences Review Committee and permission was sought from the district assembly and district health directorate before data was collected. Provision was made for the translation and interpretation of the instrument into Ewe and other local languages that are mostly understood and spoken by a large proportion of people in the study setting. Written informed consent was obtained from participants who were above 18 years. However, for participants who were below 18 years and were still minors during the time of the data collection, both individual from the adolescents and parental consents were sought before adolescents were interviewed. This had been done by giving them informed consent and parental ascent form forms to sign, indicating their willingness to participate in the study. For those adolescents whose parents were not available during the data collection; we obtained their consent and ascent of their respective guardians before their participation in the study. Participation was purely voluntary and they were informed of their right to withdraw from the study at any time. This had been done by giving them written informed consent and parental assent forms to the parents or guardians to sign, indicating their willingness to participate in the study. The purpose of the study was also explained to the parents/guardians and also to the adolescents themselves before interviewing them. They were informed of their right to stop at any point in time of the interview process when they feel so and also assured that any statement or comments including that of privacy will remain protected after the data collection. Participants and their parents/guardians were identified and approached with the help of key informants . Since the interviews were carried out in the home of the participants, their parents were informed about the study by visiting them in their homes. All the parents and the participants voluntarily agreed to participate in the study. The confidentiality of the participants was adhered to by ensuring that no information from participants was disclosed to any third party. The respondents were identified by codes and numbers instead of their real names. All the interviews were conducted by qualitative researchers with the support of research assistants who were well-trained in qualitative data collection. The computer which was used for the transcription of interviews was protected with passwords. --- Data analysis All recorded interviews were transcribed verbatim into a word document in English before codes and themes were developed thematically using ATLAS.ti. v7.5. Transcripts were analysed thematically [25]. Familiarization with the data was done to take note of key ideas and recurrent themes. Coding was done based on the research objectives as well as themes that emerged from the data itself. Quotes from the participants were used in presenting the data to substantiate issues discussed by participants. The initial themes that were developed were reviewed and refined into final themes taking into consideration internal homogeneity and external heterogeneity [26]. The themes were defined and named and a detailed analysis was conducted and written based on how they fit into the broader story of the data. A frequency table was, however, used to present the socio-demographic characteristics of the participants. --- Results --- Participants' profile Table 1 presents the profile of the participants. We noted that 12 of the participants were aged 15-18 years old. Regarding the educational status of the participants, we noted that most of them 6 were still in Junior High School while 4 were in Senior High School . Approximately, 6 of the participants had lived with the condition for 1-5 years and 6-10 years respectively. However, 4 of them had lived with the condition for more than 10 years. --- Thematic results Adolescents perceptions of mode of transmission and risk factors of onchocerciasis and its management. Table 2 presents the themes derived from the interviews conducted among onchocerciasis adolescents on the meaning created by onchocerciasis. Four main themes were realized. These were; Community perception of the mode of transmission and risk factors of Onchocerciasis, adolescents perception of the mode of transmission and risk factors of Onchocerciasis, adolescents' perceptions of ivermectin treatment of onchocerciasis and adolescents' experience regarding Ivermectin treatment. Regarding perception of the mode of transmission and risk factors of Onchocerciasis, most of the participants indicated that the community members have diverse perceptions regarding onchocerciasis. According to the adolescents, the community members believe that onchocerciasis is a serious disease that can cause blindness. Adolescents further stated that most of the community members believe that it is caused by the bite of insects while some of them also believe that it is caused by the consumption of some types of food products or stressful work . The following quotes summarised some of the responses from the participants "People say the condition can lead to eye blindness and there will be some worms on your eyes when you have such a condition. The condition mostly affects the eyes" Female Participant, 18 years --- PLOS NEGLECTED TROPICAL DISEASES "Some people say that there are types of food which are not supposed to be eaten and once eaten, you will get the disease." Concerning the adolescents' perception of the mode of transmission and risk factors of Onchocerciasis; most of the adolescents believed that onchocerciasis is caused by insect bites, blood infection [genetic infection], poor environmental hygiene, and sun. Also, others noted the disease could have been inherited from parents. The following quotes summarise some of the views of the adolescents: "I know the disease is hidden in some foods, so once we eat that food, we get infected. Food like maize has to be milled and mixed with another food item to prepare food, so the infection can be hidden in such foods, and once eaten, you get the disease. Also, when you go to the farm, insects like mosquitos and millipede and centipede can bite you and give you the disease." --- Male --- Male Participant, 18 years "What I know is that the disease affects the eyes and I can become blind, and I also believe when you stay under the sun for long . . ." Female Participant, 18 years "When I was growing up, I realized that there was something like a ball on my father's body, also, I have seen that something on my body as well. I think the condition is something in the blood because my father was also having it." --- Male Participant, 18 years Vis-à-vis of the adolescents' perception of the ivermectin treatment as part of the management of the condition, most of the adolescents specified in their interviews that the ivermectin treatment has led to positive change in the condition by helping relieve the symptoms they were previously experiencing. The following quotes represented the views of some of the adolescents: "The drug has helped me a lot the pains I used to feel in my body and joints are no more after I took that drug. It has helped me because all the challenges I have by then were all resolved after I took the drug." Concerning the adolescents' experiences regarding Ivermectin use, all the participants indicated that after the use of Ivermectin, they experienced, mild to severe side effects including fever, headache, body itching, rushes, swollen body, and blurred vision. The following quotes summarise some of the views of the adolescents: "When I took the medicine the whole of my body became swollen, and my body itches but that only lasted for some time, the pains I felt became normal and I can now see well as compared to the previous time. --- Male Participant, 18 years --- Community and health system support Table 3 presents the themes derived from the interviews conducted among adolescents affected by onchocerciasis on community and health system support available for them during the management of their condition. Two themes emerged from the interviews: communitybased support and health system support. Regarding the community-based support available for adolescents, we noted that the community support available for the management of their condition mostly comes from family and relatives and the churches. Most of the adolescents also noted that they get support from church members, such as regular visits, encouragement, and prayers. This support serves as a moral boost and a coping mechanism for soothing adolescents from the pain they might have been going through at a particular moment. The following quotes represent the views of some of the adolescents: "Yes, my church members from the church where I and my parents worship came to check up on me on my return from the health facility." Female Participant, 16 years "Yes, I had support from my church people. Some gave me money and other things, and some also pray for me when they came to our house to visit me." --- Male Participant, 15 years The family support available for the adolescents as described in their interviews includes financial and social support . --- "My mother was helping me with water and other things I needed, my pastor and church members also prayed for me and some of my friends also came to visit me." Male Participant, 19 years "My father helping me with everything and my sister also has been giving me money to be managing myself and to take me to school when I came back from the hospital." Female Participant, 15 years Concerning the Health system-based supports, we noted the main supports that were available to the adolescents in the management of their condition included financial support, free treatment, a home visit , counseling, and education. Regarding the financial support, the participants indicated that the facilities that took care of them gave them money to take care of themselves when they get home. Financial support for the adolescents could be a way to encourage other infected people who have not reported to health facilities for treatment to seek care. The following are some of their views: ". . .I was given money to use to support ourselves for the time we have spent at the hospital." "For example, they gave me some amount of money to use to support myself when I get back home and for my time spent at the health facility leaving things I could have been doing when home. . ." --- Male Participant, 15 years Female Participant, 19 years ". . . they transported us to the health facility and they gave us some money to use to support our farm work for the time we have spent there leaving our farm. . ." --- Male Participant, 18 years Concerning the free treatment, the adolescents reported in their interviews that all the cost for the treatment of their condition was borne by the health facility without them paying any fees. "They always go around and dress our operated wounds for us explaining things to us about how to care for ourselves when we get back home, they did all these for free, I did not pay any money for my treatment. . ." Male Participant, 18 years "When we went to the hospital, the doctors did not take any money from us, and the drugs and operation were free of any charge, which was very helpful to us" Female Participant, 15 years Furthermore, the adolescents indicated that when they were at the facility, there were health professionals that specifically counseled and educated them on what to do or not to do so to get better faster and become healthier. "The doctor was going around and dressed our operated wound for us, educated us, and counsel us not to do any hard work till the wound is healed and also not to take drugs unnecessarily." Female Participant, 17 years "Yes, they educated us and asked us not to buy any medicine on our own when we are not feeling well but we should rather go to the hospital with the small card they gave us so that they will take care of us instead in other to prevent any complications." --- Male Participant, 19 years The interviews also showed that home visit was one strong part of the health system support which is available for adolescents affected by onchocerciasis. Some of the participants have these to say: "when I got home after the operation the doctor was still coming to my house to help dress my wounds till it got healed." Female Participant, 16 years "I was not given any medicines again but there was a doctor who normally comes around to dress my wounds in my house, if he will not come himself, there is a nurse that will come to do it for me in the house." Female Participant, 19 years "When I came back from the hospital, one of the nurses has been coming from time to time in my house to treat the wound and also make me take medicine." --- Male Participant, 19 years --- Discussion In our study, we explored the management of onchocerciasis among adolescents, perception, community, and health system support in Nkwanta North district of Ghana. We noted in this current study that community members have diverse perceptions of the mode of transmission and the risk factors of onchocerciasis. Some community members believe that onchocerciasis is a serious disease that can cause blindness, and some believe that it is caused by the consumption of some types of food products or stressful work. Adolescents themselves believed that onchocerciasis was caused by insect bite blood infection, poor environmental hygiene, sun, or could have been inherited from parents. These findings are consistent with previous studies [27][28][29][30][31]. The findings from our study where the adolescents reported that the community members believed that onchocerciasis is caused by consumption of food products or stressful work at the farm, poor environmental hygiene, sun or is inherited from parents at birth could be attributed to inadequate health education and information about NTDs among the general populaces especial those in the remote areas of the district where the mode of communication and information are limited [32][33][34]. These findings imply that more health education campaigns, including using community communication systems on onchocerciasis and other NTDs, is imperative to correct the misunderstandings or misperceptions of communities of the mode of transmission and the risk factors of Onchocerciasis. This is very important because people 's correct understanding of how diseases like onchocerciasis os transmitted could be crucial in their effort to take measures to prevent it. Concerning Ivermectin treatment, the adolescents reported in this study that it had a great positive impact on their condition as it had helped relieve symptoms they were experiencing before the initiation of the treatment. These findings are unswerving from the reports by the previous studies [35][36][37]. However, some of the adolescents also indicated that they had experienced some side effects, including fever, headache, body itching, rushes, swollen body, and blurred vision from the drug. These findings are consistent with the reports of the previous studies [38][39][40][41]. These experience of side effects could discourage some adolescents from taking the Ivermectin treatment or participating in the MDA programm,e that is one of the major strategies to eradicating onchocerciasis in Ghana. Therefore it is important health workers educate or inform the communities about the possible side effects of the Ivermectin treatment so that the community members who have received the treatment are not surprised by these side effects if they experience them. We found that the community support available for the management of onchocerciasis among adolescents was financial and emotional support , and these supports mostly come from family and relatives and church members. These supports were considered by the patients to have been very crucial during the treatment of their condition and recovery afterwards. Prayers, encouragement, and counselling from family and church members were reported by adolescents to have helped them emotionally and strengthened them to go through whatever pain they might have been experiencing as a result of the condition and also the anxiety and depression as a result of stigmatisation [18,[42][43][44][45][46]. This point to the protective factor of social support to people affected by onchocerciasis NTDs. Hence, it is important more steps are taken by programme planners and implimentaters to include education on social support into the interventions that are targeted at elimating or eradicating NTDs to educate communties on the importance of social support to the patients living with any of NTDs. This if well done could help maximise the level of community support among the communities and also help reduce the stigmatization. In this current study, we found that financial support, free treatment, home visit, counseling, and education were health system supports available to adolescents who suffered from onchocerciasis. These supports especially the financial and free treatment from the health system which were widely reported and appreciated by the adolescents could be ascribed to the fact that onchocerciasis, as one of the major NTDs, is known to disproportionately affect the most disadvantaged: the rural poor with reduced access to health care services, therefore free treatment was very important for the management of their condition and also fight the elimination of onchocerciasis [5,[47][48][49][50][51]. --- Strength and weakness The current study was a community-based study conducted in Nkwanta North District using an in-depth understanding of the lived experiences and the perceptions of adolescents of the mode of transmission of Onchocerciasis and its management. This has helped to explore the well-detailed scope of how patients infected with onchocerciasis live with their condition and how they effectively cope with daily life experiences. Despite the strength of this study, it also has some limitations. The use of in-depth interviews for the data collection in this research project could have introduced response bias on the part of the participants. The use of purposive as well as snowball sampling introduced the possibility of selection bias on the part of the data collectors. There might also be recall bias from the participants and social desirability bias on the requested data. The use of different languages and also the use of interpreters to collect the data could have distorted the presentation of the questions to the participants. --- Conclusion We found from the study that community members have diverse perceptions about onchocerciasis. Adolescents believed that onchocerciasis was caused by insect bites, poor environmental hygiene, or could have been inherited from parents. We noted in this study that adolescents believe that the Ivermectin treatment could have had a great positive impact on the condition as it has helped relieve the symptoms they were experiencing before the initiation of the treatment. Our research recognises that community and health system supports is very important in the effective management of onchocerciasis, contributing to the attainment of Sustainable Development Goal 3.3, which is targeted at ending the epidemic of NTDs like onchocerciasis by 2030. These findings call for more community-based education by health authorities to educate the communities on NTDs and how they are transmitted. As it could help address the diverse and erroneous perceptions the adolescents and the communities have of the onchocerciasis mode of transmission. Also, further measures need to be taken by Ghana Health Service to include educational programmes on social support in the interventions that are targeted at eliminating or eradicating NTDs to educate communities on the importance of social support to the patients affected by any of NTDs. --- All relevant data are within the manuscript. ---

Onchocerciasis affects the quality of life to a greater extent among affected individuals. The World Health Organization (WHO)'s Onchocerciasis Control Program (OCP) has effectively reduced the prevalence of onchocerciasis by interrupting the transmission of the parasite and by mass population treatment in the regions at risk of the disease. Despite the successful reduction of the prevalence of onchocerciasis by WHO, the socioeconomic burden resulting from the disabilities caused by onchocerciasis are still immense. This study sought to explore the adolescents' perception regarding the management of onchocerciasis, community and health system support in Nkwanta North District of Ghana.This study adopted a qualitative phenomenological design and exploratory, descriptive qualitative approach. An in-depth interview guide was developed to collect data for the study. One-on-one interview was conducted. Data collected from 16 onchocerciasis adolescent patients were analysed thematically using ATLAS.ti v7.5.7. Quotes from the participants were presented verbatim to substantiate the themes realised.Most of the 12 participants (75.0%) were aged 15-18 years old. It was noted that 6(37.50%) of participants were in Junior High School (JHS), while 4(25.0%) were in Senior High School (SHS). It was noted that community members have diverse understandings and perceptions of onchocerciasis, including beliefs that Onchocerciasis is a serious disease that can cause blindness; it is caused by the consumption of some types of food products or stressful work. Adolescents believed that onchocerciasis was caused by insect bite blood infection, poor PLOS NEGLECTED TROPICAL DISEASES

INTRODUCTION Skilled attendant at delivery is one of the key indicators used in assessing progress towards the Millennium Development Goal of improving maternal health .This is when a qualified health worker manages labour effectively, promptly identifies and manages complications and adequately supports with effective referral systems for specialised care when needed . The global target is for at least 90% of births to be supervised by Skilled Birth Attendants worldwide by 2015 . However, for developing countries, the International Confederation of Mid-wives and International Federation of Gynaecology and Obstetrics in 2002 proposed a target of one skilled birth attendant for every 5,000 populations. This means that a skilled attendant can be expected to attend 200 births every year . Vol. 27 Empirical evidences have shown that early and regular attendance of antenatal care by pregnant women and delivery under supervision of a skilled attendant are associated with improved reproductive health outcomes with resultant decrease in maternal and peri-natal deaths . Studies have shown that SBA presence at delivery could prevent around 16% to 33% of maternal deaths . In fact, countries where SBA are utilized at delivery have reduced maternal mortality rate to as low as 50 per 100,000 live births . Sub-Saharan Africa currently contributes to 57% of the 358,000 global maternal deaths . The life time risk of a woman dying during pregnancy, childbirth or in the early postnatal period is also very high in this sub-region; 1 in 31 compared to 1 in 4300 in developed regions . Regrettably, greater than one-third of the approximately 2.65 million stillbirths and 3.3 million neonatal deaths globally occur in SSA . Generally, the proportion of SBA supervised births in developing regions increased from 53% in 1990 to 61% in 2007; yet in South Asia and Sub Sahara Africa , this figure remained less than 50% . Moreover, a substantial proportion of antenatal care users do not deliver with skilled attendants, and a significant proportion of mothers in developing countries still deliver at home unattended by SBA . In Nigeria, the National Demographic and Health Survey 2013 reports an overall coverage of 38% for SBA at delivery, which partly explains the high maternal mortality ratio of 576 maternal deaths per 100,000 live births in the country . This grave scenario requires more researches to help in identifying factors that are associated with utilization of skilled care at births among pregnant women. This study has the potential of providing useful information for evidence-based decision making for policy makers working in the field of maternal and child health. The study design was descriptive crosssectional survey. Aminimum sample size of 369 was calculated using the Leslie-Kish formula for estimating single proportion . According to the 2013 NDHS, 38% of deliveries were supervised by skilled birth attendants with the margin of error set at 5%. The sample size was increased to 409 using a non-response rate of 10%. All consenting women in the reproductive age group of 15-49 years with history of childbirths within 12 months preceding the survey were interviewed. Women who were too ill to give required information were exempted from the study. --- METHODS --- Study site: The respondents were selected using multistage sampling technique. In the first stage, one ward was selected by balloting from the 12 electoral wards in Ilorin, West LGA. In the second stage, one enumeration area was selected by balloting from all the enumeration areas in the selected ward. In the third stage, all households in the selected enumeration area were recruited into the study. In the fourth stage, all eligible women were approached in the selected households to recruit them till the sample size was achieved. Data collection method and instruments: Data were collected using semi-structured interviewerguided questionnaire based on findings from previous studies. The questionnaire was written in English language but translated into Yoruba, which is the major language spoken by the study population, and back translated into English language. The instrument was used to collect information on respondents' socio-demographic characteristics, antenatal and delivery care practices. --- Data analysis: The data were field-edited daily and Statistical Package for Social Sciences version 21 was used for analysis. Data were analysed using descriptive and inferential statistics. Bivariate chisquare test and multivariate logistic analyses were performed on respondents' characteristics and factors that significantly predict availability of SBA at delivery. Adjusted odd ratio and 95% CI were presented and used as measures of the strength of association. A p value <0.05 was accepted as significant. Respondents' socio-economic status: Using Oyedeji's classification of Social Class , respondents' socio-economic status was classified into three: low, middle and high. This classification used a composite score of respondents' educational levels and occupational types of their spouses; both were scored. The score ranged from 1 to 5 for respondents' educational level and spousal occupational types respectively. Respondents'scores from each of the occupational and educational categories were added together and rated out of 10. Those who scored less than 5 points were grouped into lower social class; scores from 5 to 7 points were grouped into middle social class while those who scored between 8-10 points were grouped into high social class. --- Ethical consideration: Approval to conduct the study was obtained from the Bowen University Ethical Review Committee and permission received from the Department of Primary Health Care, Ilorin, Central LGA. Written consent was obtained from study participants before they were allowed to participate in the study. Participation was entirely voluntary, and confidentiality was ensured. Study participants detected not to have used skilled birth attendants in the last delivery were adequately counselled against such practices in their subsequent deliveries. --- RESULTS A total of 400 copies of the questionnaire were considered satisfactorily completed by the respondents and were analysed out of the 420 that were administered . The mean age of the respondents was 30.3±6.0 years. Seventy-five percent of the respondents were married, while 58.3% had tertiary education. Most, , belonged to the middle socioeconomic class. The majority had their first pregnancies when they were ≥ 20 years of age, while 58.0% had two to four children . 4 shows that the proportion of women who delivered with SBA was significantly higher among women within the 30-39 age group, those with tertiary education, high socioeconomic status and whose age at first pregnancy was ≥20 years . Higher proportion of respondents who delivered with SBA belonged to those who had ANC visits, received ANC in private hospitals, and those living within 10-30 minutes walking distance to places of deliveries . --- DISCUSSION This study assessed the factors associated with the use of skilled delivery care among women in Ilorin, Northcentral Nigeria. It reported that most women received ANC in their last pregnancies during which discussions on major danger signs in pregnancy, labour and puerperium were done. This agrees with the 2013 NDHS report for Nigeria which shows that 67% of the women in Northgentral Nigeria received ANC from skilled personnel . However, studies elsewhere reported differing figures such as 31% in Nepal and 34% in Ethiopia . Good ANC practice has been proven to correlate positively with availability of SBA at births . Husbands were the main decision makers with regard to where to receive ANC service in most respondents. Most communities in Nigeria practice patrimonial family system where most decisions are taken by men who are often the heads of the families. Families with supportive husbands in reproductive matters are more likely to utilize maternal health services compared to families where women take reproductive actions independent of their husbands . AOR=adjusted odds ratio CI=confidence interval *significant at p<0.05 Almost three-quarter of the respondents in the current study had their deliveries supervised by SBA. According to the Nigerian NDHS report for 2013, 46.5% of the women in the Northcentral geopolitical zone had SBA present during their deliveries, which was the fourth highest figure among the six geopolitical zones in Nigeria . The reason for the increased figure reported in the current study could have been due to socio-economic class and urban location of our respondents. These could have impacted positively on their knowledge-base subsequently creating a positive health-seeking behaviour with regard to delivery care utilization which is mostly present in the urban communities. In the current study, having SBA at births was significantly associated with age ≥20 years and having higher education. Age and education status have been reported as important socio-demographic variables determining maternal healthcare services utilization . Our finding could have been due to the fact that pregnant adolescents in developing countries tend to have inadequate knowledge about reproductive health matters and are usually in poor financial status. Hence, they are less likely to have access to high quality obstetric services provided by SBA. This study reported that respondents who attended at least one ANC visit were more likely to have SBA at delivery. This could be because these respondents have received appropriate health information during their ANC visits regarding benefits of SBA utilization. Moreover, our study revealed that respondents who had one child had significantly increased odds of SBA uptake compared to those with five or more children. Besides, respondents whose homes were within walking distances from tend to deliver with SBA.These findings are in keeping with previous research . Long distances could discourage SBA utilization among pregnant women particularly in developing countries with poor road networks and high level of insecurity. Since the survey relied on information voluntarily provided by the respondents, the study may not be totally free from information bias as all the answers given may not be a true representation of actual utilization of SBA. Effort was made to minimize this bias by explaining in details how their response wound assist policy makers in designing cost-effective "safe delivery programmes" for pregnant women in Nigeria. In conclusion, although most women in the Northcentral geopolitical zone of Nigeria utilized SBA as revealed by the current study; it is below the global target of ≥90% of deliveries being supervised by SBA. Thus, more efforts are required to ensure SBA at each delivery. In achieving this goal, stakeholders must guarantee enough health facilities offering Basic and Comprehensive obstetric care services to stem the tide of maternal deaths in Nigeria and other African countries thereby making the Sustainable Development Goals a reality.

; 10.94, 95% CI; 3.60-33.26), having only one child (AOR; 4.33, 95% CI; 1.18-15.82), having at least 4 ANC attendance (AOR; 18.84, 95% CI; 8.95-55.82) and residing near delivery sites (AOR; 11.49, 95% CI; 2.43-55.56). CONCLUSION: The proportion of births supervised by SBA needs improvement in Northcentral Nigeria. Full implementation of reproductive health policies will enhance skilled births in Nigeria.

Introduction Foreign-born residents, or immigrants, comprise an increasingly significant proportion of the United States population, but have been underserved in public health promotion [1]. Acculturation to U.S. cultural practices by immigrants is associated with greater likelihood of having chronic health conditions [2]. However, the estimated health impact of acculturation depends on how acculturation is measured [3,4]. Acculturation was initially conceptualized as a unidirectional process where immigrants acquired the values, practices, and beliefs of their new homeland while simultaneously discarding those from their cultural heritage [5]. More recent views of acculturation acknowledge that immigrants frequently maintain features of their original culture in their personal lives and adapt to their host culture in their public lives [6][7][8]. Nonetheless, unidirectional measures of acculturation are still widely used [3,4,9]. Language preference, country of nativity, and duration of residence in the U.S. are used as proxy measures of acculturation in Latino and Asian immigrant health studies [3,4]. However, language use may not be an adequate proxy for Asian Indians because many were exposed to English language from an early age in elementary school classes taught in India [10]. Duration of residence in the host country has also been criticized as a proxy measure because the Indian diaspora led to many Asian Indians living in other developed countries where they were exposed to Western cultural values prior to immigrating to the U.S. [11]. Measures that assess several domains of acculturation, such as social relationships, cultural activities, and linguistic preference, are thought to be more valid than proxy measures [12,13]. However, many scales lack a conceptual framework of acculturation and are rarely used in studies evaluating health behaviors or outcomes because of respondent burden and costs [3]. Given that proxy measures are often the only available indicators of acculturation in many of the data sets routinely used to study the health of Asian Americans, it is important to know how valid they are as measures of acculturation. The California Asian Indian Tobacco Survey provides an opportunity to evaluate temporal measures of acculturation, such as duration of residence in the U.S. CAITS was a multilingual, population-based assessment of Asian Indians that contains several measures of acculturation. Our objective was to examine the association of temporal measures with self-reported measures of acculturation among Asian Indians, one of the fastest growing ethnic groups in the U.S. [14]. In addition, given that no commonly accepted acculturation scale exists for Asian Indians, we created an acculturation scale using existing survey items and report the properties of the scale. --- Methods --- Data Source CAITS was a 27-min multilingual telephone tobacco use and health survey administered to 3,228 adults of Asian Indian background and resident in California in 2004 [15]. Surnames for CAITS were compiled from names from Social Security [16] and through the Vital Statistic Office for the California Department of Health Services from 1998-2002. Using a stratified random sample, CAITS had a household response rate of 67% and randomly selected interviewee response rate of 81% [15]. We received IRB exemption from the University of California, Los Angeles for these analyses . --- Measures Three temporal measures of acculturation were examined as dependent variables: duration of residence in the U.S., percentage of lifetime in the U.S., and age at immigration. Duration of residence in years was calculated by subtracting the survey year from the year the respondent entered the U.S. Percentage of lifetime was calculated from duration of residence in the U.S. divided by respondent's current age, and age at immigration was calculated from year entered the U.S. minus the respondent's birth year. These measures were only answered by foreign-born respondents . Acculturation measures were 11 questions that represented six aspects of acculturation: language use, media behavior, social customs, social contacts, cultural identity, and generational status. These items have been included in existing scales of acculturation [9,12,13]. Table 1 provides a description of the core items and possible responses. "Language of the interview" was dichotomized into English or Asian Indian language. "How open would you be to your son marrying outside of cultural group" and "How open would you be to your daughter marrying outside of cultural group?" correlated at r = 0.95. To deal with local dependency, we generated a new variable "How open would you be to your child marrying outside of cultural group" using the average of the two responses. Of note, respondents were not given a definition or characteristics of a cultural group prior to their response. "Nativity" and "Generational status" correlated at r = 0.75 and responses from both questions were averaged together as a single item. --- Analysis Plan First, we examined the mean number of years lived in the U.S., mean percentage of lifetime in the U.S., and mean age at immigration by responses to the acculturation items. Responses to the acculturation items were analyzed both in their original categories and after dichotomization, but we only report the former because the results were similar. We also conducted standard contingency table analysis to identify meaningful temporal measure cutoff points that differed between more American acculturated responses and less acculturated responses [17]. The reference category was a dichotomized acculturation item and the classification category was the temporal measure [17]. Acculturation items were dichotomized as 0 for less acculturated or 1 for more acculturated to American culture. For example, responses for "how often do you keep in contact with family and friends in India?" were dichotomized into those who responded "very often," "somewhat often," or "neither often or rarely" versus those who responded "somewhat rarely" or "very rarely". We used a specificity cut point ≥0.70. Second, we conducted exploratory factor analyses to evaluate the dimensionality of the items in the overall acculturation scale [18]. Several factor criteria were examined to help determine the number of factors. Oblique factor rotations were then run for the plausible number of underlying factors. Confirmatory factor analysis was conducted to evaluate the fit of alternative models for the data. The goodness-of-fit of the confirmatory factor analysis models was evaluated using the Chi square statistic, the comparative fit index , and the root mean squared error of approximation . Models with a CFI of 0.90 and RMSEA ≤0.06 may be considered acceptable [18,19]. Third, we transformed linearly the recoded 11 acculturation scale items to a 0-100 possible range. For example, the item "how often do you speak your native language at home?" had five response categories labeled 1 through 5 that were recoded to 0, 25, 50, 75, 100 . The 11 items were then averaged together to produce the scale score. Item descriptives, item-scale correlations, internal consistency reliability , and Pearson product-moment correlations of the scale with the temporal measures were estimated. Post-stratification weights were used in the analyses to correct for non-coverage and differential non-response. The post-stratification adjustments were stratified by gender and age grouping, and counties were grouped by 12 California regions used in previous tobacco control research [15]. The analyses were conducted using STATA 11.2. --- Results --- Sample Demographics The average age of the sample was 37 years . Most respondents were male and well-educated. Foreign-born respondents had a mean duration of residence in the U.S. of 13 years, or one-third of their lifetime spent in the U.S. The median age at immigration to the U.S. was 25 years old. --- Construct Validity of Temporal Measures In general, greater duration of residence in the U.S., greater percentage of lifetime in the U.S., and younger age at immigration were associated with endorsing items indicative of increased acculturation . Specifically, with increasing duration of residence in the U.S., Asian Indian immigrants were more likely to prefer English as their primary language and as their preferred language used in the interview . Asian Indian immigrants who had lived for a greater duration in the U.S. were less likely to speak their native language at home , read Indian media , observe traditional cultural or religious holidays , and stay in contact with family and friends in India . Living more years in the U.S. was significantly associated with second or greater generational status and with respondent birth in a developed country. There was a non-linear relationship between frequency of Indian food consumption or openness to respondent's child marrying outside the cultural group and duration of residence in the U.S. Small sample sizes in some response categories may explain the lack of a linear relationship; inappropriate measures of acculturation for Asian Indians may be another explanation. For example, marriage outside of a cultural group may have been interpreted as marriage to someone of Indian descent but of a different Indian language/culture/religion, as opposed to marriage to someone of a different race/ethnicity. Contingency table analysis suggested a meaningful cutoff at 12-16 years duration of residence in the U.S. and 34-40% for percentage of lifetime in the U.S. between respondents who were more versus less acculturated to American culture. Product-moment correlations between self-reported acculturation items and duration of residence in the U.S. ranged from r = 0.05 for generational status to r = 0.32 for ethnic identity. Correlations of percentage of lifetime in the U.S. with acculturation items ranged from r = 0.10 for marriage of child outside cultural group to r = 0.54 for generational status. Age at immigration had a negative linear relationship with most acculturation items except native language spoken at home, frequency of Indian food consumption, and contacts with family and friends in India. Correlations between acculturation items and age at immigration ranged from r = -0.04 for contact with family and friends in India to r = -0.42 for generational status. Age at immigration had a meaningful cut-off at 29-31 years of age between the more versus less acculturated respondents. We would expect measures that assess acculturation domains to be negatively correlated with age at immigration because acculturation varies depending on whether the immigrant arrived as an adult or as a child, with the latter group more closely resembling the native-born population reportedly due to less exposure and ties to their country of origin [20]. --- Acculturation Scale Various factor criteria suggested that between 2 and 4 factors were sufficient to explain most of the shared variance. Simple structure was optimized for the two-factor Promax obliquely rotated solution . The estimated correlation between the two factors was 0.23: Factor 1 appears to represent frequency of engaging in Indian cultural behaviors and Factor 2 corresponds to the influence of Indian culture on social behaviors in the U.S. . To improve model fit, we estimated five correlated errors suggested by Lagrange multiple indices. Factor loadings were statistically significant and moderate to large in size . The CFI for the two-factor model was 0.89 and the RMSEA was 0.07, suggestive of an acceptable fit [16,17]. Despite some evidence of two potential domains underlying the 11 acculturation items, internal consistency reliability estimates were only 0.70 for engagement in Indian cultural behaviors and 0.59 for influence of Indian culture on social behaviors in the U.S. scales. Internal consistency reliability for the 11-item scale was 0.73 and item-scale correlations ranged from 0.28-0.55 . The 11-item acculturation scale had a mean of 39 and a standard deviation of 17, skewness was 0.45, and kurtosis of 3.04. The CFI for the one-factor model was 0.65 and the RMSEA was 0.10, indices suggesting suboptimal fit [16,17]. Product-moment correlations of the scale with duration of residence in the U.S. was r = 0.37, with percentage of lifetime in the U.S. was r = 0.45, and with age at immigration was r = -0.34; p < 0.001 for correlations. There was a linear relationship between the acculturation scale score and duration of residence in the U.S. . --- Discussion This study examined the associations of temporal measures with direct measures of acculturation among Asian Indians. While temporal measures may only partially capture acculturation, duration of residence or percentage of lifetime in the U.S. may be better proxies for acculturation than English preference or country of nativity for this population. Studies of Asians Indians cannot rely on language use as a proxy for acculturation because large majorities of Asian Indian immigrants are proficient English speakers [10,21]. Additionally, Asian Indians who immigrate to the U.S. may have spent significant time in a Westernized country prior to immigration to the U.S., although we were not able to quantify that percentage in our sample except for nativity in a developed country [11]. Our study had several limitations. We developed a shorter acculturation scale than those used in the literature for Asians, with nonetheless acceptable reliability for group measurements, but not for individual level measurement [22]. Our scale was predicated on a unidirectional process of acculturation, or a linear relationship between moving from one cultural identity to the other over time [5]. While the strength of this assimilation model of acculturation is its simplicity, this model has been criticized for not allowing ethnic minorities to have bicultural identities, despite the fact that many ethnic minorities describe themselves as such [7,8,23]. As previously mentioned, temporal measures of acculturation have also been criticized. However, proxy measurement and unidirectional scales continue to be widely used in immigrant health research because of the practical and financial challenges of using more indepth psychometric scales and lack of a sound theoretical approach to acculturation-related health research [24,25]. Despite these limitations, the 11-item scale captured the breadth of acculturation. The correlations of the scale were comparable to previously reported correlations of the 21-item Suinn-Lew Asian Self-Identity Acculturation Scale with duration of residence in the U.S. and age at immigration [13]. Some have criticized the use of acculturation in health research given the conceptual and methodological difficulties with the construct, as well as its limitation as a modifiable factor in health promotion [26,27]. Given these concerns, studies examining acculturation and healthcare should also account for modifiable access and utilization indicators, such as health insurance coverage, usual source of care, patient-provider communication, and socioeconomic status [27]. Specifically for Asian Indians who may be insular in their social activities and cultural practices, a greater understanding of these variables may be useful in explaining health outcomes in this growing minority population. Mean acculturation score by duration of residence in the U.S. among Asian Indian immigrants. Higher acculturation score correlates with greater acculturation to American culture --- Table 1 Acculturation Scale core items, lower-level domains, and responses --- Items Responses Language use For the 2-factor model with correlated residuals, the goodness-of-fit df = 29, Chi square = 392.66, CFI = 0.89, RMSEA = 0.7, indicating an acceptable fit. The correlated residuals for Factor 1 were home language preference and preference for Indian food , frequency of contact with family/friends in India and generational status/nativity , and preference for Indian media and frequency of contact with family/ friends in India ; the correlated residuals for Factor 2 were English fluency and respondent choice of language in the interview and interview language and openness of one's child marrying outside one's cultural group

There are few validated acculturation measures for Asian Indians in the U.S. We used the 2004 California Asian Indian Tobacco Survey to examine the relationship between temporal measures and eleven self-reported measures of acculturation. These items were combined to form an acculturation scale. We performed psychometric analysis of scale properties. Greater duration of residence in the U.S., greater percentage of lifetime in the U.S., and younger age at immigration were associated with more acculturated responses to the items for Asian Indians. Item-scale correlations for the 11-item acculturation scale ranged from 0.28-0.55 and internal consistency reliability was 0.73. Some support was found for a two-factor solution; one factor corresponding to cultural activities (α = 0.70) and the other to social behaviors (α = 0.59). Temporal measures only partially capture the full dimensions of acculturation. Our scale captured several domains and possibly two dimensions of acculturation.

I. Introduction A wall is more or less white than another wall we can see or imagine. So, our subjectivity, with the wealth of comparisons it implants in us, transforms us into tourists of ourselves, visitors of the odd sights of everyday life. It removes the dull sense that anything at all is obvious. Arlie Russell Hochschild 1 Long-term care nursing and personal care homes provide specialized medical and social care to society's most vulnerable, including younger but mostly older adults with multiple health ailments and disabilities. These are complex organizations, 2 providing ever more highly acute medical and social care, owned by for-profit, non-profit, and public entities and governed by intersecting regulations that structure tableside and bedside work. The sector's complexity drives debate about its regulation; as Kieran Walshe argues, "[n]ursing home regulation remains the constant subject of policy attention…." 3 In the context of this complexity, how states should regulate to best guarantee good living conditions and care for residents while maintaining good working conditions for staff are important considerations and the focus of this paper. Who does what work, how it is organized, and how many people are available to do it are arguably the most important factors affecting residents' receipt of quality social and health care, so it is particularly important to have the right staffing regulations. 4 Interestingly, despite the similarity of residents' needs and of LTC work tasks, staffing is regulated and organized quite differently depending on country, regional, and organizational contexts. This variety in the face of similarity invites us to explore the regulatory structures in LTC by investigating the nature and form of macro level staffing regulations -which can be either highly prescriptive or more interpretive -in connection with frontline work organization. We define prescriptive regulation as a tendency to identify which staff should do what work and when and how they should do it. Interpretative regulation reflects a tendency to broadly define care but not which staff should do it, nor when and how they should do it. The variety also allows us to explore how frontline care workers react, resist, and respond to the tensions between the regulatory context and the needs of the situation that they encounter in their everyday work. Drawing on the conceptual framework afforded by Gøsta Esping-Andersen's three worlds of welfare capitalism, we examine care work regulation and frontline work organization with examples of music activities, medication dispersal, and dining in liberal, conservative and social democratic regimes, in Canada, Germany, and Norway respectively. 5 This paper seeks to answer three questions. Where do each jurisdiction's staffing regulations fall on the prescription -interpretation continuum? What are frontline care workers' strategies for accomplishing everyday social, health and dining care tasks? Furthermore, in what ways does a policy-level prescriptive or interpretive regulatory approach affect the potential for promising practices to emerge on the frontlines of care work? Following the literature review in section II, section III outlines the study's methods. In section IV, we first describe the LTC regulatory context in each of Ontario, Manitoba, and British Columbia, --- II. Literature Review Like Peter Jacobson, we use regulation as a term inclusive of government-level legislative and administrative oversight. 6 Specific to the LTC sector, regulation has been described as interrelated policy approaches that control quality and guard against abuses; standards to make care practices consistent and to match outcomes to targets; and market-based incentive schemes like performance-based measurement and internal competition. 7 Both definitions of the term focus on government roles but ignore social relations. Our notion is more expansive, draws on feminist political economy 8 and includes the range of norms, values, and ethics that structure and frame who does what work, under what conditions, and with what consequences. As a result, we define care work regulation as the range of laws, rules, norms, ethics, values, and systems that structure care work and workers' actions and activities. Given our broader definition, we draw on several literatures focused on institutional health and social care work at multiple levels of analysis. We consider overarching gender norms and debates about ownership and profit in care; conceptual frameworks addressing forms of government LTC regulation; and additional layers of regulation emanating from professional ethics, self-regulation, and accreditation. --- Gender Norms LTC houses a mostly female clientele in need of intimate social, emotional, and medical care; and employs a mostly female workforce of healthcare professionals and non-professionals . The ratio of professionals differs jurisdictionally. In the literature, care work is understood as complex but in practice it is treated as less skilled and less highly paid work compared with other sectors. Early feminist scholars were vocal about the gendered nature of care, 9 its status as skilled work in both its paid and unpaid forms 10 and its position within formal production and informal reproduction systems. 11 There is little debate that this workspace is structured by overarching gender norms and expectations about women's capacities and sense of duty to care. With its feminized labour force there is the expectation that labour will be "endlessly stretchable" and fill care gaps to address residents' needs in the face of austere systems and familial care. 12 LTC is thus a highly gendered home space and workplace regulated by overarching gendered norms and expectations of women that are shared across places but with obligations to provide familial care that are place specific. --- "Private" in LTC Regulation In the context of the LTC regulation, "private" involves delivery , payment , quality , and standards . There are different levels of for-profit, non-profit, and public sector delivery based on a jurisdiction's historical context and social welfare approaches. 13 Even so, there remains considerable debate about the impact of ownership on the quality of residents' care. At an aggregate level, studies have shown that commercial provision of care can have negative quality implications, on balance showing higher quality in non-profit and public facilities on important quality measures for residents' clinical outcomes. 14 There remains a knowledge gap about the impact of ownership on the quality of LTC working conditions. In contrast, there is little current policy debate about user fees, because governments in all countries differentiate between accommodations and care costs. User fees can be dependent on the person's income level, which is a general feature of institutional care. Jacobson draws our attention to another aspect of the LTC sector's regulatory complexity: a continuum exists between regulations that "facilitate market forces" -such as private accreditation and professional self-regulation -and ones that "displace" or "substitute for the market" as with government regulation. 15 Private regulation can provide overarching regulatory frameworks. For instance, studies have shown how the quality of LTC is associated with higher numbers of professionals providing it, 16 although any relationship between the nature of regulation and the ratio of professionals to non-professionals on the frontlines is under-explored. Private accreditation conducted by forprofit and non-profit organizations sets standards for quality, skills and qualifications, and adds another regulatory layer. While some studies have looked at the link between accreditation and resident outcomes, 17 the role accreditation plays in structuring frontline LTC work is under-explored. --- Government Regulation, Organization Responses, and Frontline Care Work Policy-makers enact LTC sector regulations to set principles and roles; to guard against abuse, neglect, and risks to residents and workers; to control who does what work; and to delineate who pays for what especially as this concerns allocations of public funds and outof-pocket user payments. According to Walshe, governments can choose three regulatory paradigms: compliance, deterrence, and responsive regulation, with new public management most closely resembling the deterrence paradigm. 18 However, Walshe's singular focus on governmental rules and organizational responses renders frontline workers' agency invisible. Furthermore, the focus on rule compliance assumes that care is a straightforward, linear process devoid of complex social relations, an assumption categorically challenged in feminist critiques. As Karen Davies argues, care work takes time and requires flexibility; 19 thus, attending to the needs of the situation may require non-compliance with some rules in order to provide good care. This a point underscored by the application of complex adaptive systems theory to healthcare environments. 20 Even considering the intersecting layers of regulation such as gender norms, governments, professional ethics and accreditation shows how the tension between rule making and rule following is mired in obfuscation. Confronting this tension, Steven Lopez highlights frontline work with his participant observations in a non-profit nursing home in the United States, by noting that workers, managers and clients engage in "mock routinization" and "institutionalized rule-breaking" because of a "mismatch between time and tasks, the development of new skills, with the institutionalization of rule-breaking, negative effects on quality, the collaboration of shop-level supervision, and workers' experience of managerial irrationality." 21 His study reveals how complex and tension-prone is the space between regulations and frontline work and further challenges us to better understand how this space functions in different jurisdictional and ownership arrangements. Following presentation of the method, we document several government regulatory approaches vis-àvis frontline LTC work. --- III. Method There are limits to using cross-national and even cross-regional statistical staffing data because of the way data are collected and defined, and because the data do not adequately make frontline work and its constraints visible. These limits require us to gather primary data that address how staffing is regulated, how regulations are interpreted, and how work is managed. Data are drawn from an international and comparative Social Sciences and Humanities Research Council funded study of "promising practices" and a Canadian Institutes of Health Research funded study of "healthy active aging" in LTC led by Dr. Pat Armstrong. The project involves a team of 25 academic researchers and double that number of graduate students. The authors of this study are part of the "work organization" theme led by Tamara Daly and Jim Struthers. 22 Ethics for the project were reviewed and granted by the Office of Research Ethics at York University. The data for this paper are drawn from content analyses of a cross-national mapping of regulations, rules and funding arrangements specifically related to staffing, as well as from observations recorded in field notes during week-long rapid ethnographies 23 and key informant interviews conducted in 12 LTC facilities located in Bergen and Oslo in Norway; Toronto, Ontario, Vancouver, British Columbia and Winnipeg, Manitoba in Canada; and North-Rhine-Westphalia in Germany between December 2012 and December 2014. The larger programme of research includes 6 countries, 467 interviews, 21 different sites and over 1,000 hours of work observations with complementary field notes. Exemplary case sites 24 with "promising practices" in the provision of residential long-term care were selected in each jurisdiction following key informant interviews with policy-makers and others knowledgeable about the sector. We conducted observations on open and "locked" LTC units and public spaces starting at 7 am and until midnight and later. --- IV: Long-term Residential Care in Context: Canada, Germany and Norway A broad overview of each jurisdiction's long-term care legislation, ownership composition, and payment schemes is presented below. --- Canada LTC is an extended health service under the Canada Health Act, 1984 giving provinces considerable latitude to decide the terms of its public funding and legislation, with some opting for capped budgets and others including it as an insured service. Admittance to a facility is provincially assessed on the basis of need and space availability. There is a co-pay model, with residents responsible for a varying payment depending on the province/territory. For-profit providers dominate in some provinces, though they own at least one quarter of the homes in most provinces. Many facilities are accredited voluntarily by either the Commission on Accreditation of Rehabilitation Facilities International or Accreditation Canada, of which both are non-profit organizations. Additionally, health professional licensing is handled by each of the provinces. There are provincial similarities in scope of practice, but dissimilar or no staffing ratio standards. In Ontario, the Long-Term Care Homes Act, 2007 merged municipal homes, charitable homes and nursing homes into the same regulatory framework. 25 Beds at near full occupancy are remunerated at full capacity and receive per diem activity-based subsidies from the provincial government using a case mix formula derived from the Minimum Data Set Resident 2.0 assessments. 26 Currently, there are about 78,000 LTC licensed beds located across 643 homes, 27 with more than 60 per cent owned or managed by commercial chain conglomerates. 28 Ontario's local health integration networks -regional health authoritiessign accountability agreements with individual homes. Ontario has basic and preferred monthly accommodation fees paid by the residents. Standards for Manitoba's provincially funded "personal care homes" are set out in the Personal Care Homes Standards Regulation, 2005. 29 Of the 125 homes most are located in the urban regions, and nearly 4 in 10 are provincially run; over one third are private non-profits; and just under one third are for-profits . Like Ontario, Manitoba's regional health authorities hold responsibility for LTC. The MDS-RAI assessment is used in the Winnipeg region, but only for planning purposes and across Manitoba staffing levels are determined on a flat-payment system. There are four levels of care, with the fourth being the highest. To supplement the provincial government funding, residents pay between $34 and $79 per day, depending on a person's marital status and after tax income. 30 Staffing levels in Manitoba are standardized so that all residents receive 3.6 paid hours of direct care from nurses and care aides combined, regardless of the level of care required by the resident. This amount excludes care provided by those who perform laundry, cleaning, and dining care. The Community Care and Assisted Living Act Residential Care Regulation governs the 281 nursing homes in British Columbia. 31 Nearly one quarter of the homes are in the public sector, one third are controlled by non-profit religious or lay organizations, and the remaining 40 per cent are proprietary. 32 There is a co-payment dependent on peoples' after-tax dependent with a minimum user fee of less than $325 CAD and a maximum of $2,932; fees cannot exceed 80 per cent of a person's net income. 33 --- Germany As the fifth "pillar" of the social security system, there is a universal, national, and mandatory system of "Soziale Pflegeversicherung" or social long-term care insurance in Germany. 34 Nearly the entire population of Germany has coverage with the public health insurance and the long-term care insurance system. Benefits also cover home-based services and cash payments to family providing care. Persons insured by private health care insurances are obliged to purchase equivalent coverage from private care insurance funds . 35 Facilities are funded from the LTCI 36 and residents private copayment. 37 Women "choose" residential care more often than men, often after outliving a partner, while men more often "choose" cash payments while being cared for by partners, often wives. Before the current system was introduced in 1995/96, long-term care provision responsibility resided mainly with the family. 38 Arguably, the system is still built on the foundation of family support. Reliance on informal family care and market-based formal care help with the state's cost containment imperative. While the system provides universal access for a defined set of care services, the goal of the LTCI is to control rising costs for individuals, and to enable people to age in place with family supports. This insurance was accomplished by the state's creation of a "new type of social rights," establishment of specific funding, maintenance of a family care requirement, and bolstering market-based options for purchasing care. 39 Most homes are run by non-profits and for-profits with the remaining 618 homes run by the public, and mainly by municipalities . 40 There are three care levels in Germany -I, II, III plus an additional recognition on hardship cases. Level I is reflecting the lowest need and the smallest benefit reimbursement as well as hardship cases reflecting the highest need and receiving the highest benefit amounts . 41 An individual needs to have basic body care needs exceeding 45 minutes for level I; 120 minutes for level II and more than 240 minutes for level III. The German system is heavily reliant on professional standards to guide structure, process, and outcome quality. For instance, the system uses "national expert standards in nursing" developed by the German Network for Quality Development in Nursing working with the German Nursing Council. 42 The standards define the quality level of professional care that users of both health and LTC services can expect when being cared for by nurses and elder carers. In addition, Germany accredits nursing homes. 43 In the past, quality assurance has been a role played by "provider bodies" such as the länder level Medical Advisory Service of the statutory Health Insurance Funds Medizinische Dienste der Krankenversicherung . The MDK-MAS conducts needs assessments for care requirements as well as for quality assurance and publishes all audit results. The Health Insurance Funds contract with LTC homes provided service, funding, and personnel criterion are met. Each German länder holds responsibility for surveilling and monitoring LTC homes' compliance. In terms of workforce accreditation and certification, LTC providers are required to uphold provisions of a quality management system such as e-Qalin. In 2013, just under one third of LTCI beneficiaries were in residential services). 44 Furthermore, those with the most wealth opt for services in the home or institutions, while those with less financial means opt for cash payments and are cared for by relatives. Like Norway, there is "free choice" for users about location of care provision and providers . 45 Gender, socio-economic position and immigrant status all affect the role of family care, levels of professional care, and additional paid care services. The system has been criticized for its bias favouring functional impairment over dementia and privileging Germans over migrants. 46 --- Norway Starting in 1988 with the passage of the municipal health care law, local authorities gained responsibility for long-term care along with primary health care and various types of housing and care services. 47 This "multi-level government model" is centred on local autonomy with integration between the central and local government levels -a "typical" Nordic pattern. 48 Following the act's passage, spaces in LTC were increasingly reserved for older adults with extensive needs, and the average stay of residents decreased, 49 all while home care, including 24 hour in-home nursing, was expanded. By 2010, most of people residing in the 997 nursing homes were aged 67 or older with extensive care needs; 50 about 41,000 people resided in nursing homes, representing about 16 per cent of those receiving long-term care services. 51 As in other countries, the vast majority of health and care staff is female. Assessments for long-term care are conducted by the municipalities for placement into both public and private non-profit and for-profit providers. These providers compete because Norwegians have what is understood as "free choice" to determine whether to go into a public or private facility, reflecting a move within the country towards consumerism even for state funded services. 52 There is debate, however, with some arguing that the threshold for getting into LTC is "too high." 53 Of those living in institutions, 10.8 per cent live in a privately owned nonprofit or commercial facilities. 54 There are more privately owned facilities in the major cities, with nearly half in both Oslo and Bergen . 55 Six main commercial chain firms provide services. 56 Municipalities have become incorporated, mimicking for-profit organizations. National and local taxation funds LTC and co-payments are set by the municipalities: 75 per cent of income over NOK 6 600 up to a maximum basic amount of NOK 75 641 plus any income that exceeds this up to the full cost of the place, with the amount varying by municipality. The government does not take property and capital assets into consideration. 57 The family provides as much help as does the state when care occurs in private homes, but less so when someone is in residential care. As Daatland and Veestra note "[o]f parents with Activities of Daily Living needs about two out of three are institutionalized." 58 The Norwegian Center for External Quality Assurance in Primary Health Care accredits nursing homes as well as primary care physician offices and other health care institutions. In summary, Ontario is the most privatized jurisdiction, while Norway is the least. Private co-payments are required in all of the places examined, although the algorithms and actual amounts vary. In all instances, co-payment calculations are subject to some income dependent modifications. The reliance and obligations of informal care providers also varies jurisdictionally. German legislation is the most explicit about the primacy of family responsibility, while Norway is the least reliant on informal family care. Norway's system seems most explicit about LTC being a right of citizenship, though the German system is based on social rights founded on the principles of pooled risk and shared responsibility in its codified LTCI scheme. Manitoba retains the insurance model, but Ontario and British Columbia have created separate, capped funding envelopes. Finally, all of the systems are regionalized, however, this also translates into jurisdictional differences. In Ontario, Manitoba, and British Columbia, the legislation is provincial and funding disbursement is to a regional health authority. In Germany the legislation is national but managed at the level of the German länder. In Norway, the legislation places onus and responsibility on the municipal level. Finally, all of the jurisdictions have non-compulsory private accreditation. --- V. Findings This section presents findings of our jurisdictional care work regulation review and provides examples of frontline care work drawn from our ethnographic field studies in Canada, Germany, and Norway in the areas of social care , health care , and food . --- i. Care Work Regulation We focus on five regulatory areas. First, staff qualification regulations stipulate the certifications that are required to complete different care functions. Table I compares the study's jurisdictions. Norwegian care aides receive the most training with one to three years of secondary and post-secondary qualifications, while Canadian and German care aide training varies, but generally a six-month course of instruction is completed at a public community college or a private "career" college. In Germany, dementia care aids have been recently introduced; they require much less training to practice. Practical nurses in Canada are college trained like Norwegian and German counterparts, while Canadian Registered Nurses have university degrees like their Norwegian counterparts. The highest trained German occupation in nursing homes is the qualified care worker, who requires three years of on-the-job training. Table II presents comparative "staff mix" regulations. Like the OECD, we found varying requirements for the ratio of professional to non-professional staff. 59 While minimum nursing staff numbers were required in Norway and Canada, in Germany an impressive half of the staff must be qualified care workers . Compared with Canada there are higher numbers of Norwegian nurses on the floor. In both European countries, we found more qualified or professional staff in the homes. The reverse is true in Canadian settings; care aides, with less formal training, far outnumber nurses and provide the bulk of care work. As shown in Table III, staffing intensity ratios calculate the minimum staffing allotment overall, usually measured in hours per resident per day inclusive of direct care staff. Germany has regionally determined minimums tied to its care levels; overall staffing levels are higher with more professional staff than in Canada. According to the most recent representative survey in 2010 the resident-staff ratio was 100 residents to 44.9 care workers. 60 The Norwegian informal levels also far exceed levels practiced by Canadian provinces. Manitoba also has a minimum number of paid hours, though these are shared by professionals and non-professionals. Table IV shows jurisdictional approaches to funding the LTC sector. As Sutherland and colleagues argue, funding patterns can be population-based, global, activity-based, pay-forperformance, or bundled. 61 Population-based formulas -calculated with age, sex, socioeconomic and other health-related characteristics -are used to allocate funds from central to regional governments. A variety of other models are used to directly fund organizations. The pattern of funding, whether global, directed or activity-based, can determine an organization's flexibility with respect to their staffing complement. Directed funding can challenge frontline staff if there are time lags between when funding flows and when workloads have already increased based on residents' increased needs, while global funding better allows a facility to internally shift in response to changes in need. As table IV shows, Ontario's activity-based funding, which is an even more stringent form of directed funding, allows the narrowest degree of freedom around staffing flexibility. Regulations governing the division of labour determine who can do what work, and whether work performed is more task-oriented or relational ; and separated or integrated . Table V summarizes the potential for work integration between care aides, nurses, and dietary workers in each site. In care work, a task-oriented focus -for example being focused on getting certain tasks like bathing completed to meet a pre-determined schedule is in contrast with one that is relational -which more flexibly adapts the order, frequency and duration of care to meet the resident's needs. --- ii. Care Work Organization on the frontline Below, we have drawn from our field notes and key informant interviews to illustrate the ways in which social care activities ; medication dispersal ; and dining care demonstrate a reactive, resistive, or responsive model of work organization and the division of labour in different settings. In Canada, nurses and assistant nurses were responsible for supervision, documentation and regulated acts , while care aides were responsible for a range of body and care tasks differing depending on the province. In general, most care aides engaged in washing, feeding, toileting, and, when time permitted, listening, chatting, and comforting residents. In the Canadian context, the work was more constrained and divided such that care aides did body work and cleaning of some of the space, including tables and beds. Sometimes they used computers to document, but often they used paper and pen. Sometimes they put away laundry. Recreation therapists were responsible for social care and their time was usually shared with sixty or more residents. There were also dietary workers who cooked and served meals, and cleaned kitchens, serveries, and dishes. Canada tended to have hierarchical and task-oriented workplaces. 62 Outside of Canada, care aides' roles were much more expansive. For instance, in Germany and Norway care aides had more decision latitude and more varied work. They did the body work, cleared tables and beds and put away laundry like their Canadian counterparts, however, they also cooked, planned, baked, cleaned, took residents outside for walks, and bought items at local stores for parties. Mostly this is related to the approach Hausgemeinschaft and not a general pattern in Germany. In Germany, assistive personnel also ensured residents consumed medicines. a. Social Care: Activities-Following the generally strict and hierarchical division of labour in Ontario 63 specially qualified recreation therapists -with at least college education -performed social care in scheduled increments. Ontario workers complained that their work emphasized more counting than caring. The work was highly prescribed, documented, standardized, and audited. As one recreation therapist noted: That's what the Ministry looks to when they come in when we're audited. We write down what programs [residents] attend; what needs we meet socially, emotionally, spiritually, physically, and then …we do … a care plan for them. … We do tick off the boxes on the computer screen … with respect to what programs they attend … and there's a psychosocial box that we have to fill in and an activity section … we have to fill in. 64 In addition, because the "task" of social care was the purview of the recreation therapists, and the schedule of social care may interfere with tasks other workers needed to perform, this led to staff conflicts. One worker's experience highlights this conflict: There are times when I'm doing an activity and I really get upset with staff because if somebody is sitting there listening to music, they'll come and just take them out to give them their bath or toilet them or whatever. You take them out and there's that feeling of loss and confusion so they come back and they're not the same. Some of them are agitated … and I know if they were with the doctor they wouldn't come in and take them from the doctor's presence to toilet them or whatever, right? 65 Furthermore, this worker's experience illustrates how, though social care may be counted, it "does not count" in terms of the hierarchy of tasks, with body work and medical work coming first and little appreciation for how the social is an integral part of the care. In this instance described above, workers appeared to be reacting to the pressures to complete their own "tasks," with little attention to residents' relational care needs. Our observations and interviews in a very large Norwegian long-term care facility revealed a different pattern of integration between health and social care and a different level of staff empowerment for responding to residents' needs for relational care. There, in a 32-resident secure unit within the larger facility, music therapy informed almost every aspect of care delivered to cognitively impaired residents over the past five years. Staff members worked together as a team, in sharp contrast to the Ontario sites both in terms of the teamwork and the integration of the social and medical care. To implement the program, the Director of Music Therapy and her assistant trained staff in how music programs that were individually tailored to each resident could be successful in eliminating the need for psychotropic or sedating medications to manage agitation, depression, and aggression among residents with moderate to severe forms of dementia. As she explained: … the easiest way of telling it is that in the music in daily activities as you call it, you use music as a stimulant in the patient for getting them calmed down … But as a music therapist [you are] working out ways of communicating with … the patient with music so you are sort of reflecting with the person. … [I]t's sort of psychological processing and your goal is not to stimulate that person with the music to get them to do what you want. It's more like what is their meaning and you try to make meaning out of things speaking together through music. So it's a different way of thinking. … So when I meet somebody we do music together as a verb. We don't use music as an object. … One of the main theories in music therapy is that everybody is born with a basis to communicate. As a child … you already start to communicate. And this is a musical way of communicating. So we all are really musical. But it's not a musical way of being able to play scales or sing perfect. That you have to learn. But what lies underneath [is] the music everybody knows … and that's why everybody gets moved by music. So I use this small thing to communicate with the patient. 66 All staff working with residents in this secure unit received training about how to integrate singing, dancing, touch, and rhythm into all phases of their daily interactions with them. The success of music therapy on this floor has led to a dramatic reduction in the use of moodaltering medications and has contributed greatly to staff being satisfied about their work. These positive results have also led to the gradual introduction of music therapy on other units. A nursing social worker described its transformative impact on her job in this way: I have been working a lot with music here and we see that makes [residents] more relaxed. Maybe they can tell about their past. Maybe they speak more. People that don't have any language anymore they can suddenly sing a whole song from the memory and then they suddenly started speaking more because of the music … Before, maybe five, six years ago I didn't sing at all. Never. Never sang because I don't like my voice. But we started this project and I started singing and I just thought that it doesn't matter if I have a bad voice. It's not for me, it's for the patient. Now I sing all day long. I dance and sing with my patients and if they're maybe … if they have problems brushing their teeth I can start singing a song I know they like and some manage. It's just moments that make things easier for them just by using music, just by singing. It's really, really interesting. 67 In the German sites, half of the staff need to be qualified care workers . There are also care aides separately funded by the LTCI. One organization actively resisted state funding level limitations; it increased the staffing complement by adding large numbers of student apprentices. The costs of the training of the apprentices are refunded not carried by the facility. They also included a sizable number of "1-Euro Jobbers" -who were remunerated at 1 € per hour and additionally funded through a labour market program aimed at job re-training. As a result, we observed a much higher level of social interaction in this facility. 68 Apprentices performed bodywork and social care under the direction of the nursing staff, which then enabled the nursing staff to work in a more direct way with residents. In our observations, we noted that the large numbers of staff, apprentices and 1-Euro Jobbers available to provide care was the precondition for the comprehensive social care that was provided on the units. In this site, the facility resisted lower staffing allotments in favour of a model that ensured there were plenty of people available to provide care, even if they were precariously employed, by actively resisting the funding constraints imposed by the legislation. As a result, the facility had enough people available to provide care and did not lock its doors, even on units with highly mobile people living with dementia. We also found that there was plenty of singing, smiles, and every-day activities for residents to be engaged in that supplemented the "formal" activity schedule . One researcher's field notes recorded the interactions as follows: When we arrive we see two apprentices sitting with one resident and talking to each other but also to the resident. Other residents are sitting around the table. The atmosphere feels calm and relaxed. All residents are dressed nicely. One woman in a wheelchair makes sounds . She seems a little agitated especially if the young man takes his hand away from her hand. She kisses and touches his hand. She seems very much needing these contact/touches and I'm very impressed that I saw various staff members touching her very kindly and allowing her to kiss and touch their hand, arm. I ask the apprentices if they sit with the residents … every day or if they have other duties. … They say that they are sitting there every day and that they are supposed to sit there and that they don't have many other things to do during this time of the day. 69 In this home, social care was imbued throughout the care work. Workers of all qualifications engaged in social care, but the capacity to do so was set within the organization's active resistance to the constraints imposed by the German model that espoused cost containment, even while it was more interpretive in privileging professional standards and ethics. In addition, even though subject to critique, the facility had more people available to care by employing people subsidized by the state to get job re-training. In summary, these examples from the three countries reveal differences between the integration of social care with medical care and bodywork, and the relative priority afforded to relational care. Each also illustrates how workers and organizations operated in ways that were reactive, responsive, or resistive to the pressures in order to meet the needs of the situation. Social care was a clearly defined episodic activity in the Ontario sites, while in the German one we visited there were blurry boundaries between health and social care, and in the Norway sites, social care was an integral part of health as an important alternative to medication and also a way for care workers to find meaning in their work. --- b. Health Care: Medications-Medicine dispersal usually happens close to dining times. There are some commonalities amongst the jurisdictions: medication dispersal usually involves nurses taking out a medications cart, moving from resident to resident, and often crushing and mixing tablets with soft food. This is usually one person's responsibility per unit. In the Canadian jurisdictions, giving medications is a regulated act; thus, there are strict regulations that distinguish it from bodywork such as washing, dressing, and toileting. Only nurses, usually Licensed Practical Nurses , are permitted to perform medications dispersal and to ensure medication consumption. We observed that while medication rounds occurred, RNs' work involved computer-and paper-work and addressing complex health needs. Meanwhile, if it was the morning, care aides were getting people up by providing the vast majority of body care and transport to the dining room for breakfast. Like breakfast, lunch and dinner involved serving, feeding, and bussing tables. In order for the LPNs to avoid being called upon to do frontline care work such as moving residents requiring two people while dispensing medicines, many organizations allowed signs on medicine carts that indicated that no one was to talk to nurses while doing medications work. Doling out medicines usually happened while residents were being brought to the dining rooms and it was done in an assembly line fashion, with nurses responsible for as many as 32 residents. Nurses stood over residents who were usually sitting in a passive position at a dining table waiting to be served their meal. In terms of work organization, care aides complained about declining teamwork due to the nursing staff no longer having the time to help with bodywork when care aides were most pressed for time during the mornings. The lack of extra hands often meant that care aides reacted by moving residents -even those who needed two people -without a partner. Care aides argued that managers knew about this but ignored their reactions because everyone knew that the work could not be completed otherwise, like the "mock routinization" described by Lopez. 70 In one German home, medications were secured at night, but out in the open in the Great Room during the day where residents and nurses spent most of their time together, much as you might find in a person's own home. When it was time to consume the medicines, the nurse gave the medications to the resident, poured more water into the residents' cup, and then walked away -but not out of the room -and dispensed medicines to another resident. Care aides and apprentices sitting at the table calmly ensured that the medicines were consumed, sometimes with gentle words, other times by "consuming" something themselves by drinking, thereby turning medicine time into an opportunity for social connection with a resident with dementia. German regulations allow the qualified care worker to use professional judgment and this enabled the work to be seamless, natural and very home-like -very different from the highly clinical encounters we observed in the Canadian context. In this example, the qualified care worker delegated only the role of watching the consumption of the medicines, while she remained in the room but not standing over the person. Each person providing care understood that the resident was to take the medicines, but done in this way, the resident could take them when ready as the care aide was there to spend time with the resident. The German home was less hierarchical and the division of labour was less rigidly enforced. This site followed a Hausgemeinschaften model where eight to twelve residents live in one unit; thus there is a better staffing ratio in a facility following this concept, but also because the site where we observed trained a large number of apprentices who provided an extra set of hands. German legislation is weighted in favour of half of the staff being qualified care workers in terms of staffing intensity and more dependent on their professional judgment compared with the Canadian jurisdictions. Compared with other homes in Germany, this site actively resisted the state imposed care gap due to austere funding by having more people around to provide care. The organization's actively resisted under-staffing by having more "hands" available to provide care who would not be considered full-time staff, and thus not subject to the rules about having half of the staff as nurses, and allowing the type of social care that they wished to provide to flourish. With the work more distributed, in combination with more workers, there was more flexibility to resist narrow job definitions, and to respond to residents' needs in a timely and relational way, while still maintaining a complement of nurses comparable to similar facilities. In one Norwegian site, high staff to resident ratios allowed for the work to be responsive to residents' needs. Medication dispersal happened during quiet times, when residents were resting in their rooms. The nurses were unhurried in the process and took time with each resident. The process happened outside of the main space where dining and socializing occurred unless a resident happened to be in that space. The nurse chatted with the eight residents for whom s/he was responsible, about one-quarter to one-fifth the number of residents that nurses were responsible for in Canadian facilities. c. Food: Meal Times-Congregate mealtimes are a common feature of residential care, but there was tremendous variation when we compared mealtimes between Canadian and European sites. While all of the sites were subject to government's safe food handling regulations, Canadian regulations are highly prescriptive with respect to who could cook and touch raw and cooked food, with Ontario the most prescriptive with respect to how many hours the dietary servers must work, and where the food preparation takes place. Central kitchens prepared the food to be ready for a certain time, which largely determined the work schedules of others such as front line care workers who were not a part of meal production. Even though some dietary workers set and cleared tables, it was usually care aides who did so, and also brought residents to the dining space, offered food choices, delivered the prepared food, helped residents with eating and drinking, scraped the plates, and cleared the tables. The autonomy and dignity of both workers and residents were compromised because often there were between twenty and thirty people in a single dining room. The regulatory goal was that each resident would be fed without delay; however, the resident numbers were burdensome and residents often waited for everyone to be brought to the space, for medicines to be dispensed and for the food to be served. Facilities had to interpret frontline work organization within the confines of prescriptive dining regulations; this was often done by requiring care aides to record the quantities of food and drink consumed by each resident at each and every meal. With each care aide responsible for between eight and twelve residents who usually did not sit together, timely and accurate recording was a practical impossibility, and there was a great deal of resistance that accompanied this job function. In some places, care aides were required to enter information into computer programs directly following the dining hour when they could otherwise be engaging with residents. In other places, "tick-boxes" on paper were filled in at the end of the shift. Care aides revealed that they reacted to the constraints by estimating and sometimes copying the previous day's input, raising serious questions as to the reliability of the data and showing the extent to which this documentation was less important than other tasks that competed for their time. Facilities reacted to regulations about when residents should eat by documenting residents' preferences in care plans. For instance they only allowed someone to sleep-in and receive a later continental breakfast if they could "care plan it." While following European regulations for safe food handling, in Germany and Norway food could be prepared freshly on the unit or re-heated from food prepared in central kitchens. The unit stoves were used at predictable though not fixed times in relation to the residents' needs. The result was the smells of food wafted through the air. We observed that the workers also engaged the residents in the work. For instance, one care worker in Germany set the table while the residents passed the cutlery. The residents' participation made "activation" a normal part of the day and not a defined and separate activity. The residents also hand-washed and put dishes in the dishwasher. In this site, when potatoes were left from lunch, the workers asked residents what should be done with them; they participated in decisions about how the potatoes would be cooked later that night. One of the residents who liked to clean up, collected the dirty dishes from the table and was allowed to wash and put the dishes away. We watched and the staff did not re-wash the dishes afterwards. Staff cut apples and shared them at the table, while also eating a slice themselves to stimulate the social nature of dining. Residents could have wine or other alcohol at the table. Residents swept floors and workers did not re-sweep. Residents cut and workers did not re-cut. For supper on the dementia unit, a family member helped prepare potatoes and an omelette. The food was soft, easy to chew and swallow, smelled palatable, and included thin slices of cucumber. There was a single plate of bread, cheese, and meat for the table, and people chose what they wanted from it. Bottles of water were left on the table and residents poured water for one another. This Hausgemeinschafts-model places emphasis on residents' involvement in housekeeping, keeping a more home-like atmosphere, having smaller groups and the presence of at least one care worker always in the common space. --- V: Discussion and Conclusions We found marked jurisdictional differences both in terms of regulatory approaches and how care was provided on the frontlines. How regulations structured frontline care work was evident when we compared how activity, medication dispersal, and dining were performed in the Canadian, German, and Norwegian jurisdictions. In this section, we locate each jurisdictions' position on the prescriptive -interpretive regulatory axis, discuss frontline reactive, resistive, and responsive care work organization, and propose an analytic framework that links the regulatory form to frontline work organization. --- i. Prescriptive and Interpretive Regulatory Axis Prescriptive regulation identifies what should be done and which staff should do it and delineates when and how they should do it. In contrast, interpretative regulation is more open-ended; it identifies that care should be provided but not which staff should do it, nor when and how it should be done. Germany's legislation is focused on delineating national, regional, local, and family responsibility. Care is defined and care workers are expected to provide care that is "in accordance with the generally recognized state medical and nursing knowledge." 71 However, as our ethnographic study showed, facilities can engage in rule bending to accomplish their care goals. In Norway, the legislation is highly interpretive. As Mia Vabø and colleagues argue, "eldercare is regulated not by special laws but by general legislation. Care services are offered to all citizens in need of care, regardless of age, income, family relations and so on." 72 The Norwegian Act identifies that health services are a municipal responsibility, but health professionals' responsibility to carry the services out according to their professional standards . The European Acts we reviewed are similar in ascribing agency to health professionals, and thus relying on professional standards and ethics as a framework. The Canadian context is more varied. The most minute care tasks are detailed in Ontario's prescriptive legislation, including from how to handle continence care and residents' weight changes to how often linens should be laundered. In contrast, Manitoba's legislation is interpretive, with broad categories of care work laid out and general guidelines provided. For instance, soiled linen should be collected "regularly; surfaces cleaned "as often as necessary;" meals offered "at reasonable intervals" in each 24 hour period and nursing services "organized and available to meet residents' nursing care needs, in accordance with guidelines approved by the minister and consistent with professional standards of practice." 73 However, on the issue of pharmacy and medication management, the Manitoba legislation is quite prescriptive. In British Columbia, the Act is more interpretive around care: staff assist with activities of daily living , consistent with the "health, safety and dignity of persons in care." It is more prescriptive with respect to facility design elements and dining hours but still remains more interpretive than Ontario in allowing for more time during the morning rush and "brunch" on weekends and holidays. Table VI summarizes these findings. Overall, we noted the following associations: prescriptive regulatory environments tend to be accompanied by a lower ratio of professional to non-professional staff, a higher concentration of for-profit providers, a lower ratio of staff to residents, and a sharper division of labour. On the other hand, interpretive regulatory environments tend to have higher numbers of professionals relative to non-professionals, more limited for-profit provision, a higher relative ratio of staff to residents, and a relational division of labour that enables the care to be more fluid and responsive. In one US study, it was found that higher numbers of nurses produced fewer "deficiencies" in care. 74 With higher numbers of professionals around to guard against deficiencies, a jurisdiction's regulatory tendency towards interpretation might reflect its reliance on professional ethics and frontline judgment as its overarching regulatory benchmark. --- ii. Responses from the Frontline As we found when considering the example of music therapy in Ontario, highly prescriptive regulation seems to impact frontline care workers' abilities to perform teamwork and integrate health and social care. Geraldine Lee-Treweek argues that when we consider the care and the worker separately, it is easier to identify the space for resistance as an everyday strategy to control and "get through" work. For example, private nursing homes' workers controlled their work by making the care depersonalized, engaging in non-compliance or selective adherence to tasks, and coming to their own conclusions about residents' behaviours. 75 In the German site, resistance was not an individual struggle; it was taken up by the organization. Hiring many apprentices helped to provide more social care overall, and it enhanced the working and living environment. Indeed, as has been demonstrated aptly in other sectors, the adoption of new public management involving heavy regulatory oversight and onerous reporting requirements has significantly changed the university environment from a collegium to a workplace. 76 How states choose to govern has implications for the quality of the workplace. Indeed, how care workers retain decision latitude within highly prescriptive structures is demonstrated by several studies of frontline care, all conducted within highly regulated systems. Rule breaking has emerged in the literature as an important coping mechanism. For instance, Canadian care aides' decisions when performing dementia care were found to be discordant with organizational and legislative rules, 77 which led aides to break rules in order to be able to provide care. Furthermore, this occurred, on a case-by-case basis, with supervisors' complicity. In some Canadian facilities, the only time LPNs are on the floor is during the medication dispersal. They are behind desks, filling in paperwork at other times. To allow them to concentrate, facilities have allowed the use of do not disturb signs, which may in fact further weaken their connection with non-professional staff and allow for rulebreaking. Similarly, in the US, Lopez reports informal patterns of work depart significantly from official procedures designed to protect the health and safety of Long-term Care Facility workers and residents, underlining the routinization of rule-breaking. Furthermore, with insufficient federal funding, which limits facilities' ability to hire sufficient staff to meet basic care standards, care aides could not complete work on time and thus engaged in a mock routinization of the work that broke or bent important care rules and compromised quality of care. 78 We noted that rules were broken and bent when workers needed to actively react or resist in order to attend to the needs of the situation. Similarly, Ryan DeForge and colleagues identify care workers' "workarounds" as a way to address workplace structures to show how reacting to mandated practices helps workers to provide care. 79 Donna Baines notes that the context within which care work occurs means that care workers toil on a "compulsion-coercion continuum." This happens because care workers often perform unpaid work to keep their jobs while at the same time feeling a compulsion to do so because of a sense of duty, obligation and genuine care. 80 By examining government regulation and the care planning processes in LTC facilities, one study found a large time burden created by the formal care planning process and documentation, observing that "fear of citation" can lead facilities to write less specific care plans. 81 Jennifer Black and colleagues reporting on LTC dietitians surveyed in British Columbia found the majority perceived implementing new residential care regulations increased their workload, thus suggesting they did comply with the regulations. 82 In our study, Canadian facilities used care plans to document any deviations from official rules, and documentation took up the majority of LPN and RN time demonstrating that the nurses used care plans as a means to depart from the official rules. We found that the most highly privatized jurisdiction had the most prescriptive regulation. Studies have shown higher quality is associated with non-profit and public facilities. Public and non-profit facilities more often increase the number of care workers as they fund the work from other sources of funding. As one German site illustrated, having apprentices available to supplement care is an active form of resistance to conditions of under-funding, and provides a calmer and more therapeutic environment in which to provide care. Also of note, the European facilities we examined had smaller units and did not amalgamate their dining spaces into larger ones. Instead the spaces were congregate but intimate and more on the scale one would find in a large family home. Other studies have shown that even highly detailed regulations can be interpreted in different ways. Regulation and external oversight can be primary drivers of improvement initiatives in LTC, 83 although the content and consequences of regulations are not always apparent to frontline staff or administrators 84 and interpretations can vary. For instance, one study that investigated in-house puréed food production in an Ontario LTC found variation in how government guidelines were interpreted. 85 In Germany and Norway, frontline workers had responsibility for far fewer residents, and provided customized food plates when residents were ready to eat. Do more prescriptive rules, regulations and oversight of LTC improve or diminish care? There can be serious problems with abuse, deficiencies and violations 86 and regulations can be a guard against these. But there is a downside to heavy and highly prescriptive regulation. Julianne Payne and Jeffrey Leiter examine hospital and nursing home management comparing Australia and the United States. They found managers perceived increased regulation and reporting as obstacles in the context of declining state support, market competition and increased client demands. 87 Likewise, Nancy Foner argues that bureaucratic rules associated with medical care complexity and state regulation interfere with nursing home aides' abilities to provide compassionate and supportive care. 88 In our study, we found that highly prescribed rules led to work that was inflexible and incongruous. In contrast, the flow of the day was calmer in the German and Norwegian sites where there was less paperwork and more time to provide health and social care. Given that more prescriptive regulation tends to occur in jurisdictions where care aides are in more regular contact with the residents and far outnumber nursing staff, it is not surprising that some studies conducted in similar jurisdictions have found that formalization -"the degree to which rules and procedures are followed by the organization and employees in carrying out different activities" -was positively correlated with job satisfaction among long term care staff. 89 Indeed, another found that certified nursing aides and licensed vocational nurses in nursing homes accepted regulatory oversight as important for providing good care. 90 It is possible that, in the presence of less formal training and no self-regulating body, care aides may like the clearly delineated job roles that come with more prescriptive regulations; however, acceptance is different than adherence, and as mentioned above there have been plenty of studies that demonstrate the myriad workarounds that care aides put in place in order to get the job done. An important consideration may also be the extensive initial and specialized training for care aides as is done in the European settings. When considering training, Kihye Han and colleagues found that certified nursing assistants in LTC were more satisfied with their jobs if they worked in states with stricter regulation requiring additional initial training hours. 91 Other scholarship suggests that staff do follow, make an effort to follow, or should follow, rules and regulations in the course of their work. Katherine McGilton and colleagues, for instance, found charge nurses in LTC perceived a need to "balance competing resident, family, staff, management, and regulation demands, while completing all of their responsibilities." 92 iii. Lessons for Care Work Regulation & Frontline Care Workers Our findings show how the regulatory approach to staffing and administrative funding is highly prescriptive in Ontario while the regulatory and funding orientation in Norway tends to be more interpretive. German facilities also have some latitude to interpret regulations. As a result, care work in Ontario tends to be very task oriented with definite divisions of labour that hindered workers' abilities to provide quality care. In other words, the prescriptive regulations did not promote a high standard of relational care, nor did they promote good working conditions. Instead, regulations promoted reactive work organization. We found that resistive work organization emerged within conditions of austerity when interpretive regulations conceded to professional judgment and organizations then had flexibility to provide care. Organizations also loosely interpreted rules around who was to be included as staff so as to increase the number of bodies without affecting the need to hire even more nurses than would be considered standard. Finally, we found a more responsive model accompanied regulation that was more interpretive, privileged professional decision-making, and provided funding sufficient to meet most residents' needs. Baines and Daly argue that the forms of resistance that are associated with feminized work are often overlooked because they are not large scale, highly visible strategies. 93 However, care workers do resist overbearing and punitive regulation in order to attend to the needs of the situation. Thus, care workers who retained more decision latitude and the opportunity to engage in more relational work geared to better meet the timely needs of residents and coworkers experienced more responsive work organization. The more interpretive regulations in Norway yielded more responsive work organization and hold promise for the provision of relational care that is supportive of workers' and residents needs. Sharmila Rudrappa elevates individual acts with her concept of "radical care work", which describes her findings of racialized, female workers going from being "passive recipients to active agents who participated in making a more equitable world". 94 As a consequence, it is important not only to look at common strategies for resistance, but also to identify how the orientation of regulation offers different spaces for resistance. In some countries with growing private-for-profit sectors, there is a desire to heavily regulate in order to better control the care provided. What this analysis, however, shows is that the form and content of regulation matters greatly for the ways that front line workers can care, and that de-professionalizing this sector may increases the need for prescriptive regulation that in turn hinders the provision of good quality, flexible care.

This paper examines the tension between macro level regulation and the rule breaking and rule following that happens at the workplace level. Using a comparative study of Canada, Norway, and Germany, the paper documents how long-term residential care work is regulated and organized differently depending on country, regional, and organizational contexts. We ask where each jurisdiction's staffing regulations fall on a prescription-interpretation continuum; we define prescription as a regulatory tendency to identify what to do and when and how to do it, and interpretation as a tendency to delineate what to do but not when and how to do it. In examining frontline care workers' strategies for accomplishing everyday social, health, and dining care tasks we explore how a policy-level prescriptive or interpretive regulatory approach affects the potential for promising practices to emerge on the frontlines of care work. Overall, we note the following associations: prescriptive regulatory environments tend to be accompanied by a lower ratio of professional to non-professional staff, a higher concentration of for-profit providers, a lower ratio of staff to residents and a sharper division of labour. Interpretive regulatory environments tend to have higher numbers of professionals relative to non-professionals, more limited for-profit provision, a higher ratio of staff to residents, and a more relational division of labour that enables the work to be more fluid and responsive. The implication of a prescriptive environment, such as is found in Ontario, Canada, is that frontline care workers possess less autonomy to be creative in meeting residents' needs, a tendency towards more task-oriented care and less job autonomy. The paper reveals that what matters is the type of regulation as well as the regulatory tendency towards controlling frontline care workers decision-making and decision-latitude.

Background The under-five death rate is the probability of a child dying before attaining five years of age. It remains the most useful indicator of child wellbeing [1] which reflects the overall strength of the health system of countries and the value the society place on health care [2]. The Millennium Development Goal 4 sought to reduce the global under-five mortality rate by two-thirds between 1990 and 2015. Concerted efforts were made to ensure the realization of this goal through the promotion of exclusive breastfeeding, good nutrition, optimal vaccinations, correct management of common childhood infections, ensuring a safe environment and access to potable water [3]. These interventions led to the prevention of about 4 million U5D between 2000 and 2015 [4]. The reduction was most dramatic in countries with the highest U5D [3]. However, the majority of U5D recorded at this time was from sub-Saharan Africa and Southern Asia [3,4] and these were mainly low-and middleincome countries . It was therefore not surprising that most of these countries could not meet up with the MDG 4 goal. There were inequalities in the reported U5D within LMIC with variations across location, sex and socioeconomic class [5]. Sex differences in U5D have been observed in different parts of the world and the pattern depends on the socio-economic development of countries. For developing countries, the natural setting supports female survival advantage [6]. This is because male infants have some inherent biological features which make them less likely to survive compared to females. These features include the effect of the x-linked immunoregulatory genes which gives females more resistance to infection [7,8]. Waldron affirmed that higher proportions of males being born prematurely with the accompanying complications and there is the risk of lung immaturity in males as a result of the effect of testosterone on the lungs which predispose them to respiratory distress syndrome [7]. For developed countries, male disadvantage disappeared over the years as a result of the improvement in child healthcare [6,9] but the female survival advantage persists till age five [10]. However, the natural female advantage for survival can be lost in settings where females are deprived of access to health care [11] and good nutrition, as well as exposure to harmful environments [6,9]. This is a common finding in many LMIC where male preference have persisted as a result of deep seated patriarchal cultures seen in these countries [12]. It is not clear if the earlier listed interventions had benefitted both male and female children equally or if there is a sex disparity in their survival. In the presence of disparity, it will be imperative to investigate the factors which contribute to sex disparity in U5D as this can reveal specific contributions to U5D and provide guidance for more targeted approaches and intervention in addressing the problem. A cursory examination of most national U5D data will mask inequalities and not make them obvious. This can hinder the invention of novel and equally effective approaches that can work synergistically with existing strategies to effectively address U5D . The United Nations suggested that a closer look at existing data can give rise to more novel approaches to flatten the curve of U5D in developing countries [3]. One way of achieving this is the decomposition of factors that contribute to the disparity. This will allow for the appreciation of more intricacies in the factors that could be associated with the inequality and its outcomes can be an invaluable tool that can lead to the production of cut-edge interventions to reverse the trend of U5D in developing countries. More efforts are required in LMIC where the bulk of U5D still occur for these regions to achieve the goal of Sustainable Development Goal 3.2, which is to ensure health for all ages [13]. Also, the countries which succeeded in achieving the MDG 4 need to keep up the efforts to achieve SDG 3.2 by continuing the effective interventions and exploring other novel approaches . Therefore, the goal of this study is to decompose the factors associated with sex differences in U5D in the LMIC. We posit that due to the male preference culture that is prevalent in many LMIC, there will likely be more pro-female U5D inequality in these countries. --- Methods --- Study design and data We obtained under-five children data from the Demographic and Health Surveys . The DHS holds approximately every five years across the participating LMIC. The ICF collects the data in conjunction with the designated organizations in the participating countries. Typically, the survey is cross-sectional, nationally representative and population-based. We pooled data from the most recent DHS conducted between 2010 and 2018 and in the public domain as of 10 September, 2020. A total of 59 LMIC met these inclusion criteria, and their data were included in this study. We pooled the data of 856,987 under-five children, from 66,495 neighborhoods across the 59 LMIC. --- Sampling strategies The DHS utilized a similar clustered multi-stage sampling procedure in the participating countries based on countries' sampling frames drawn mostly from the last census counts. Countries were stratified using the existing geographical and administrative structures. The multi-stage mechanism included the states/divisions/ regions in the first stage, districts as the next stage in some countries, and finally, the clusters as the last stage. The clusters were the primary sampling units [14,15]. The households were then selected from the PSUs, from which women aged 15-49 years were interviewed. The surveys generated different datasets. We used the child recode data that captured diverse information on all births of the interviewed women five years before the survey. Sampling weights were computed and provided alongside the data by DHS. These computations were based on the multi-stage sampling method to ensure the representativeness of the sample concerning the general population. The DHS uses similar surveys and research protocols, standardized questionnaire, similar interviewer training, supervision, and implementation in all the countries. The full details of the sampling methodologies and other information are available at dhspr ogram. com. --- Variables --- Dependent variable The dependent variable was UD5 which was defined as death among live births within the first five years of life, that is deaths within 0 to 59 months of birth [14]. To ascertain the correctness of this outcome, mothers were first asked if they had given birth to any child five years preceding the date of the study. They were then asked to recount the date of birth and were assisted to estimate such dates when necessary. They were asked if each of those children were alive or dead. The dates of death or the ages at death for the dead children were then used to determine U5D. Therefore, U5D was binary: Alive or Dead before 5 th birthday. --- Main group variable The main group variable is the sex of the child: male or female. --- Independent variables The variables identified to be associated with childhood deaths in the literature [16][17][18][19][20] were selected using Moseley's systematic conceptual framework on the study of child survival in developing countries [17]. The variables were made up of individual-level and neighborhoodlevel factors. --- Individual-level factors The individual-level factors consist of a child's characteristics, mothers' characteristics and the households' characteristics. Child's characteristics were weight at birth , birth interval . birth order and whether a child is a twin ). While mothers' characteristics were maternal education , maternal age , marital status , maternal and paternal employment status , and health insurance . Households' characteristics were the sex of the head of the household , access to media , sources of drinking water , toilet type , cooking fuel , housing materials , household wealth index and place of residence . The sources of clean fuel are electricity, liquefied natural gas/biogas and unclean fuel include wood, charcoal, kerosene, straw shrubs, animal dungs and grass. The improved sources of drinking water include a protected well, borehole, bottled water and spring rainwater, while spring water, tankers, unprotected well with drum, sachet water, surface water, and other sources constituted the unimproved sources. The housing material was based on a composite score according to the type of wall, floor and roof materials. If cement/carpet/rug/ceramic tiles/vinyl asphalt strips were used for the floor, the floor quality is coded 1, else it is coded 0. In the same vein, wall material quality is coded 1 if it is made of cement blocks/bricks, else 0. If roof material is made of calamine/cement roofing shingles/cement fibres/ceramic tiles/zinc, it is coded 1, else 0. If all the materials fall under "1" they are regarded as "improved", else, they are "unimproved" [14,15]. --- Neighborhood-level factors We defined "neighborhood" as the clustering of children. The DHS uses "clusters" as the PSU [14,15], hence "neighborhood" in this context is the clustering of children within the same geographical environment and children were "neighbors" if they belonged to the same cluster. In this study, we considered neighborhood socioeconomic status as a neighborhood-level variable. It was computed using the principal component factor method from the scores that were aggregated from the proportion of respondents within the same clusters without education, belonging to a household in the two lowest wealth quintiles, no media access and unemployed. The "xtile" function in Stata version 16 was used to categorize the scores into five categories: Least disadvantaged, 2, 3, 4 and most disadvantaged [5]. --- Statistical analyses We used both descriptive and inferential statistics in this study. Descriptive statistics including charts, tables, and percentages were used to show the distribution of the children by country, regions, U5D and other key variables. A bivariable analysis was conducted using the Z-test for equality of proportions of U5D among male and female children within each country and region . We also determined if any association existed between the explanatory variables and U5D among the male and female children . The risk difference in under-5 deaths among male and female children were computed. A RD greater than 0 suggests that U5D is higher among male children than among female children . While a RD = 0 signifies no difference and a negative RD indicates that U5D was higher among female children than among male children . The RDs were computed to identify the countries where significant differences existed in the U5MR by gender. We estimated both random and fixed effects of the RD. The fixed effects are the weighted country-specific RD and the random effects are the overall RD irrespective of a child's country of residence as shown in Fig. 1. The purpose of the random effect was to estimate the overall prevalence and distributions of prevalence of U5MR among males and females irrespective of the countries the children are located. The fixed effects are to establish and identify the country-specific estimates. Charts were used to show the distributions of the RDs by the countries . We categorized the countries into four distinct categories based on their prevalence of U5D and the size of their RD: High U5D and high pro-male inequality High U5D and high pro-female inequality countries Low U5D and high pro-male inequality Low U5D and high pro-female inequality . The Mantel-Haenszel Odds Ratio and tests of heterogeneity of ORs were used to ascertain that the countries were different with regards to the odds of U5D among the male and female children. A test of homogeneity of ORs among all the countries with a significant OR of U5D was also used to determine if the odds of having U5D in those countries were homogenous. Lastly, the multivariable-adjusted logistic regression method was applied to the pooled cross-sectional data from the U5D pro-male countries to carry out a decomposition a Significant at 0.05 in the z-test of equality of proportions analysis using the multivariable Fairlie decomposition analysis procedures. Sampling weights were applied in all our analyses to adjust for unequal cluster sizes, stratifications and to ensure that our findings adequately represent the target population. Multicollinearity among the independent variables was tested using the "colin" command in Stata version 16. The command provided the Variance Inflation Factor . The VIF is approximate of 1/ ranging from 1 to infinity. The R 2 -value is obtained by regressing the j th independent variable on other independent variables. All variables with VIF>2.5 were removed from the regression analysis. Literature has shown concerns about VIF >2.5 [18]. Health insurance cover, media access, paternal employment status, type of cooking fuel and housing material were not captured in some countries and were dropped in the decomposition analysis. The decomposition analysis was conducted by obtaining the logit estimates of the magnitude of contributions of the factors to gaps in U5D between males and females as the dependent variable among those countries that had significant RDs. --- Decomposition analysis We applied multivariable Fairlie Decomposition Analysis based on the binary regression model. The FDA is one of the decomposition techniques used in the quantification of the contributions to differences in the prediction of an outcome of interest between two groups in multivariate models [19]. The method is an extension of the Blinder-Oaxaca Decomposition Analysis [20][21][22], which has been roundly criticized for inefficiency in handling the logit and probit model [22,23]. The FDA was purposively developed for non-linear regression models including the logit and probit models [24]. The FDA was carried out by calculating the difference between the predicted probability for one group using the other group's regression coefficients and the predicted probability for male children using its regression coefficients [23]. The Fairlie decomposition technique works by constraining the predicted probability between 0 and 1. Fairlie et al. showed that the decomposition for a nonlinear equation Y = F, can be expressed as: Y A -Y B = 1 st ������������������������������������������������� ⎡ ⎢ ⎢ ⎣ N A � i=1 F � X A i βA � N A - N B � i=1 F � X B i βA � N B ⎤ ⎥ ⎥ ⎦ + 2 nd ������������������������������������������������� ⎡ ⎢ ⎢ ⎣ N B � i=1 F � X B i βA � N B - N B � i=1 F � X B i βB � N B ⎤ ⎥ ⎥ ⎦ Where N A is the sample size for group J . In Eq. , Y is not necessarily the same as F X β , unlike in BODA where F = X i β. The 1st term is the part of the gap in the binary outcome variable that is due to group differences in distributions of X, and the 2nd term is the part due to differences in the group processes determining levels of Y. The 2nd term also captures the portion of the binary outcome variable gap due to group differences in Fig. 1 Risk difference in under-five deaths between male and female children by countries in LMIC unmeasurable or unobserved endowments. In other words, the explained factors are those factors attributable to gender differences in individual observable characteristics and life circumstances while the unexplained factors are related to gender differences in the unobservable characteristics and life circumstances. The estimation of the total contribution is the difference between the average values of the predicted probabilities. Using coefficient estimates from a logit regression model for a pooled sample, β * , the independ- ent contribution of X 1 and X 2 to the group, the gap can be written as and 1 N B X N B i=1 F α * + X A 1i β * 1 + X A 2i β * 2 -F α * + X B 1i β * 1 + X A 2i β * 2 1 N B X N B i=1 F α * + X B 1i β * 1 + X A 2i β * 2 -F α * + X B 1i β * 1 + X B 2i β * 2 respectively. The contribution of each variable to the gap is thus equal to the change in the average predicted probability from replacing the group B distribution with the group A distribution of that variable while holding the distributions of the other variable constant. Further numerical details have been reported [23][24][25][26][27]. We implemented the FDA in STATA 16 using the "Fairlie" command. --- Results --- Sample characteristics and analysis of inequality Table 1 shows that the overall sex ratio of the children was 1.06 . There were more reported males than female children in the survey across all the countries except for Angola , Congo , Congo Democratic Republic , Lesotho , Namibia and Zimbabwe . The highest proportion of male children were found in Armenia , Papua Fig. 2 Risk difference between children from houses with sex differentials in under-five-deaths by countries in LMIC New Guinea and the Philippines . The overall weighted prevalence of U5D was 51 per 1000 children, 55 among males and 48 among females . The prevalence of U5D among male children ranged from 4 per 1000 children in Armenia to 120 in Sierra Leone, while it ranged from 2 in Albania to 107 in Sierra Leone among female children. The z-test of equality of prevalence among male and female children was statistically significant in Burundi, Ethiopia, Malawi, Rwanda, Tanzania, Uganda, Angola, Cameroon, Chad, Congo, Gabon, Zambia, Zimbabwe, Benin, Burkina Faso, Cote d'Ivoire, Nigeria, Senegal, Sierra Leone, Tajikistan, Bangladesh, India, Pakistan, and Yemen . Table 2 shows that U5D was highest among multiple births compared with singletons . The lowest death rates were in the neighborhoods with the least SES disadvantage with 3.5% among males and 3.0% among females. All the explanatory variables considered were significantly associated with the U5D among all the children combined and by gender divides. --- Risk Differences in U5D among male and female children The risk differences, a measure of inequality, in the risk of having U5D among male and female children across the countries studied were presented in Figs. 1, 2 and3. Also, a meta-analysis of the prevalence of U5D among male and female children in each of the countries was carried out and presented the results in Fig. 1. The prevalence of U5D was generally higher in male children in all the countries except Liberia in West Africa; the Kyrgyz Republic in Central Asia; Bangladesh and Nepal in Southern Asia; Armenia in Western Asia; Turkey in Southern Europe and Papua New Guinea in Oceania. Pro-female inequality was however not significant in any of these countries. Irrespective of regions, the fixed effects of pro-male differences in U5D were widest in Cote d'Ivoire while the fixed effect of pro-female RD was widest for Turkey 5.3/1000). The random effects, that is the RD of U5D irrespective of country of residence per 1000 children was 7.5 : 5.8-9.1), evidence of significant overall pro-male inequality in U5D. The greatest contribution Fig. 3 Scatter plot of rate of under-five-deaths and risk difference between sex of children in LMIC to the random effect was found in India at 2.9% while the least was in Lesotho at 0.7% as shown in Fig. 1. In Figs. 2 and3, the red and orange colors indicate statistically significant pro-male inequality and insignificant inequality respectively. Based on RD, five of the nine countries in Eastern Africa, five of the six countries in Middle Africa, two in Southern Africa and four countries in West Africa showed statistically significant pro-male inequality. Three countries in Southern Asia, one country each in Central Asia, Western Asia, Central America and the Caribbean . The level of the heterogeneity of the RDs was 67% . --- Relationship between the prevalence of under-five deaths and magnitude of inequality The relationships between the prevalence of U5D and the magnitude of male-female inequality, a function of RD, across the 59 countries involved in this study are presented in Fig. 3. Countries such as Cote D'Ivoire, Chad, Sierra Leone, Nigeria and Burkina Faso had high U5D and high pro-male inequality; Liberia and Lesotho had high U5D and high pro-female inequality, Tajikistan, South Africa, Senegal and Egypt low U5D and high pro-male inequality while countries such as Turkey and the Kyrgyz Republic had low U5D and high pro-female inequality. --- Decomposition of gender inequality in the prevalence of under-5 death The Mantel-Haenszel pooled estimate of the odds ratio of having U5D controlling for the countries of the children. We estimated OR = 1.17 and tested a null hypothesis: OR=1; and obtained z = 155.45 and p = 0.000 and Test of heterogeneity: X 2 = 71.83, degree of freedom = 58, and p = 0.000, I-squared = 19.3%. Of the 59 countries, statistically significant pro-male odds ratio was found in only 25 countries. The countries were Afghanistan , Angola , Benin , Burkina Faso , Cambodia , Cameroon , Chad , Cote D'Ivoire , Ethiopia , Haiti , India , Indonesia , Kenya , Malawi , Mozambique , Niger , Nigeria , Rwanda , Senegal , Sierra Leone , Tajikistan , Tanzania , Timor Leste , Uganda , and Zambia . We then computed Mantel-Haenszel pooled estimate of the odds ratio of having U5D among the children in the 25 countries with pro-male inequalities while controlling for the countries. We had OR= 1.18 and tested the homogeneity ORs: X 2 = 50.49, d.f. = 24, and p = 0.001. These 25 LMIC pro-male inequality in U5D were included in the FDA. Figure 4 show the detailed decomposition of the part of the pro-male inequality caused by compositional effects of the determinants of U5D. The "explained" are depicted by red color while the "unexplained" portions of the pro-male inequalities are depicted by the blue color in Fig. 4. The lighter the red color, the lower the percentage contribution of the "explained" portion and the lighter the blue color, the lower the percentage contribution of the "unexplained" portion. There were wide variations in the factors associated with the pro-male inequalities across the countries. We found a connection among birth order, birth weight, birth interval and having multiple births as factors associated with U5D, while other variables formed another cluster. Different factors had the largest association with U5D in different countries. In most countries, birth order, birth weight, birth interval and multiple births contributed most to U5D. Specifically in India, the largest contributions to pro-male inequality in U5D were birth interval and birth order . In Afghanistan, birth weight, birth order and birth interval contributed 56.0%, 34.0% and 20.0% of the unexplained determinants of U5D respectively, while maternal age contributed 21.0% of the explained determinants. For Timor Leste, the greatest contributors to the inequalities were household wealth quintile, rural-urban differences in place of residence, and mothers' marital status, while birth interval and birth weight were the greatest contributors to pro-male inequalities in Ethiopia. The contribution of the neighborhood factors to U5D inequality were mostly from explained determinants and they were not as strong as the contribution of individual factors as seen in Fig. 4. The highest contribution by residence location was seen in Afghanistan and Timor Leste , while neighborhood socioeconomic class had even less contribution to U5D inequality with the highest contribution were seen in Haiti and Cambodia . --- Discussion In this study, we identified sexual inequality in the burden of U5D in LMIC using pooled data from 59 countries. Also, we quantified the individual-and neighborhoodlevel factors explaining the male-female differences in U5D. This study showed that U5D in most LMIC had a high-risk difference with pro-male inequality but with variations in the contributions of the determinants of U5D. However, most of the identified determinants were explainable. This showed that the natural female advantage at survival was still at play in many of these countries [28] and this reflects the level of development of the health system that is required to provide the platforms to reverse the natural male child's predisposition to an early death. It also implies that the identified determinants can still be addressed to reduce U5D in these countries. The four scenarios that considered the prevalence of U5D and the level of inequality provided thoughtprovoking insight into the spread and persistence of U5D in the countries studied. The natural scenario of high U5D and high pro-male inequality was expected in countries where the health system is underdeveloped [29,30]. However, the explanation for this gender inequality in U5D may be misleading as subtle gender discrimination against female children is still seen in the affected countries. For example, for Nigeria, Adeyinka et al made predictions using under five mortality data from 1964 to 2017 that there will be a switch to pro-female inequality in the future [31]. This prediction was made based on the estimates from the use of artificial intelligence and modelling techniques to project the future pattern of U5D in Nigeria. Similar discrimination against the female children has been reported in India as well where male infants were being selectively vaccinated compared with females [32], giving the males a higher odd of survival. This is already evidenced in the higher number of U5D being recorded for female infants in some states in India [33]. Other discriminations against female infants which results in higher female mortality include selective abortion of female fetus, higher household fund dedicated for the care of male infants and general neglect of female children [33]. If the discrimination against female children is not effectively addressed [34], the gains from reduced U5D from improved health system will be subsumed sooner or later. Also, the countries with high pro-male inequality need to learn from countries with low U5D and make extra concerted efforts to reduce U5D with the already available strategies which are effective. --- Fig. 4 Decomposition of pro-male inequality attributable to compositional effects of under-five death determinants in 25 countries Implementation strategies may need to be reviewed to identify problem areas that have been hindering the progress of halting U5D in these countries. Of the 10 countries with excess female mortality as reported by Alkema et al [35], only Bangladesh and Nepal still had pro-female inequality in this study. This suggests a reduction in female discrimination in the remaining eight countries [35]. It is also interesting to observe that both India and China were long known to contribute significantly to pro-female inequality in Asia [10] but India in this study had pro-male inequality similar to reports from an earlier study [30]. This might be as a result of under-developed health system which still exist in some states in India [36]. Countries with high U5D and high pro-female inequality usually have the problem of female inequality as the U5D pattern does not fit into the natural pattern. High gender inequalities have been reported from both Liberia [37] and Lesotho [38] with the latter country also struggling with the effect of HIV which have been shown to have a higher impact on women [39]. Countries such as Turkey and the Kyrgyz Republic with low U5D and high pro-female inequality have some underground mechanisms that promote discrimination among females. This is because, with a reduction in overall U5D, the female survival advantage is expected to be preserved. For example, Turkey has been shown to have a culture of male preference and male children receive more attention than females [40]. Altindag et al. reported that women in Turkey preferentially use contraceptives following the birth of a male child which results in more spacing of children and give the male children a better opportunity to survive [40]. However, such use of contraceptives was not done following the delivery of a female child thereby giving them less chance of survival. There is also a high level of female inequality in the Kyrgyz Republic despite improvement in childhood anthropometric indices at the national level, even though poverty still contributes significantly to stunting [41]. Infection is still responsible for a good percentage of childhood illnesses in many LMIC countries because of suboptimal living standards and inadequate childhood vaccinations and male children are more at risk of death because of the less resistance to infection due to their genetic make-up [8]. The facilities and skills to support premature infants and infants with respiratory distress are also not readily available and the male child is also more predisposed to developing both conditions than their female counterparts [41,42]. The countries with no significant sex disparity in U5D were mostly the upper-middle-income countries that have more resources to ensure better living conditions and provide improved health care services that can mitigate the peculiar health challenges that predispose the male child to higher mortality. This trend, however, suggests inequality as it points to likely female discrimination [43] because an improvement in the health system is expected to improve the survival of both male and female children. There is a need for further investigation to understand why there are no differences in the U5D in both sexes in these countries. It is, however, important to note that there were countries that were not as economically buoyant as these earlier ones but still had no sex disparity in U5D. They include Tajikistan, Kyrgyz, Cambodia, the Philippines and Honduras. A closer examination of the focus and investment in the health sector of these countries provides some likely reasons for the absence of disparity. For example, in Tajikistan, there have been giant strides in economic growth in the last two decades which has resulted in a drastic reduction in poverty level among the populace because of investment by the World Bank. This includes investment in Under Five health [44] with significant improvement in under-five nutritional indices and healthcare workers' management skills for childhood diseases [45]. However, as earlier pointed out, there is a need for further research to exclude discrimination against female children which may be responsible for the inequality in U5D seen in these countries. The contributions of the explained and unexplained components among countries with pro-male U5D inequality varied across the affected countries. In India, birth order conspicuously contributed to this inequality but there have been conflicting reports on how birth order affects U5D in this country. While Singh and Tripathi reported that U5D was associated with birth order one and two from nationally representing data [46], Sahu et al reported that the risk for U5D was higher among birth order 4 and above in rural communities in India [47]. The argument in the first study was that lower birth order was associated with younger maternal age which could affect the skills required for under five care and predispose to U5D. Also, higher birth order in a rural community may stretch the already limited resources that are needed to ensure optimal care of children. The mothers in the second study were also mostly uneducated and this is a strong predictor of U5D. However, both birth order and birth weight were unexplained contributors to pro-male U5D in Afghanistan. In this country, it was reported in an earlier research that both large and small for gestational age and birth interval lesser than 24 months were associated with early neonatal deaths and the males significantly had a higher odds of dying than females [48]. These are in consonance with the findings from the current study. However, reports from another study in the same country showed that birth interval of 48 months and the male gender were protective from LBW, a condition that is among the leading cause of neonatal mortality [41]. This appears contradictory to the findings from this study as Afghanistan had a pro-male U5D inequality. The role of birth weight in the promotion of male inequality in Afghanistan need to be further investigated for better understanding. Multiple birth was also an explained contributor in Senegal but unexplained in Tanzania. The associated complications of multiple birth have been well documented but its role in pro-male U5D inequality needs to be understood in order to address it in Tanzania. The last authors however reported that the male child was less likely to have LBW. Further investigation is required to ascertain the reason for this. In addition to the high pro-male inequality in U5D among these LMIC, there was high heterogeneity in the RD and this may be due to the different levels of health system development and variations in the predisposing factors as shown in the variation in the explained components of U5D. This is likely related to the differences in the stage of economic development and the priority given to U5 health care among these countries. Whereas it is logical to expect that countries with high U5D will have promale inequality. All the independent variables included in our model were significantly associated with U5D just as reported in earlier literature [16,[49][50][51][52]. The result of the Fairlie decomposition analysis shows that U5D was due to more of explained components than the unexplained component which implies that reduction of U5D is possible if more strategic efforts are employed in LMIC income countries. Among the variables considered, maternal education appears to be an important determinant that is associated with U5D as it can influence the presence or otherwise of the other factors [12]. A woman who is educated is more likely not to have an under-age marriage [53,54] so she will not have her babies too early and even if she has the children late, she is more likely to have supervised antenatal care and delivery [55,56] that will ensure the safety of her baby. An educated woman is also likely to have access to the media, have health insurance [57] and be employed. Her partner is also more likely to be employed and even if she is unmarried, she will be in a better position to successfully head a household. It is worth reiterating that female-headed households were associated with less U5D in this study which is similar to what has been reported earlier in the literature [51,58]. The likely reason is a better understanding of maternal and childhood conditions and this will lead to less bureaucracy in the decision-making process about accessing health care services for children. Furthermore, an educated woman is more likely to have the socioeconomic advantage that will prevent her from being poor and have fewer factors that can predispose her to have low birth weight babies like malaria and HIV [12]. If she has a low birth weight baby, she will have better access to good management and not patronize substandard treatment centers. She is also more likely to do family planning which will help in spacing her babies and this will prevent her from having too many babies. Therefore, an investment in female education by these LMIC will go a long way in reducing U5D. For the few unexplained components of the determinants, more investigative researches are required to explore them. For example, it is important to understand why birthweight was an unexplained component of U5D in Afghanistan and why the contribution of birth interval to U5D cannot be explained in India. The contribution of neighborhood determinants to U5D inequality was however not as much as those by individual factors. This may be as a result of shared cultures and national policies whose effects are likely to be far-reaching and this could have mitigated the differences expected in U5D as a result of the different categories of socioeconomic classes and locations of residence. Although residence location had the highest contribution to U5D inequality in this study in Afghanistan, there have been contrasting reports of how location affects U5D in this country. Kibria et al reported that rural infants were more likely to die in Afghanistan in their study of a nationally representative population of under-fives, but this association became insignificant after adjustment for maternal age and place of delivery [59]. This contrasts with reports from other countries [60][61][62] where residence in rural areas was associated with higher newborn mortalities, higher incidence of LBW and lower APGAR scores . --- Study strengths and limitations This study is one of the first analyses in LMIC that investigated individual and neighborhood factors contributing to sexual inequalities in U5D across 59 LMIC. The use of large nationally representative data enhanced the quality of our findings in terms of generalizability. Also, the FDA applied in our study is an improvement over the commonly used Blinder-Oaxaca decomposition analysis which has been reported to be inefficient in handling logit and probit models [21][22][23]. However, the study is not without some limitations. First, the measure of child mortality which is dependent on information provided by mothers may underestimate the actual rate as a result of recall bias. Most mothers may not be comfortable with talking about their dead children, and so, may not give accurate responses. The traditional practices in some countries also forbid parents from reporting the death of their children. Secondly, the cross-sectional nature of the study means that causal inferences cannot be made from our findings. --- Conclusions In conclusion, significant sex inequality exists in U5D among LMIC with mostly male pro-inequality. There were different determinants for this male pro-inequality in the structural and compositional components considered across the different countries concerned. However, the pattern of this sex inequality reflected the presence of both weak health systems and female inequality. These countries will need to address the failing health system, address gender inequality and invest in female education to stem the tide of preventable U5D in LMIC if the SDG 3 is to be achieved. --- Contribution to Knowledge The contribution of the study to knowledge is in two folds: it identified countries with significant gender differences in under-five deaths. it quantified the contributions of the explored characteristics to the gaps/ inequalities in sex differential in under-five deaths among countries with significant differences. --- --- Abbreviations --- --- Funding The authors received no funding for this study. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: There exist sex disparities in the burden of Under-five deaths (U5D) with a higher prevalence among male children. Factors explaining this inequality remain unexplored in Low-and Medium-Income Countries (LMIC). This study quantified the contributions of the individual-and neighborhood-level factors to sex inequalities in U5D in LMIC. Methods: Demographic and Health Survey datasets (2010-2018) of 856,987 under-five children nested in 66,495 neighborhoods across 59 LMIC were analyzed. The outcome variable was U5D. The main group variable was the sex of the child while individual-level and neighborhood-level factors were the explanatory variables. Fairlie decomposition analysis was used to quantify the contributions of explanatory factors to the male-female inequalities in U5D at p<0.05. Results: Overall weighted prevalence of U5D was 51/1000 children, 55 among males and 48 among females (p<0.001). Higher prevalence of U5D was recorded among male children in all countries except Liberia, Kyrgyz Republic, Bangladesh, Nepal, Armenia, Turkey and Papua New Guinea. Pro-female inequality was however not significant in any country. Of the 59 countries, 25 had statistically significant pro-male inequality. Different factors contributed to the sex inequality in U5D in different countries including birth order, birth weight, birth interval and multiple births. Conclusions: There were sex inequalities in the U5D in LMIC with prominent pro-male-inequality in many countries. Interventions targeted towards the improvement of the health system that will, in turn, prevent preterm delivery and improve management of prematurity and early childhood infection (which are selective threats to the male child survival) are urgently required to address this inequality.