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introduction and theoretical background depression in older adults the world population is rapidly aging between 2015 and 2050 the percentage of people in the world over the age of 60 will nearly double from 12 to 22 depression among older adults is one of the most serious public health problems facing modern societies the appearance of depression is associated with serious consequences including disability functional decline diminished quality of life increased mortality increased service utilization and high levels of suicide in adults in older adults depression is connected with a marked reduction in cognitive abilities which in turn is commonly accompanied by a decrease in social and physical activities alongside coronary heart disease cancer and cardiovascular diseases depression is a major public health problem that has become a common chronic disease in older adults depression symptoms greatly influence both physical and cognitive functioning of older adults longitudinal studies have reported that depressive symptoms are connected to functional decline as determined by both selfreported and objective measures of physical performance they also contribute to limitation of basic activities of daily living in high functioning older adults initially free from disability as depression deepens and more symptoms surface the likelihood of becoming disabled increases moreover depressive symptoms may accelerate the disablement process in older adults already exhibiting early signs of disability and individuals with chronic depressive symptoms have greater declines in functioning compared to those who remained nondepressed latelife depression is also associated with an increased risk of decline in cognitive functioning older adults with depression are more likely to have concomitant cognitive deficits especially executive cognitive functioning deficits or are subsequently more likely to develop dementia older adults with depression often develop cognitive impairment following onset of depression thus depression might be a risk factor or an early symptom of dementia one of the risk indicators for depression is lack of social support and social networks many of depressed older adults are also lonely and a correlation has been found between depression and loneliness depression with feelings of loneliness leads to more pronounced motivational depletion and serious consequences including social isolation reduced selfcare decreased mobility and poor diet participants reported loneliness feelings in the week prior to the interview the loneliest group was that of age 75 women reported higher levels of loneliness than men as did arabs compared with jews today loneliness is also perceived as a biological structure similar to hunger thirst or pain which are internal mechanisms activating behavior that prevents harm to the person hunger makes us seek food loneliness prompts us to seek social relationships correlations have been reported between the feeling of loneliness and several physical health problems cardiovascular diseases chronic diseases cancer stroke high blood pressure and mental illness low levels of emotional wellbeing and a high level of suicidal thoughts the problems caused by loneliness lead to decreased quality of life increased mortality poor recovery from illness and high hospitalization rates among older adults depression in older adults may result from a variety of reasons apart from loneliness feelings including malnutrition some studies have reported a strong and independent association between nutritional deficit and depression demonstrating that depression increased the risk of impaired nutritional status whereas others have shown a modest association or no association significantly over 10 of adults with depression residing in the united states also suffer from malnutrition malnutrition impacts quality of life by undermining individual autonomy to perform necessary instrumental and social activities of daily living malnutrition is defined as a state in which a deficiency excess or imbalance of energy protein and other nutrients causes measurable adverse effects on tissuebody form function and clinical outcome it is more prevalent and increases among older adults although malnutritions etiology is multifactorial adverse physiological psychological and social causes of malnutrition in older adults are consistently reported in the literature aging is accompanied by physiologic changes that can negatively impact nutritional status sensory impairment may result in reduced appetite and poor oral health and dental problems can lead to difficulty chewing inflammation and a monotonous diet that is poor in quality the progressive loss of vision and hearing may also limit mobility and affect the elderlys ability to shop for food and prepare meals along with physiologic changes older adults may also experience profound psychosocial and social changes contributing to poor nutritional status these include cognitive impairment heavy use of medication periods of lengthy hospitalization isolation retirement from paid work bereavement increasing frailty and loneliness and depression these factors influence the ability of older adults to meet dietary needs or to digest absorb utilize or excrete nutrients that are ingested the outcome is reduced energy intake and lean body mass resulting in a reduced metabolic rate and a proportional decline in total energy expenditure that may lead to malnutrition apart from the possible direct connection between loneliness feelings and depressive symptoms loneliness feelings can have widespread implications for the mental and social lives of older adults and these implications can explain some of the effects of loneliness feelings on depressive symptoms specifically one mediator might be at play malnutrition the current study the current study was conducted in israel in 2020 during a covid19 pandemic quarantine providing a unique opportunity to assess the effect of loneliness feelings on depressive symptoms mediated by malnutrition among older adults from different cultures during a particularly stressful period we posited three hypotheses 1 loneliness feelings due to the covid19 pandemic is associated with depressive symptoms 2 loneliness feelings due to the covid19 pandemic are indirectly associated with depressive symptoms through malnutrition older adults feeling lonely will report higher levels of malnutrition which will be associated with increased depressive symptoms 3 loneliness feelings depressive symptoms and malnutrition levels will differ between older adults from different cultures as a result of covid19 imposed quarantines method study design and participants the research employed a crosssectional study of a convenience sample of 201 jewish and arab older adults aged 65 and over representing the two main ethnic groups living in israel inclusion criteria were age 65 and over and the ability to speak and understand hebrew or arabic procedure the study was approved by the research ethics committee of the college at which the research took place recruitment of participants was random and the final sample comprised 100 jews and 101 arabs researchers explained the study objectives and procedure to the participants including their right to withdraw freely at any time strict confidentiality was maintained data collection was performed by professional interviewers through telephone interviews adhering to covid19 quarantine restrictions using appropriate translated validated and structured questionnaires data collection took place from april to may 2020 measures independent variable loneliness loneliness was measured by a single direct question «do you sometimes feel lonely» with four options never seldom sometimes often dependent variable depressive symptoms depressive symptoms were measured by the geriatrics depression scale developed by yesavage and brink the purpose of the questionnaire was to determine participants depressive symptoms by using a simple and reliable tool that does not require the time and skills of a professional interviewer the tool is composed of 15 items in a yes no response formats mediator malnutrition malnutrition was measured by the determine nutrition screening initiative developed jointly by the american diabetes association the american family doctors association and the national council of old age the purpose of the questionnaire was to detect older adults at risk for malnutrition the tool is composed of 10 items in a yes no response format covariates the study controlled for socioeconomic variables background variables included gender age marital status and years of education age and years of education were both defined as continuous measures gender was coded as dichotomous marital status was coded as with partner 1 or without a partner 0 all instruments were translated into hebrew and arabic by bilingual translators the complete questionnaire underwent a pilot test the questionnaire took approximately 15 minutes to complete the verbal instructions were comprehensible and there was no need for further changes before administering the questionnaire data analyses descriptive statistics were employed to calculate the means and standard deviations of the continuous variables and the percentage and frequency of the categorical variables in the second stage bivariate analyses were performed to examine the association between depressive symptoms and the independent variable mediator variable and socioeconomic variable using an independent ttest oneway anova pearson or spearman correlation tests mediation analyses were then computed in which the selected mediator was entered to test the components of the mediation model using the bootstrapping method to assess the indirect effects of the mediation model thus the meditation model was examined by directly testing the significance of the indirect effect of the independent variable on the dependent variable through the mediator while controlling for background variables that were identified earlier as significant in the bivariate analyses this method is based on regression analysis calculating the direct effect total effect and indirect effects of an independent variable on a dependent variable the total and specific indirect effects were calculated through bootstrapping set at 5000 samples confidence intervals were calculated using this method by sorting the lowest to highest of these 5000 samples of the original dataset yielding a 95percentile confidence interval all analyses were run using spss 250 with the process statistical program all estimated effects reported by process are unstandardized regression coefficients results of the participants 105 were women and 96 were men ranging in age from 65 to 95 years of education ranged from 6 to 21 and 711 had a partner the group had equal numbers of arab and jewish participants there were significant differences based on ethnicity with regard to education with jewish participants reporting more years of education than arab participants the cohens effect size value was high arab participants reported a significantly higher level than jewish participants of loneliness malnutrition and depressive symptoms for most variables the cohens effect size values were relatively high table 2 presents the bivariate tests between the study variables with depressive symptoms as the dependent variable results revealed that all demographic variables except for gender and marital status were significantly related to depressive symptoms advanced age was positively correlated with depressive symptoms lower educational level was correlated with higher reported depressive symptoms an ethnic difference in depressive symptoms was also found with arab participants reporting higher depressive symptoms than jewish participants both the independent and mediator variables were significantly related to the dependent variabledepressive symptoms high malnutrition and high loneliness were positively associated with depressive symptoms the mediation analyses using process model 4 we tested hypotheses two and three whether malnutrition mediated the relationship between loneliness feelings and depressive symptoms controlling for covariates the results indicated a significant total direct effect of loneliness feelings on depressive symptoms a significant direct effect and a significant indirect effect through malnutrition the results also showed that loneliness feelings were associated with higher malnutrition scores and that malnutrition was positively associated with depressive symptoms finally ethnicity was associated with depressive symptoms however no significant associations were found between depressive symptoms and the other covariates gender age education and marital status discussion the general purpose of this study was to examine the extent to which loneliness feelings are connected with depressive symptoms of older adults from different cultures during isolation by conducting research during a covid19 pandemic quarantine in israel we measured whether older adults who suffered from higher degrees of loneliness feelings due to the covid19 quarantine had higher levels of depressive symptoms and what potentially accounted for this association the findings confirmed the first hypothesis that older adults suffering from a high degree of loneliness feelings suffer from higher levels of depressive symptoms these results are consistent with other studies executed before and during the covid19 pandemic reporting that loneliness feelings are associated with mental wellbeing the mediation model confirmed the second hypothesis that the connection between loneliness feelings and depressive symptoms is accounted for by level of malnutrition the association between loneliness feelings depressive symptoms and level of malnutrition can be explained by two different aspects dietary behavior and the influence nutrition has on depressive symptoms with regard to dietary behavior loneliness feelings may affect appetite and nutrient intake through a decline in mood physical functioning or cognition these various declines combine with the difficulty people have eating alone appetite can be further inhibited by changes in social status particularly when older adults experience loneliness andor bereavement due to loss of a spouse or friends of the same agegroup eating in the company of others can help prevent malnutrition it increases caloric intake and is related to healthier food habits and maintains the motivation of older adults to eat and cook providing them with opportunities for social interaction and connectedness the current study took place during a covid19 quarantine when older adults as a highrisk group were counseled to stay at home with their permanent partners only and to avoid as much as possible from going shopping and to depend on home deliveries hence it is likely that older adults were forced not only to eat alone but to be alone most of the time resulting in insufficient food intake and consequently malnutrition the second aspect concerns the connection between depression and the diet of older adults recent studies have suggested that depressive symptoms are more prevalent in individuals with impaired nutritional status than in other older patients it has been observed that individuals with specific nutritional deficiencies such as lack of folic acid and vitamin b12 as well as antioxidant vitamins had more depressive symptoms than those with normal nutritional status the mechanism that might be at work here is that older adults who suffer from loneliness feelings tend to eat less and lack a healthy appetite and for that reason they will not consume all the nutrients they need and will suffer from malnutrition or depressive symptoms this mechanism accelerates during a quarantine when even older adults who do not suffer from loneliness ordinarily suffer from isolation the third study hypothesis was that research variable levels will differ between cultures particularly due to the extremity of the covid19 quarantine indeed arab older adults reported greater loneliness feelings higher level depressive symptoms and greater malnutrition compared to the jewish older adults the results with regard to depressive symptoms are consistent with studies reporting that being a member of an ethnic or racial minority is a risk factor for depression specifically arab respondents have reported higher depressive symptoms than jewish respondents however there are also contradictory results concerning the higher levels of loneliness and malnutrition the covid19 quarantine may have posed new challenges to the arab study participants that explain the study findings arab society in israel is known for family consolidation and solidarity the extended family maintains a multigenerational structure with grown children obligated to filial piety responsibilities the covid19 quarantine forced new ways of communication upon family members exposing the absence of digital literacy among arab older adults for arab older adults internet use does not protect against loneliness moreover the extended family often lives together with the daughters and daughtersinlaw cooking and serving the older adults the quarantine isolated the arab older adults from their extended family resulting in reduced help with cooking and serving meals moreover the strong connection between feeling loneliness and malnutrition cited above amplified the problem conclusion and implications the present study was executed during a covid19 pandemic quarantine the results indicate that there is a connection between loneliness feelings depressive symptoms and malnutrition the primary conclusion is that loneliness feelings are a serious problem facing all older adults since they negatively affect both depressive symptoms and malnutrition in order to overcome these feelings it is important to connect older adults to social network technologies and teach them how to use these technologies families can also receive guidance for meeting while maintaining social distancing another option is to encourage neighbors in the same building to talk to each other and find ways for mutual support research indicates that members of the arab society in israel are a highrisk group and much more vulnerable to loneliness feelings depressive symptoms and malnutrition in times of crisis such as the covid19 pandemic the lives of many arab older adults changed from being surrounded and supported by their extended family to being alone during the quarantine and to suffering from malnutrition in order to fight these two related outcomes one possible solution is to provide psychologicalnutrition intervention by telephone this would provide by missing human contact and nutrition guidelines and encouragement to cook and eat healthier foods we should point out three main limitations of the current study one is the crosssectional study design which does not allow for prediction of a causal relationship between the variables a future study should use longitudinal data to examine the relationship between loneliness feelings and depressive symptoms a further limitation might be the use of only one question concerning loneliness feelings however previous studies have also used one question in order to describe loneliness feelings third a generalization of the findings is limited because the sample and the sampling procedure do not guarantee the representativeness of jewish and arab older adults the sample was conducted by telephone and included only older adults who answered the telephone at that moment those who did not answer or did not have a telephone are not represented in this study these various factors may have biased the results despite these limitations the present study provides initial insights into the mechanisms of the association between loneliness feelings malnutrition and depressive symptoms during periods of quarantine imposed isolation conflict of interest statement the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article ethical standards the number of the approval from tel hai college is 320205

research on loneliness conducted in different countries has demonstrated that it is a common universal phenomenon although its prevalence varies between societies and cultures 11 in the united states more than 19 of older adults aged 65 and older reported loneliness feelings 12 in australia the comparable figure was 40 13 in a study of loneliness in israel 14 it was found that nearly half 47

introduction there are disagreements about and contradictory indications of the state of qualitative inquiry as a global endeavour denzin for example argues that qualitative inquiry faces a global onslaught from conservative and neoliberal critics especially in the field of educational research and especially in the united states following the writing into legislation of the requirement for federal educational research funding to be allocated to socalled scientific research scientific research has been extensively defined in us legislation and includes reference to measurements or observational methods that provide reliable and valid data across evaluators and observers… evaluated using experimental or quasi experimental designs…with a preference for random assignment experiments… the argument of critics is that qualitative research is not scientific or not scientific enough and cannot produce definitive evidence about what works in social policy interventions qualitative research produces too many disconnected noncumulative studies that do not provide convincing evidence for central education health business and so forth a key point that atklinson and delamont make is that qualitative research is still widely funded in countries such as the uk paper for the uk department of education the terms of the debate may be changing in the uk delamont and atkinson also note the development of a number of successful interdisciplinary journals in the field along with increases in the numbers of issues per year of these journals and thus the numbers of papers published they also note the continuously expanding market for qualitative research methods texts and sourcebooks such as sage handbooks and major works not least denzin and lincolns handbook of qualitative research now in its fourth edition there are some disagreements in the field then in some respects representing different interpretations of the prospects for qualitative inquiry in the usa and the uk however what i want to argue in this paper is that these disagreements rather miss the point the issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding and policy attention in diverse countries around the world but rather to what purposes are qualitative methods being put what research agendas are being pursued and who sets them it is clear that qualitative methods are indeed being taken up widely across regions and disciplines with the scale and scope of the annual international congress of qualitative inquiry from which this special issue derives being part of the positive evidence it is also undeniable that internationally social research in general qualitative approaches to social and educational research in particular have been under very specific attack for fifteen year or more criticism is manifested in different ways and with different levels of severity in different countries and different disciplines the pressure derives from concerns about the quality and the utility of social and educational research more generally not just concerns about qualitative approaches it also derives from an increased government focus on valueformoney in research and how social research might better serve social policy qualitative methods of inquiry can be seen to play to this policy and utility agenda as much as to a social justice agenda or indeed a disinterested scientific agenda qualitative methods can be deployed in policydriven research as well as in more openended inquiry and thus may survive and even prosper but not necessarily in ways that all qualitative researchers will welcome researchers and evaluators in many applied research fields including health care and education have noted the reduced timescales now associated with qualitative work and the narrowness of many research agendas being pursued this is also the case in what we might term the more traditional disciplines of anthropology and sociology mills and radcliffe report on the increasingly truncated timescales for anthropological fieldwork and the use of a more limited range of ethnographic methods among freelance development consultants and in development agencies such as the world bank thus while it can be argued that qualitative research remains widely supported the form that such research takes might be said to be somewhat limited and even of poor quality given arguments for exploratory and extensive field immersion that are apparent in many ethnographic textbooks such an orientation towards the use of qualitative methods is apparent in a range of policy development settings and intervention agencies thus for example valerie caracelli writing from the perspective of the us government accountability office argues for the inclusion of qualitative methods in evaluation studies to assure contextual understanding she states that recently there has been an acknowledgement about how ethnographic studies can inform agency actions and how it can be used to study culture in organisations however whether truncated timescales and narrow policy agendas can be easily reconciled with the theory and practice of ethnographic studies is a moot point moreover studying culture in organisations in order to inform agency actions seems to suggest the utilization of qualitative inquiry as as technology of government rather than as an approach to understanding emergent issues that policy may not want to address a recent uk cabinet office report produced in the context of the move toward evidenceinformed policy and practice presented guidelines for judging the quality of qualitative approaches and methods interestingly one of the key quotes in the report used to justify the use of qualitative methods comes not from the epistemological or methodological literature but from a civil servant a government department research manager i often commission qualitative research when its about users or stakeholders and it is in this context of the potential cooption of qualitative inquiry to the agendas of policy that i want to focus on a particular subissue of this wider debate that of research selectivity and concentration in the uk and its implications for qualitative research methods significant changes are being enacted in the uk with regard to university finance governance and the nature of scholarly activity that carry potentially very severe implications for the practice of social research in general and for qualitative approaches to research in particular there is an argument that social research is increasingly being nationalised and corporatized in the uk seen by many social researchers as well as policymakers as an arm of government and more important to universities for its incomegenerating potential than for its contribution to knowledge and the public good thus arguments about whether or not qualitative approaches to research remain popular are rather irrelevant what is at stake is the legitimacy and quality of the research which is being undertaken and the purposes to which it is being put as noted above policymakers and some social science scholars themselves have argued that social and educational research particularly qualitative research is too often conceived and conducted as a small scale cottage industry producing too many small scale noncumulative studies which do not provide firm evidence for decisionmaking it is axiomatic to such criticisms that providing evidence for policymaking is indeed the proper role for social science additionally governments around the world are seeking better value for money from their investment in research and university teaching and this has involved restricting and focusing resource allocation selectivity and concentration of research resources are particularly being pursued in the uk the conservative dominated coalition government is cutting public spending in the wake of the 2008 banking crisis and global recession so there are fewer resources available for research than might otherwise have been the case and selectivity and concentration have become even more severe in the uk over the last couple of years concentration of research is effected both through focused core allocations from the higher education funding agencies and through highly competitive bidding to research councils and foundations as described below success leads to further success and to relatively few universities securing the overwhelming majority of available funding this in turn produces the issue of universities seeking research funding first and foremost for their own corporate survival rather than for the public benefits that may accrue it also leads to social research becoming part of a nationalized approach to managing national social problems rather than being part of an international community pursuing better understanding of the nature of social problems and what produces them funding agencies and individual universities are now concentrating resources on fewer research units and programs and are taking decisions to develop a big science model of social science this is being pursued by funders supporting fewer larger projects with explicit policy encouragement for researchers to develop crossinstitutional mixed method approaches to address the supposedly big issues of our time health and well being an aging population sustainable growth and so forth these issues are indeed important and research evidence should be produced to interrogate and inform public debate but such issues are being presented as part of a commonsense takenforgranted tradeoff of government funding in exchange for social scientists serving policy critique diversity of perspective and the insight into complexity which detailed qualitative studies can provide are potentially being marginalized social science is being reconceptualised as a technical service to government rather than developed as a democratic intellectual resource for the community the remainder of the paper will provide some brief illustrative examples of policy initiatives and how this change is being accomplished funding universities university policy and funding is located in the uk government department of business innovation and skills evidence in itself of where government priorities lie universities are not housed in the department for education a recent bis white paper stated quite clearly that we intend to maximize the impact of our research base on economic growth it went on to compete effectively the uk must harness its strengths in…research…and its expertise in areas such as design and behavioural science… in essence the white paper argues that investment in research should be oriented to those areas that promise most economic return with behavioural science being deployed to understand and change peoples behaviour in relation to key threats to economic development such as poor health and global security moreover the white paper goes on to assert that major social and economic challenges can only be resolved through interdisciplinary collaboration and thus government will actively support strong collaborations across disciplines and institutions research including social research will be marshaled and directed in the national economic interest such policy discourse then sets the tone for the activities of intermediary agencies such as research funding councils and individual universities while individual research councils can set their own agenda their budgets derive from government are unlikely to stray too far from policy imperatives similarly universities while independent must compete for specific forms of funding under common national rules and thus common institutional structures of research prioritization monitoring and compliance emerge across institutions the research allocation which universities receive from the higher education funding council is based on quality ratings derived from an accountability exercise originally called the research assessment exercise and now known in its current iteration as the research excellence framework as a result of these exercises funding has become highly concentrated in historically elite institutions with for example only four universities receiving 32 of all hefc research funding in 200910 and 25 universities receiving 75 of funding of course it might be argued that not receiving such funding is not necessarily such a bad thing since it leaves the majority of universities outside the mainstream funding agenda and thus outside this particular mechanism of government control however the mainstream agenda remains dominant since university managers simply cannot ignore it some research success however small is regarded as better than none especially with respect to the reputational gains associated with research activity and associated student fee income for all practical purposes when it comes to research funding in the uk the ref is the only game in town clearly this level of selectivity begs serious issues for university finance management and the pursuit and measurement of impact is likely to drive research activity further towards applied and policyoriented research moreover the pursuit of specific research tenders and contracts is also likely to be increasingly emphasized by individual universities as noted above both to fill gaps in core funding left by increasing selectivity and concentration and to maximize the metrics available for the environment element of the profile so this element of core research funding derived from the higher education funding council which is intended to provide the underpinning platform for basic university research is becoming increasingly selective and concentrated and is now being significantly oriented towards applied rather than basic research thus while technically the agenda for this research activity remains under the control of individual scholars and research groups increasingly they need to think about developing research programs which fit with government university and departmental priorities in order to maximize quality gradings and income in turn universities and departments are developing strategies and programs to manage the ref accountability procedures and research impact and environment issues more generally such that research is becoming an increasingly planned bureaucratized and managed activity ironically given the current emphasis in some quarters on the gold standard of scientific method university research is ceasing to be scientific in the sense of the disinterested pursuit of knowledge and becoming a corporate commercial activity undertaken on behalf of individual universities themselves and their financial survival in turn the social relations of research within universities and departments are changing it might of course be argued that twas ever thus universities have always had to fund their activities and individual scholars and research groups have always had to manage and mediate the relationship between funding opportunities and the research that they think is important to design and undertake my argument is that this balance of calculation is under severe pressure in the uk at the present time both with respect to the overall funding available and with respect to the position of qualitative research activity within this funding environment it might be further argued that this balance should change and that the pursuit of more applied policyoriented research should be undertaken a second paper could be written about the issues at stake and the arguments deployed my point for moment however is simply that such change does indeed seem to be occurring funding social science still to reiterate in principle the research agenda pursued with this funding regime remains under the control of faculty and research groups however another irony of the current situation in the uk is that if anything the funding strategy of the research council the economic and social research council further compounds the problem rather than providing any sort of counter weight in principle the esrc is an arms length body independent of government allocating awards for excellent social science research in response to competitive bids refereed by peer review it might be thought therefore that the esrcs agenda would reflect the research agenda of the social scientific community as a whole however all research council funding derives from government and as such is clearly influenced by government priorities the esrc is no exception the esrc shapes the content of the social science research agenda much more directly than government policy but does so in large part because its funds derive from government again of course there are many intermediary processes and activities with esrc officials seeking to maximize funding available in difficult times in return for responding to government priorities likewise peers review proposals on merit but these proposals have already been produced in response to priority areas and specific funding calls the esrc works within the context of an overarching crossresearch council strategy there are seven research councils in the uk distributing funds across the natural and social sciences humanities and medicine each council has become progressively more managerial over recent years not simply responding to bids from the scholarly community for funding but actively shaping the agenda around which bids can be made establishing priorities and issuing specific calls for proposals as noted above the assumptions embedded in this statement of strategy reflect the development of an institution which sees itself governing social science rather than supporting it defining priorities selecting future leaders and concentrating phd training in a few selected centres so that those leaders are in any case selected from an increasingly narrow institutional and intellectual base the use of the term training for the development of future scholars also seems indicative of a directive rather than a supportive role the deliver plan goes on to address this specifically and states we will develop national capability through …broadening the skill of all social science phd students by emphasizing transferable skills training…we will require institutions to provide training on core topics such as impact public engagement and media training…to ensure the continuing pipeline of excellent researchers for the nation the strategic plan and delivery plan also identify a need for the longer larger projects to be interdisciplinary and involve crossinstitutional collaborations which are defined as essential in studying and resolving complex challenges in effect social science is being reconceived and restructured as the behavioural science arm of government so that social science can influence behavior and inform interventions it might be argued that because esrcs budget and level of activity is very small when compared with overall funding for social science in the uk its influence will be similarly small the esrc budget is c £166m in 201415 the total science budget for uk higher education is £46b detailed breakdowns between different natural and social science allocations are difficult to identify but it is likely that esrc does not fund more than 10 of overall social science teaching and research activity including that supported from student fees thus again there is a case for suggesting that most uk social science research is beyond the reach of esrc and in turn government policy agendas but as with the ref influence far exceeds scale of activity as universities and research groups seek to bid for research council funding despite success rates dipping well below 20 and develop postgraduate training activities to mirror esrc provision so that they are not excluded from future funding possibilities nevertheless further concentration of funding might be construed as an opportunity as well as a challenge for qualitative social research to reach out to community support and other forms of charitable foundation and european union funding an interestingly critical issue for the current policy of selectivity concentration is at what point might the nationally statesupported funding base shrink so low that the research councils influence over the sector as a whole will disappear furthermore there is a separate paper to be written about whether or not and if so in what ways social science should develop so that it can influence behavior and inform interventions on behalf of government many would argue that social science should engage more directly with the public and help to inform democratic debate and decisionmaking though such activity is not necessarily coterminous with simply acting in response to and in support of government policy likewise with respect to the content of research training some would point to statistics indicating that only around 20 of research council supported research students secure academic posts in universities and thus a wider training in employability is important yet by the same token the statistics indicate that 80 go on to work in researchrelated and more general administrative teaching and managerial roles in other public sector charitable and commercial organisations if these figures are accurate then not only is such a problem not the responsibility of esrc to solve it is not actually a problem at all since phd graduates are already securing employment outside academia and the influence of social science training could be said to be extending well beyond university departments in fact students often value these broader elements of their doctoral programs as academic employment opportunities are so limited nevertheless time spent on public engagement and media training is time not spent on fieldwork and data analysis the core of any qualitative research training these matters are not necessarily clearcut but my point for the moment is simply that these developments are shaping social science in general in the uk at the present time qualitative educational and social research in particular short term consequences and implications the first and most obvious consequence is that relatively small scale funding to undertake specific qualitative and case studytype work is no longer available from esrc hitherto esrc ran a specific small grant scheme which was able to accommodate small scale exploratory investigations pilot projects and postdoc projects from early career researchers it was particularly suitable for supporting individual scholars to undertake detailed case study work over the period of a year or eighteen months by buying their time to concentrate on research for short periods and of course because the grants were small more could be funded in the absence of knowing in advance which project would show most theoretical and empirical advance funding more small scale projects seems sensible this support is no longer available the smallest open call grant now available is £200k still modest by international standards but substantial enough to indicate that a larger scale mixed methods approach would be more likely to win funding when evaluated against valueformoney criteria additionally esrc used to support a first grant scheme which was similarly oriented as the name implies towards early career researchers who again often applied for small scale funding for qualitative work this thus qualitative work must now be conceived and proposed either in terms of much larger scale longitudinal ethnographic investigations or as part of a large scale cross disciplinary and crossinstitutional mixed methods research design again involvement in such work is no bad thing and no doubt will contribute to the continuing popularity which delamont andatkinson claim for qualitative methods in the uk but it should not be the only qualitative research that secures support moreover when such large scale investigations are only funded because government wants to influence behavior and inform interventions be they mixed method or ethnographic and perhaps especially when they are ethnographic then they beg many questions about the legitimate role of social science in a democracy as noted above qualitative research is a wonderful vehicle if you want to understand the motives of people the key issues here comprise both the scale of endeavour now expected and the control of the research agenda social scientists are being positioned by government and by some leading members of the social science community as experts in social policy whose function is to respond to social problems again social science should indeed be prepared to respond to social issues but not to the exclusion of critical social inquiry furthermore the expertise of the community depends on what we might term a hinterland of basic social theory and social research from this hinterland expertise can be drawn and framed in response to particular issues the move from basic to applied research but if social science can only now act in relation to prescribed issues problems and large scale empirical research designs then over time it will lose the ability to construct its objects of study independent of the context of inquiry it will in effect cease to be social science in any meaningful sense with respect to the social relations of research opportunities for early and mid career social scientists to develop their own intellectual trajectories are likely to decrease as areas of strategic investment are defined by funding agencies moreover large scale grants are likely only to be awarded to senior researchers who have a track record of managing and delivering on previously funded work thus early career researchers must now attend to bidding for research grants especially in areas of applied research and look to secure collaborative funding with more senior colleagues this is now a core feature of any social science career developing scholars must also become able to design impact strategies and build networks including with policymakers as well as other scholars in order to become included in collaborative research designs in effect involvement in social research is being reconstructed as a technical and professional career and indeed a quasigovernmental career rather than as a contribution to science or as an independent and critical service to the community and the democratic process the very nature of the purposes and practices of social research is being changed my argument is not that that these matters are entirely novel or uncontentious social science has had an uneasy relationship with government funding for many years similarly outcomes are not easily determined there are many mediating interpretations actions and institutional processes between grandiose policy documents often written first and foremost to secure funding rather than control it and the activities of individual researchers and research groups yet the material and discursive context of interpretation and mediation means the direction of travel becomes ever more difficult to resist nor is my argument that none of these things should be happening to reiterate universities research groups and individual scholars have always had to fund their work and certainly should be responsive to the needs of social policy development however responsiveness to policy and to wider contexts of action should take their proper place in the overall career trajectories of social researchers and scholars more generally intellectual curiosity about how society operates and with what effects and consequences for individuals and social groups must remain the driving force of social science and scholarly activity otherwise it simply becomes a technology in service of government rather than an independent and critical intellectual resource for democratic debate longer term trends and prospects a more general issue is whether or not the social science community is right to accept that proximity to government will necessarily ensure its sustainability part of the backcloth to the current debate is the uncertain status and legitimacy of both science and government at the present time government and the process of mainstream electoral politics is itself generally unpopular and under pressure to deliver especially with respect to economic competence and with regard to the provision of public services can we always assume the benign intent and impact of government what reasons are there for state intervention in the lives of ordinary citizens how appropriate is it for social research to attempt to influence behaviour and inform interventions it is at least arguable that government intervention can disempower communities and it certainly locates agency in government and professional bureaucracies including those of social science rather than local communities a different approach would involve social research helping to build communities capacities to develop themselves rather than simply providing evidence for central policymaking and the development and evaluation of government intervention programs in this respect it may be the case that deriving legitimacy for social research from proximity to government is selfdefeating such a strategy links social research to an inherently unpopular institution and at one and the same compromises the basic claim for the legitimacy of science that of disinterested inquiry of course many qualitative researchers also want to pursue a social justice agenda not just a social scientific agenda but here too collaborating with local organisations institutions and communities rather than government would seem to hold much more promise with respect to both the quality of the research and its potential impact on social and economic life a second element of an alternative approach to the further development of qualitative research must be to maintain involvement in international networks and debates and resist attempts to render qualitative research into a parochial set of research techniques to be pursued in the national interest the use of qualitative research methods has a long and distinguished history in education and the social sciences discussions of qualitative methodology have been at the forefront of many decades of debate over whether and if so in what ways we can conduct enquiry and build knowledge in the social sciences it might even be argued that it is qualitative methods or perhaps more generally a qualitative sensibility and approach that constantly questions the development of social research as a technology the strengths of qualitative research are at their most manifest when used to address both the substantive topic under investigation and the way in which that topic is constituted and realised in action by the social processes at play the phenomenon under study is not simply taken as given thus local activity and development can draw intellectual sustenance from global debates a key strength of a qualitative approaches to social research is facetoface engagement with participants this must be maintained as both an ethical and political strength as well as an epistemological strength many recent international discussions of quality in qualitative research revolve around issues of engagement deliberation ethical process and responsiveness to participant agendas along with the need to maintain a critical perspective on both the topic at hand and the power of particular forms of knowledge it is these strengths of a qualitative approach that should be privileged in any discussion of their inclusion larger scale social research activities not in order to influence behaviour but in order to maximise the possibilities for the democratic development of research procedures if research is to serve the periphery as much as the centre in political debate and decisionmaking then engagement of research participants in both setting the research agenda and evaluating the outcomes of the process must be developed as central to the future development of social research methodology

there are disagreements about and contradictory indications of the state of qualitative inquiry as a global endeavour the paper argues that these disagreements rather miss the point the issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding but rather to what purposes are qualitative methods being put what research agendas are being pursued and who sets them the paper illustrates these issues with respect to the effects of research selectivity and concentration in the uk and argues that qualitative research should continue to develop as an iuntellectual resource for the community rather than as a technical service to government policymaking what is required is the gold standard of randomised controlled trials rcts for establishing cause and effect in social programs such criticism is not confined to the usa in a speech to the uks economic and social research council in 2000 titled influence or irrelevance the then secretary of state for education david blunkett 2000 asserted that many feel that too much social science research is inwardlooking too piecemeal rather than helping to build knowledge in a cumulative way and fails to focus on the key issues of concern to policymakers practitioners and the public p1 more recently similar arguments have arisen once again in a paper from the uk department for education in language paralleling the us debate the paper asserts that randomized assignment of treatment to samples is the most appropriate way to conduct research in general educational research in particular and that more experimental research should be undertaken in education specifically via rcts goldacre 2013 such criticisms combine critique of methods employed with critique of purposes pursued arguing that social research in general qualitative approaches to social and educational research in particular are not responsive enough to the needs of government so significant challenges to qualitative inquiry are apparent but others are more cautious in their assessment of these challenges fielding 2010 for example shares denzins concerns with respect to the dirigisme and antiintellectualism of the gold standards lobby p127 but notes that circumstances vary internationally and that threats to qualitative research should not simply be read from a north american perspective others still argue that qualitative inquiry is healthy diverse and growing both geographically in terms of its global reach and in terms of its diffusion across disciplines and across applied research fields such as

introduction numerous studies have demonstrated that social networks have a positive effect on finding a job 1 2 3 4 along with the gradual introduction of social network analysis into research on china many studies have directly focused on the chinese labor market 5 6 7 8 9 10 11 12 13 in general job seekers who use social networks are able to attain higher earnings and a better occupational status than job seekers who do not use social networks studies on china also tend to place more emphasis on the institutional environment linking social network analysis to the market reform process 711 as an informal source of resource allocation social networks play an important role alongside formal sources such as the market and the government in the early stages of chinas market reform when the rules and norms of the market were not sufficiently clear the role of social networks as informal channels for resource allocation gradually increased as marketization deepened over time the market rules became clearer and stronger and the space for networkbased activity declined this means that the effect of social networks followed an inverse ushaped trend as marketization intensified over time however recent research has shown that the percentage of individuals who use social networks when searching for a job does not follow an inverse ushaped pattern as supposed rather it has continued increasing and according to recent data analysis has reached 80 this means that it is now common to obtain help from ones social networks when seeking a job we have strong reason to believe that those actors who use their social networks when seeking a job are not a small special group given that nearly 80 of job seekers utilize their social networks the heterogeneity within this group is likely very large against the background of an increasing percentage of job seekers using social networks and the increase in heterogeneity a new but very important question arises are the returns to social networks among those actors who use social networks when seeking a job consistent when we focus on job seekers who use social networks do the returns to social networks vary from person to person or group to group this question discusses the return of social networks which is in fact the endogeneity of social networks endogeneity has been a hot topic in the fields of social networks and social capital and the existence of endogeneity has led the scholars to doubt whether there are really returns to social capital accordingly in this study we fully examine the complete causality and further point out the existence of group differences in the returns to social capital while discussing the returns to social capital this will help us to answer the endogenous challenge of social networks and help us to have a more complete and accurate understanding of the returns of social networks in the labor market effects of social networks the origin of heterogenous returns social network analysis has attracted abundant interest in and research on the effects of social networks since the 1970s the beginning of the rise of social network research regarding whether social networks play a role in the labor market and if so how various theoretical perspectives such as the network strength approach 14 network resource approach 3 network structure approach 14 and network signal approach 15 have been discussed whether considering strong or weak ties under the network strength approach information or favorable treatment under the network resource approach or structural holes under the network structure approach the effect of social networks has been comprehensively demonstrated among the many fields that have incorporated social network analysis the study of the labor market has always been at the forefront of social network analysis and the jobsearch process is a good context in which to examine the role of social networks as discussed above the effects of social networks may be diverse as most job seekers use social networks 16 when exploring the role of social networks a failure to account for differences in the relationship between social networks and status attainment imposes limitations when we move away from an overall analytical perspective and instead analyze the differences in the returns to social networks then there are two possible theoretical assumptions positive returns and negative returns the social capital embedded in social networks has both instrumental and expressive effects 17 most of the previous studies on the effects of social networks in the labor market have focused on the income effects of social networks in fact the process of acquiring status in the labor market and the corresponding outcomes involve both the instrumental effects represented by income and the expressive effects of the job search process and its outcome one of the most direct expressive effects is job satisfaction after the job search job satisfaction refers to the degree of satisfaction with the job found and is a subjective evaluation made by the job seeker it is a global evaluation and may include dimensions such as satisfaction with the job itself satisfaction with the salary package satisfaction with the opportunities for promotion and satisfaction with colleague relationships the economic behavior of actors is embedded within a social structure and job seekers might not simply choose the job with the highest salary and income when seeking an occupation but may be motivated by a global evaluation of various other noninstrumental indicators such as colleague relationships and career development therefore when we analyze the returns to social networks we should not limit ourselves to the instrumental indicator of the returns in terms of earnings but should consider both instrumental and expressive returns both of these dimensions have two possible theoretical relationships with the use of social networks positive return or negative return positive returns hypothesis in the social capital theory nan lin describes a pyramidal social structure in which each actor is located at a certain point on the pyramid 3 social resources also exhibit this pyramidal structure the higher up the actors are within this structure the fewer positions and occupiers there are 3 there are very few positions and occupiers at the top level where those who control the largest number of valuable resources are located the further up the structure one goes the fewer actors and the more resources there are at the bottom of the structure the number of actors is larger and the resources are fewer in his theory lin proposed the strengthofposition proposition the better the position of origin is the more likely the actor is to access and use social capital which is likely to be of higher quality 17 the strengthofposition proposition is consistent with traditional structural theory which describes the structural advantages of each actor and extends to social capital research the initial position refers to both the actors ascribed position and achieved position the ascribed position is the position inherited by the individual from their parents and relatives the achieved position refers to the social position acquired and occupied through selfeffort a better initial position results not only in more social resources being available to the actor but also in human capital political capital and family background advantages among others when social capital is combined with other advantages it can result in combined advantages such that the whole is greater than the sum of its parts however actors with an average or worse initial position are at a double disadvantage on the one hand due to structural constraints the social resources that they can mobilize through their social networks are inferior in both quantity and quality to those of actors with a better initial position on the other hand they also lack other relevant advantages that could be combined with their social capital in order to exploit the combined advantages when an actor has a weak endowment of all types of capital the whole may be less than the sum of its parts in summary the better the initial position of the actor the more likely that actor is to use their social network moreover the more likely the actor is to use their network the greater the return from the social network is likely to be in this paper we take current employment earnings and job satisfaction as the returns of getting a job so we state the research hypothesis of positive returns to social networks as follows hypothesis 11 the more likely an actor is to use their social networks the higher the current employment earnings they would obtain hypothesis 12 the more likely an actor is to use their social networks the more satisfied with work they would be negative returns hypothesis bourdieu proposed the concept of social capital in contrast to economic capital and cultural capital at the beginning of his first elaboration of capital in the forms of capital 18 social capital similar to economic capital human capital and cultural capital is one of the forms of capital and the return to such capital in terms of the income of job seekers may exhibit diminishing marginal effects with an increase in capital types the importance of social capital is relatively minor when the actor has a sufficient number of other types of capital that can generate returns while the importance of social capital is inevitably higher when the actor has access to fewer types of capital or even to social capital only returning to the pyramidal social structure described by nan lin those actors who are initially in a better position have relatively superior social capital human capital and political capital according to the previous literature human capital and political capital have a positive effect on actors in the chinese labor market 19 20 21 therefore in addition to social capital other types of capital such as human capital and political capital provide higher rewards to those actors who are initially better positioned the return to the social capital embedded in social networks is a return to only one of many types of capital and is simply icing on the cake accordingly for those actors with a poor initial position the returns to social capital account for a greater share of their overall earnings due to their relative lack of other types of capital the use or nonuse of social networks has a relatively greater or even decisive impact on such actors earnings for these actors the returns to social capital obtained through the use of social networks are relatively more important and can often be a muchneeded helping hand therefore the better the initial position of the actor is the more likely that actor is to use his or her social network however the less likely the actor is to use his or her network the greater the returns to the social network are likely to be accordingly we obtain our research hypothesis on the negative returns to social networks hypothesis 21 the less likely an actor is to use their social networks the higher the current employment earnings they would obtain hypothesis 22 the less likely an actor is to use their social networks the more satisfied with work they would be two types of selection bias who prefers to use social networks who benefits more from social networks pretreatment and treatment effect heterogeneity on the basis of the principles of homogeneity and endogeneity ted mouw raised suspicion of the social network effect in 2003 2223 this resulted in a great deal of social network research in response to mouws challenge 24 a variety of methods have been used to address endogeneity these include the heckman twostep selection model propensity score matching instrumental variables simultaneous equations system and suspicion 25 26 27 28 29 30 31 recently brand yu and their colleagues pointed out in a series of studies that when we want to accurately estimate a causal relationship we should consider all of the endogeneity along the causal chain the pretreatment heterogeneity bias and the treatmenteffect heterogeneity bias 32 33 34 specifically first people are not randomly assigned to an experimental group and a control group rather people with certain characteristics are more likely to become members of the experimental group on the other hand people with these characteristics are not only more likely to be in the experimental group but they are also likely to obtain benefits that differ from those of their peers without these characteristics 3335 endogeneity is a universal and unavoidable problem in all social sciences however since mouws criticism of how endogeneity has been handled in social network analysis the approach has been questioned and challenged this is because the establishment of social networksinteractions among actorsis always purposeful and highly subjective this makes it difficult for samples to satisfy the requirement that treatment status be randomly distributed and leads to estimation bias in the regression analysis given this difficulty combined with the challenge of the complete endogeneity along the causal chain mentioned above both of which affect the research on social networks in job search we need to rethink the returns to social networks in the labor market if there is endogeneity bias in the form of pretreatment heterogeneity bias then people with certain characteristics are more likely to use social networks in when job searching if there is endogeneity bias in the treatment effects then people with those certain characteristics are not only more likely to use social networks but the returns that they obtain from their social networks are likely to vary either increasing or decreasing with an increase in the likelihood of use these two types of endogeneity bias are exactly what we try to analyze in this paper recent research from china has pointed out that the use of social networks in job searching is not randomly distributed and that those people who use social networks share common behavioral traits 36 actors who are strongly relational are more likely to use social networks when searching for a job a preliminary study focused on investment in everyday relationships to discuss relational tendencies 36 it has been demonstrated that the more actors invested in everyday relationships the higher their tendency to use guanxi when engaging in instrumental actions such as searching for a job apart from attitudes toward relationalism are there any other external characteristics that identify a behavioral tendency toward relationalism however there is still a further problem since social networks are not randomly selected are the returns to social networks the same among different groups of people this paper focuses on those people who use social networks in their job search and explores whether the effects of social networks vary from person to person specifically in light of the two competing theoretical hypotheses proposed above is it true that the more likely people are to use social networks the higher the returns to social networks are or is it the case that the more likely people are to use social networks the lower the returns are data measures and methods data we used data from the 2014 jobsearch networks survey to examine the heterogeneity in the effects of social networks on job search jsnet2014 contains data on individuals residing in 8 large cities throughout china that is representative data with a total sample size of 5480 this survey used probability proportional to size sampling in which a random sample was taken from three levels for each city in each randomly selected neighborhood households were selected from a household list through a systematic sampling technique to obtain a complete list of both permanent and migrant households a map of each neighborhood was drawn and a list of the households that live there was made from each randomly sampled household an adult aged 1869 was selected to be the respondent by randomly selecting birthdays above all jsnet provides a representative sample and reliable results the jsnet data are an excellent source of information about social networks and job search which are the key variables in our research unfortunately there are no more data on job search networks update after 2014 therefore so far these data are the most appropriate and the latest data on the measurement of social networks and occupationally related variables measures dependent variable earnings earnings here refers to current employment earnings which are the occupational earnings of the worker at the beginning of their entry into their current job this study focuses on the relationship between the social networks used by job seekers in their job search and the subsequent occupational earnings obtained and to strictly preserve the temporal chain of causality we directly used the occupational earnings at job entry the rapid economic development over the past 40 years since chinas reform and opening up has resulted in substantial price increases therefore we used the consumer price index for each city in each year to eliminate the effects of inflation allowing occupational earnings to be comparable across each generation of new workers moreover due to the rightskewness of the original income distribution after eliminating the effects of inflation we then took the logarithm of the earnings to bring the distribution of earnings the dependent variable closer to a normal distribution job satisfaction job satisfaction is a global indicator we focused on job seekers at job entry and on the following five dimensions of satisfaction the work itself pay and benefits opportunities for promotion colleague relationships and upper management each item was measured with a 5point likert scale ranging from very unsatisfied to very satisfied we summed up the scores across the five items and found the average which represents the overall satisfaction of job seekers with the results of their job search independent variables the use of social networks the use of social networks is both the most dominant independent variable in the model for predicting income and is the dependent variable in the model for predicting the likelihood of using social networks in coding the variables the use of social networks was defined not only for those respondents who directly answered that they had used social networks when searching for their job but also for those who mentioned using social networks in other followup questions this is because in chinese social life the use of social networks ie the use of connections is often seen as synonymous with going through the back door which often has a negative connotation of unfairness some respondents were reluctant or hesitant to answer directly that they had used their social networks but in the followup questions they expressed indirectly that they had done so control variables we measured respondents attitudes toward relationalism by their willingness to handle things through social networks this is a continuous variable with a higher score indicating that respondents were more receptive to the idea of handling things through social networks and thus that they are more accepting of relationalism the control variables in this paper also include personal attributes family background and structural variables such as gender age hukou education party membership fathers education fathers party membership labor market sector an indicator for highincome industries occupational requirements and year of job entry all variables used in this study can be found in table 1 methods to test whether the income return to social networks varies according to the propensity of the actors to use social networks when searching for a job we used the stratificationmultilevel method 33 to develop our model for empirical analysis our approach is similar to propensity score subclassification 27 in that the whole sample was divided into a number of balanced subsamples which were then analyzed in the next step the specific analysis in this study followed four steps step 1 first we needed to discuss the probability with which social networks are used during job search this probability is unknown and needs to be estimated we developed a logit regression model with a dummy variable as the dependent variable and the resulting predicted probability is the probability that the actors use their social networks with higher values indicating a higher probability step 2 we constructed balanced propensity score strata following a principle that we call homogeneity within groups heterogeneity between groups specifically there should be no significant differences in the average values of covariates and in propensity scores between the treatment and control groups in this study homogeneity within groups means that the two types of job seekers those who use social networks and those who do not were randomly distributed across the subsamples defined by the propensity scores and that there were no significant differences in the distribution of those independent variables that influence the use of social networks heterogeneity between groups means that the different subsamples had significantly different probabilities of using social networks the higher the stratification of a subsample the more likely it is to represent the individuals in that subsample who use social networks step 3 next we estimated the propensity score stratumspecific treatment effects in terms of the instrumental returns and emotional returns to social networks we can eliminate the heterogeneity bias in the use of social networks because of our withingroup homogeneity we can directly use multiple linear regression models to estimate the earnings and emotional returns to social networks in each subsample which means that we can obtain the treatment effects for each stratum step 4 finally we observed the relationship between the social network effects and the ranking of each subsample in terms of propensity scores if the social network effects are greater in the higher ranked subsamples then there is a positive selection effect related to the use of social networks in the labor market the more likely someone is to use social networks the higher the return to their social network is in terms of earnings or job satisfaction in contrast if the social network effects are lower in the higher ranked subsamples then there is a negative selection effect and the more likely people are to use social networks the less rewarding the use of those social networks will be specifically to conduct this analysis we fit the data using a variance weighted least squares regression with the ranking of the subsamples as the independent variable and the social network effects for each subsample as the dependent variable since the sample for this step is simply the number of subsamples the sample size was too small for direct estimation via ordinary least squares vwls uses standard deviations as weights which relaxes the requirement for homoskedasticity and overcomes the smallsample problem of ols results descriptive statistics table 1 presents descriptive statistics for the sample and compares both of the groups we focused on those who use social networks when searching for a job and those who do not use social networks the continuous variables are described in terms of their means the categorical variables are described in terms of percentages for all categories other than the reference category and the last column shows the results of a significance test clearly there were a number of significant differences between job seekers who use social networks and those who do not most notably job seekers who use social networks had higher entrylevel earnings than those who do not with the former earning an average of 340 per month and the latter earning only 226 the same trend was observed for job satisfaction job seekers who use social networks had a mean job satisfaction value of 36 while job seekers who did not use social networks when seeking employment had lower job satisfaction a value of 347 however it is not yet clear as to whether the differences in earnings and job satisfaction observed at this point are the result of job seekers use of social networks because the binary analysis indicates that the use of social networks when seeking a job is not a random event but is influenced by numerous demographic and social factors for example the average age of job seekers who use social networks was found to be 29 years old which is significantly higher than that of job seekers who do not use social networks those who seek jobs in the private labor market sector were found to also more likely to use social networks than those in the public labor market sector in addition factors such as the year of job entry household registration at the time of the job search education and attitudes toward relationalism as well as occupational requirements all affect whether social networks are used in the job search process selectivity in using social networks the logit model as the descriptive analysis in table 1 shows the distributions of the two types of job seekers those who use social networks and those who do not were not consistent across many variables to obtain an unbiased estimate of the social network effect we first looked at the selection in social network use who is more likely to use their social networks in their job search we constructed a logit model with the use of social networks in job search as the dependent variable in order to predict the likelihood of using a social network the variables included in the model to control for factors influencing the use of social networks in job search were gender age household registration education party membership parental education parental party membership workunit sector an indicator for highincome industries occupational requirements and the year of job entry the results are shown in table 2 from the results shown in table 2 it is easy to see that the use of social networks when seeking a job is indeed influenced by many factors both personal characteristics such as age education household status and attitudes toward relationalism as well as structural factors such as labor market sector occupational requirements and the year of job entry again this finding verifies that the use of social networks in job searching is not random but that those who use social networks share certain common behavioral characteristics 37 people do not randomly become social network users or nonusers rather people with certain common characteristics become social network users the logit model can provide a predicted probability of using social networks and this probability value is important as it is the basis for the stratification conducted in the next step propensity score strata on the basis of the predicted results of the logit model presented in table 2 we divided the ranked predicted probability values to generate six subsamples that were heterogeneous between groups but homogeneous within groups these subsamples are referred to as strata one through six in table 3 we divided the sample in descending order so that a higher stratum number indicates a higher likelihood of using social networks in the job search specifically the probability that job seekers in the first stratum used their social networks in the job search process was the smallestless than 01and the number and proportion of job seekers who actually used social networks in this subsample was also the smallest with only 84 out of 393 people using social networks the probability of using a social network was slightly higher in the second stratum than in the first and ranged from 01 to 019 the number and proportion of job seekers who actually used social networks were also higher than those in the first stratum with 124 out of 354 respondents using social networks finally respondents in the sixth stratum had the highest probability of using a social network with each person having a probability of more than 85 the number and percentage of those who actually used their social networks were also the highest at 437 out of 589 each column in table 3 represents a stratum and each row represents an independent variable that helps predict the likelihood of using a social network ideally within each stratum of the subsample the effects of each independent variable on the dependent variable would be statistically insignificant which means that the use of social networks is not confounded by any other factor in the subsample and can be considered a purely exogenous variable however in practice it is very difficult to obtain such a perfect match and there are many cases where the individual variables are still significant for example the variable paternal party membership in the fifth stratum has a pvalue of 0044 indicating that in this stratum paternal party membership still influences whether respondents use their social networks as suggested by xie and his colleagues 3334 we need to further control for these still significant variables in the next step of the model when we predict the effect of social networks after obtaining the six propensity score strata we then calculated the effects of the use of social networks in each stratum and subsequently fit the relationship between the number of strata and the effects of social networks using vwls the difference between vwls and ols is that vwls relaxed the assumption of homoskedasticity in fact the variances did vary across the different subsamples in addition we also found the average treatment effect for the overall sample following the conventional method for propensity score matching the final results of the analysis are presented in table 4 and table 5 turning first to table 4 the table is divided into three panels the top panel reports the coefficient standard error and z value of the social network effect for each of the six subsamples as the subsample ranking increased the effect of social networks on earnings became progressively smaller and eventually become negative it should be mentioned that because the subsamples in each stratum were created according to the empirical stratification results the subsamples themselves were not representative and the results for those subsamples were not generalizable to higherlevel groups in fact this step is only an intermediate step in the entire analysis process and the results are only meaningful after weighted summation as in propensity score stratified matching or regression fitting using variance weighting as in the sm model the middle and bottom panels of table 4 present the results of a composite analysis based on the effects of each stratum the middle panel presents the calculated average earnings effect of social network use for the overall sample according to the propensity score subclassification method b ∑ k k1 b k var ∑ k k1 ˆ2 var se var z bse where b is the average effect of social network use k 1 2 6 indexes the number of strata b k is the coefficient representing the effect of social network use on earnings in each stratum n k is the number of observations in each stratum n is the number of observations in the whole sample and se is the standard error of b when the average treatment effect b is divided by its standard error se the z value used for statistical inference is obtained in the overall sample job seekers who use social networks had significantly higher earnings than those who do not which is consistent with the findings of previous studies the bottom panel of table 4 shows the relationship between the social network earnings effect and the propensity to use social networks estimated via vwls the results indicate that there was a significantly negative relationship between the strata ranking and the social network effect table 5 is structured in the same way as table 4 looking at the top of the table reveals that within each subsample the coefficient representing the effect of social network use on job satisfaction showed steadily increases the results in the middle panel were calculated in the same way as the earnings effect and indicate that in the overall sample there was no significant difference in job satisfaction between job seekers who use social networks and those who do not the bottom panel of the table shows the relationship between the effect of social networks on job satisfaction and the propensity to use social networks obtained via vwls the results show that there was a significant positive effect between the strata ranking and the social network effect and this effect was statistically significant that is the higher the propensity to use social networks when seeking employment the higher the job satisfaction of job seekers this result is the opposite of that for the earnings effect conclusions and discussion the job search process for laborers is actually the process of allocating labor resources through the labor market from the planned economy in chinas prereform period to its dualtrack system at the beginning of the reform and then into the era of the market economy as the reform deepened resources have been allocated through three channels redistribution the market and social networks 4171938 of these redistribution channel and the market channel are formal channels for resource allocation while the social network channel is an informal resource allocation channel theoretically as marketization increases over time market rules become increasingly clear institutional rigidity becomes stronger the power of formal channels increases and the use of informal channels such as social networks should decrease however the most recent empirical data show that the proportion of workers using social networks during the job search process has increased to nearly 80 of the samples 39 these realistic data suggest that the use of social networks in job searching is no longer restricted to a special group and the internal heterogeneity within the group of social network users is gradually increasing 40 this leads us to ask for this internally heterogeneous group is there also variability in the effect of social networks that is are the returns to social networks consistent across those job seekers who use them focusing on the use of and returns to social networks during job searching this paper attempts to address the twopart endogeneity issue first the endogeneity in pretreatment effects which means whether the use of social networks is a random event second the endogeneity in treatment effects in this study meaning whether the return to social networks is consistent among those actors who use them when searching for a job we employed a large set of survey data on social networks and used a heterogenous treatment effects model in our empirical analysis we obtained the following main conclusions first the use of social networks in job searching is not random and the propensity of job seekers with different characteristics to use social networks is not the same in the process of job searching which is an instrumental action the choice of job seekers to use or not to use social networks is not a random event rather there are certain characteristics that lead some people to use their social networks while others choose not to these characteristics are both individual and structural most previous research on social network effects has been based on analyses of regression models research based on ols assumes that all the behaviors of the study occur randomly however the creation and the use of social networksinteractions among actorsis purposeful and highly subjective it is difficult to satisfy the requirement of random distribution 2223 in our empirical analysis we found that there do indeed exist some shared characteristics that result in essential differences between the two types of people those who use social networks and those who do not second the returns to social networks are different for job seekers with different propensities to use social networks this means that in the labor market job search process there are two different selection biases working at the same time there is not only pretreatment heterogeneity which means that the use of social networks suffers from selection bias but also treatment effect heterogeneity which means that the effects of social networks are also biased due to endogeneity even within the group of those who use their social networks when searching for a job the returns to that use differ from person to person third there is negative selection in the instrumental effect of social network use in the job search process but positive selection in the expressive effect the higher the propensity to use ones networks the lower the income return to social networks and the higher the job satisfaction the lower the propensity to use ones networks the higher the income return and the lower the job satisfaction endogeneity has been a major challenge in social network analysis in recent years especially in research on social network effects in labor markets 222341 scholars have tried to respond to this endogeneity challenge which takes many forms such as the homogeneity of social networks 24 the selectivity of social networks 121337 and reverse causality 42 previous studies on social network effects have not found heterogeneous returns to the use of these networks which may have been due to the limitations of their research methodology this study identified endogeneity in both pretreatment effects and treatment effects and estimated the effect of social network use while considering the complete endogeneity problem people differ not only in their use of social networks but also in how they are affected by that use this study provides ideas for analyzing the heterogenous returns to social networks we first estimated the probability of using social networks and then stratified the sample on this basis to calculate the effects of social networks among those with different propensities to use their social networks finally we tested the relationship between the ranking of the strata and the effect of social network use nan lin has reviewed 31 studies on the relationship between social capital and status attainment from the last two decades of the last century and 30 of those studies demonstrated a link between social capital and status attainment 17 are these links the same for different actors nan lins strengthofposition proposition states that the better the initial position of an actor is the more likely they are to access and mobilize higher levels of social capital this study builds on this proposition and further explores the differences in returns related to different propensities the results show that in a pyramidal social structure there are not only differences in the distribution of resources but also differences in the returns to resources limitation this paper also has some limitations in this study we first explored the heterogeneity in the returns to social networks however more advanced research may be conducted in the future in our exploration of the use of social networks we used various external individuallevel characteristics to comprehensively analyze the propensity to use social networks we believe that a third dimension could be introduced in future research that enables an indepth exploration of the relationship between group characteristics and the propensity to use social networks and the differences in the corresponding returns for example information about class 43 a concern of sociological research could be included are there differences in the propensity of members of different classes to use their social networks and are there differential returns this would further enrich the social implications of social network research second this study was concerned with the returns to social networks at the beginning of the job seekers entry into their career in addition to the role of social networks in the job search process which is to help job seekers find jobs and earn high salaries social networks may also have longterm effects and delayed returns in the real labor market job seekers use of social networks to obtain jobs may not necessarily generate benefits at the beginning of their entry into the workforce whether those who find jobs through social networks are sheltered by that network after they enter their job thus obtaining longterm professional development rapid promotions and job security is an interesting question 44 the collection of panel data will help us answer this question effectively in addition this study was concerned with the use of and returns to social networks in the labor market and the labor market segmentation model is a classical theoretical model in labor market research the object of analysis in this paper was the use of social networks in the labor market as a whole a prominent feature of chinas social development in the past 40 years since its reform and opening up is inequality what kind of differences might exist in the use of and returns to social networks in different periods and regions whether institutional differences industrial differences and differences in occupational levels have caused labor market segmentation for different reasons and whether this segmentation has led to differences in the use of and returns to social networks are specific topics to be discussed in depth in future research data availability statement the data presented in this study are available on reasonable request from the corresponding author author contributions conceptualization xg data curation qc formal analysis qc funding acquisition xg investigation xg methodology xg and qc project administration xg writingoriginal draft xg writingreview editing xg all authors have read and agreed to the published version of the manuscript

with the advancement of social network research over time a research consensus has been reached that the use of social networks in job searching can provide positive returns this study focused on the heterogeneity in the returns to social networks using job search and social networks jsnet survey data on urban residents of china we examined the differences in the propensity to use social networks in job searching and the returns to social networks in terms of job seekers earnings and job satisfaction using propensity score stratification and the heterogeneous treatment effects model hte model the use of social networks in job searching was found to be nonrandomly distributed and the propensity to use such networks varied according to job seeker characteristics for job seekers with different propensities the returns to social networks were also different moreover there was negative selection in the instrumental effect of social network use in the job search process but positive selection in the expressive effect the higher the propensity to use ones networks the lower the income return to social networks and the higher the job satisfaction the lower the propensity to use ones networks the higher the income return and the lower the job satisfaction

introduction due to the rapidly ageing population and increasing longevity in addition to increasing improvement in medical care a growing number of people are living for long periods of time with chronic disease the who reported that chronic diseases kill 40 million people per year which is equivalent to 70 of all deaths globally each year 15 million people die from a chronic disease and 80 of these premature deaths occur in lowincome and middleincome countries 1 in recent years the number of individuals with chronic diseases in china has continued to rise with many residents facing serious health challenges there were 260 million people with chronic diseases in china in 2012 and this number has increased by an average of 89 each year deaths from chronic diseases account for 866 of total mortality as a result of the rapidly ageing population the number of elderly people in china in 2050 is predicted strengths and limitations of this study ► the china health and retirement longitudinal study is the first national survey focusing on middleaged and elderly individuals and provides detailed information about respondents and their living spouses ► this was the first analysis of foregone care among chinese middleaged and elderly people with chronic diseases ► this paper evaluated foregone care only among middleaged and elderly adults who perceived a need for healthcare but did not seek treatment however it did not take into account those not perceiving the need for healthcare therefore the prevalence of foregone care may have been underestimated to some extent ► crosssectional data cannot be used to draw causal conclusions open access to total 400 million accounting for onethird of the total population and the average number of chronic diseases that individuals 60 years have is estimated at 22 china has entered a period of high economic burden caused by chronic diseases which account for approximately 70 of the total economic disease burden 2 according to a report by who in 2015 the direct medical costs for chronic diseases in china were us 500 billion and by 2030 rapid ageing may increase the financial burden of chronic diseases by 40 access to equitable healthcare according to need and regardless of demographic ability to pay or social background is an important goal for worldwide healthcare service systems 3 china has implemented a series of healthcare reforms during the past two decades including the expansion of health insurance coverage and the reformation of the health service system with the ultimate goal of affordable and equitable healthcare for all the reforms of the healthcare systems have minimal benefits at the beginning and progress with expanded benefits 4 however healthcare in china remains highly unequal across different subpopulations and both the demand for and inequality in healthcare utilisation have increased significantly in this country due to its rapidly ageing population several studies have addressed this issue by examining factors associated with healthcare utilisation among the elderly in china 5 6 7 8 foregone care is another aspect of healthcare access an individual with forgone care needs is defined as one who does not use healthcare despite perceiving a need for it forgone care is an important aspect in the assessment of healthcare system performance as it represents the gap between the perceived need and actual utilisation of healthcare services from the citizens perspective ageing is accompanied by an increase in the prevalence of noncommunicable chronic diseases 9 in china the elderly people are more sensitive to the economic burden of diseases overall because of the high prevalence of chronic diseases and low incomes of this population and the absence of social security mechanisms 10 thus elderly individuals with chronic diseases may have a higher prevalence of foregone care compared with those who do not have such conditions several studies have empirically tested the associations between individual and community factors and foregone care these studies indicate an association between higher rates of foregone care and female sex younger age rural living lack of health insurance lack of financial support low levels of education and poor health 11 12 13 14 15 16 although foregone care is an area of high interest for researchers and policymakers there is a dearth of research on this subject among middleaged and elderly individuals with chronic disease in china the overall goal of this study was to identify the prevalence of foregone care and its associated factors among middleaged and elderly people with chronic conditions two specific objectives were defined comparison of the prevalence of foregone care between middleaged and elderly individuals with and without chronic diseases and using andersons behavioural model to identify factors associated with foregone care among middleaged and elderly individuals with chronic diseases methods and data data sourcesample this study was based on data from a nationally representative household survey of middleaged and elderly people the china health and retirement longitudinal study charls is a biennial survey conducted by the china centre for economic research at peking university the sample was drawn in four stages first countylevel units were sampled directly these counties cover 28 of 30 provinces in mainland china other than tibet second village and community units within county units were chosen with the help of the national bureau of statistics using recently updated villagelevel population data the sample used administrative villages in rural areas and neighbourhoods in urban areas as primary sampling units three psus were selected within each countylevel unit using probability proportional to size sampling to select a total of 450 psus third household units were selected in each psu the sampling frame was constructed using google earth base maps and a computerassisted personal interview programme was then used to sample households and to conduct the interviews using laptops finally all ageeligible sample households who were willing to participate in the survey were interviewed charls baseline data include detailed information about respondents and their living spouses the main questionnaire includes information on basic demographics family health status and functioning healthcare and insurance work retirement and pension income expenditure and assets in the 2013 wave the survey sample consisted of 18 605 individuals ≥45 years old and their spouses in this paper we excluded spouses ≤45 years old and the remaining 18 377 observations were included in the analysis statistical analysis binary multivariate logistic regression was applied to estimate ors of foregone care the dependent variable foregone care was dichotomised into 0 reported utilisation of healthcare and 1 reported nonuse of healthcare all explanatory variables were recorded as binary variables variable selection the dependent variables were three kinds of foregone care nonuse of outpatient services nonuse of inpatient services and nonattendance for physical examination participants were asked the following two questions have you been ill in the last month and what was the main reason for not seeking outpatient treatment and open access the responses were used to estimate nonuse of outpatient services participants were asked in the past year did a doctor suggest that you needed inpatient care but you did not get hospitalised and the response was used to estimate nonuse of inpatient services participants were asked did you undergo a physical examination in the last 2 years and the response used to estimate nonuse of physical examination independent variables were selected based on andersens healthcare utilisation model this model has guided systematic investigations into the factors that can lead to the use of healthcare services including predisposing enabling and need factors 17 predisposing factors include demographic characteristics and both social structure and health beliefrelated factors in our analyses we included sex age and marital status as demographic characteristics and education employment status and family size as social structure factors enabling factors are those that make health service resources available to an individual they can be measured by determination of family attributes such as income access to health insurance or other sources of thirdparty payment enabling factors in the community in which the family lives can also affect the use of services community attributes include the number of healthcare facilities and personnel in a community and the region of the country in addition to the ruralurban nature of the community in our analyses access to public insurance income levels and financial transfers received and given were considered as family components while area of residence and medical facilities were considered indicators of community attributes need factors were both perceived need and need diagnosed or evaluated by a healthcare professional the former was based on selfreported health status and the latter included chronic diseases depression body mass index and limitations on activities of daily living variables included in the multivariate model are presented in table 1 results sample characteristics the total sample consisted of 18 377 respondents ≥45 years old missing data were automatically removed during data processing no chronic disease was reported by 2888 of respondents with 7112 reporting ≥1 chronic disease in charls the chronic conditions included hypertension dyslipidaemia diabetes cancer chronic lung stomach memoryrelated andor liver diseases heart problems stroke kidney emotional and nervous problems arthritis or rheumatism andor asthma patients with chronic diseases were divided into two categories including individuals with one chronic and those with multiple chronic diseases in one person descriptive statistics of the characteristics of the individuals with versus without chronic conditions are presented in table 2 chronic disease prevalence was slightly higher among middleaged and elderly women than men middleaged and elderly individuals aged 4555 years accounted for 4328 of those without chronic disease which was higher than the proportion of those with one or multiple chronic diseases however with increasing age the proportion of individuals with one or multiple chronic diseases exceeded that of people without these conditions indicating that the risk of chronic disease increases with age the proportion of people without chronic diseases and with one or multiple chronic diseases gradually increased among middleaged and elderly people who were divorced singleseparated or unemployedretired indicating that the risk of chronic disease was relatively high among this group middleaged and elderly people with lower educational levels and small family size also had a higher risk of chronic diseases regarding enabling factors the ratios of population subgroups with social health insurance did not differ significantly the ¥14968126 income group had the highest probability of having more than two types of chronic disease and the proportion of people without chronic disease was greater in the highincome compared with the lowincome group compared with middleaged and elderly people who did not receive support from others people with economic support exhibited an increasing trend towards lack of chronic disease 7375 towards one chronic disease and 7814 towards multiple chronic diseases people who provided economic support to others exhibited the opposite trend among need factors middleaged and elderly individuals whose selfreported health was fair or poor had an increasing trend towards having no chronic disease one or multiple chronic diseases and those whose selfreported health was good or excellent exhibited the opposite trend these results indicate that the risk of chronic disease was negatively associated with health status depression and probable depression were also associated with a significant increasing trend towards having one or more chronic diseases there was also an increasing trend in probability from people without chronic disease to one chronic and then to multiple chronic diseases among middleaged and elderly people with bmi 24 or with any adl prevalence of foregone care the data presented in table 3 demonstrate the prevalence of foregone care among middleaged and elderly individuals overall the prevalence of nonuse but oughttohaveused outpatient services within the last 4 weeks was 1021 and the prevalence of nonuse of inpatient services was 684 comparisons of foregone care among open access different groups demonstrated that the underutilisation rate was higher among people with multiple chronic diseases furthermore the results demonstrate that individuals without chronic disease had the highest probability of not having undergone a physical examination in the last 2 years multivariate regression analysis binary logistic models were constructed to examine the determinants of foregone care among middleaged and elderly chinese people with chronic diseases estimated coefficients describing the predicted effects of the variables are presented in table 4 we also calculated overall significance values for a multivariate logistic regression open access with the exception of sex all other predisposing factors were predicted to have significant impacts on foregone healthcare specifically middleaged and elderly people 55 years old were less likely to report outpatient or physical examination foregone care compared with those 55 years old individuals who were married or had a larger family had a higher likelihood of foregone physical examination while those with high levels of education had a significantly lower likelihood of foregone physical examination middleaged and elderly people with chronic diseases who were retired without pensions exhibited a higher likelihood of outpatient and inpatient foregone care compared with retired people with pensions open access open access among enabling factors we found a significant association between social health insurance and nonuse of outpatient and inpatient services hence enrolment in social health insurance schemes may significantly reduce the likelihood of outpatient and inpatient foregone care among middleaged and elderly people with chronic diseases the highest income group demonstrated a significantly reduced likelihood of forgone inpatient and physical examination care compared with the lowest income group receipt of financial transfers increased the likelihood of nonuse of outpatient services and providing transfers was associated with reduced probability of foregone physical examination compared with middleaged and elderly people living in urban areas those in rural areas were significantly more likely to forego outpatient and physical examination care among need factors significant associations were detected between selfreported health multiple chronic diseases depression and outpatient inpatient and physical examination foregone care middleaged and elderly people with chronic diseases with fair good or very good selfreported health had a lower likelihood of outpatient and inpatient foregone care compared with those with poor health status and the likelihood decreased with increasing health status however individuals who selfreported their health as fair had a higher likelihood of foregone physical examination middleaged and elderly people who had multiple chronic diseases demonstrated a higher probability of foregone outpatient and inpatient care while exhibiting a lower likelihood of foregone physical examination individuals with depression had a higher likelihood of outpatient inpatient and physical examination foregone care middleaged and elderly people with bmi values 24 had a lower probability of outpatient and inpatient foregone care any adl increased the possibility of outpatient service foregone care drinking alcohol did not have a significant impact on any kind of foregone care while smoking significantly increased the likelihood of foregone physical examination discussion along with the rapidly ageing population in china the number of chronic diseases continues to rise and the elderly face serious health challenges although many studies have analysed healthcare utilisation in diverse population groups few have examined foregone care in middleaged and elderly chronically ill chinese patients this study focusing on middleaged and elderly people was performed to analyse the prevalence of foregone healthcare and its associated factors in china in this study we found that 1021 and 684 of respondents had foregone outpatient and inpatient care respectively however the prevalence of physical examination foregone care was relatively high this may be attributable to the fact that chinese social healthcare insurance schemes do not cover physical examinations therefore many middleaged and elderly people are apt to forego physical examinations because of the associated economic burden the prevalence of outpatient and inpatient foregone care rose alongside increasing number of chronic diseases furthermore the results of regression analysis confirmed that respondents with multiple chronic diseases were more likely to forego outpatient and inpatient care these data indicate that a greater demand for health services is associated with a higher probability of foregone outpatient and inpatient care however the likelihood of physical examination foregone care exhibited the opposite trend people without chronic disease were most likely to forego physical examination and the prevalence decreased with increased number of chronic diseases this result suggests that middleaged and elderly individuals with chronic disease may have stronger awareness of preventative healthcare among predisposing factors our results indicate that the possibility of foregone outpatient and physical examination care decreases with increasing age this is consistent with previous results literature reports 11 18 people in older age groups generally have more need for healthcare related to more serious conditions and may be more flexible with their time when seeking healthcare compared open access with younger individuals middleaged and elderly people with chronic diseases who have fixed incomes accessed more healthcare and exhibited a relatively low likelihood of foregoing care this finding indicates that some medical financial assistance programmes may need to be extended particularly with respect to unemployed and elderly retired people without pensions to facilitate further reduction of the possibility of foregone care in addition our analyses revealed that middleaged and elderly people with chronic diseases who were married and had large families exhibited a relatively high probability of foregone physical examination consistent with a number of existing literature reports 19 we did not identify any association between sex and foregone care which is also in line with several previous publications 12 20 of enabling factors our results demonstrate a strong association between socioeconomic variation and foregone care specifically we found a significant association between household income level and foregone care people with chronic diseases in the highest income group reported less foregone inpatient and physical examination care compared with those in the lowest income group however we did not find a significant association between income level and outpatient foregone care similar to previous studies 11 16 18 these findings indicate that due to higher hospitalisation costs income levels remain an important impact factor influencing the possibility of inpatient foregone care however for outpatient services there were no significant differences in the likelihood of foregone care among different income groups indicating that the universal coverage of medical insurance in china may be gradually improving the equity of outpatient care utilisation among middleaged and elderly people with chronic disease from different income levels we also found that although social healthcare insurance can significantly reduce the level of outpatient and inpatient foregone care among chronically ill elderly patients these schemes may not significantly impact physical examination foregone care among elderly patients with chronic disease hence policy efforts may need to focus on chronic elderly patients having urban resident medical insurance or new cooperative medical insurance and strategies may need to be adjusted to promote the effective utilisation of preventive healthcare middleaged and elderly people with chronic diseases who have received financial transfers from others exhibited a slightly higher likelihood of outpatient foregone care while those who had made transfers to others had a significantly lower level of physical examination foregone care residents in rural areas had a significantly higher likelihood of outpatient and physical examination foregone care as previously described 21 these findings may reflect the ruralurban income gap and differences in medical security in china as andersen described need factors best describe the true needs for healthcare 17 consistent with previous studies we found that middleaged and elderly people with multiple chronic diseases or depression were more likely to forego outpatient and inpatient care 8 22 23 this may be because of high demands for medical services or lack of patient compliance among this group likely leading to a relatively high probability of foregone care regarding physical examinations multiple chronic diseases were associated with a reduced possibility of foregone care however depression was associated with an increased likelihood consistent with published data 8 2427 selfreported health was negatively associated with outpatient and inpatient foregone care except for individuals whose selfreported health was excellent this indicates that the superior health of respondents was associated with a lower likelihood of foregone care 28 adl limitations did not affect inpatient and physical examination foregone care however these factors significantly increased the likelihood of outpatient foregone care this finding maybe related to the fact that people with adl often have some difficulty seeking outpatient treatment in a timely manner 29 the findings of this study may provide evidence on healthcare underutilisation and associated factors among middleaged and elderly people some limitations of our study must be acknowledged we evaluated foregone care only among middleaged and elderly adults who perceived a need for healthcare but did not seek treatment however we did not take into account those who did not perceive the need for healthcare some patients objectively require healthcare but do not perceive that need therefore the prevalence of foregone care may have been underestimated to some extent in addition crosssectional data cannot be used to draw any causal conclusions about why these individuals may have foregone care conclusion our findings reveal that the prevalence of foregone physical examination is relatively high among middleaged and elderly people and that this prevalence decreases with an increased number of chronic diseases as a result of their greater demand for health services respondents with chronic diseases demonstrated relatively higher likelihoods of both outpatient and inpatient foregone care hence the adjustment of health insurance policies and improvements in the hierarchical medical system in china may be helpful to the effective utilisation of preventive care and outpatient and inpatient services some predisposing factors including age marital status employment education and family size enabling factors including social health insurance income level and area of residence and need factors such as selfreported health multiple chronic diseases and adl significantly affected foregone care among middleaged and elderly people therefore we may need to address these socioeconomic and demographic factors for reducing foregone care and enhancing the effective use of health services among open access middleaged and elderly people in china finally further work including longitudinal studies is required to gain a better understanding of the causal relationships between foregone care and its associated factors the study was approved by the ethics committee of nanjing medical university reference number 2017613 provenance and peer review not commissioned externally peer reviewed data sharing statement extra data can be accessed via the dryad data repository at datadryad org with the

objective in general published studies analyse healthcare utilisation rather than foregone care among different population groups the assessment of forgone care as an aspect of healthcare system performance is important because it indicates the gap between perceived need and actual utilisation of healthcare services this study focused on a specific vulnerable group middleaged and elderly people with chronic diseases and evaluated the prevalence of foregone care and associated factors among this population in china methods data were obtained from a nationally representative household survey of middleaged and elderly individuals ≥45 years the china health and retirement longitudinal study which was conducted by the national school of development of peking university in 2013 descriptive statistics were used to analyse sample characteristics and the prevalence of foregone care andersens healthcare utilisation and binary logistic models were used to evaluate the determinants of foregone care among middleaged and elderly individuals with chronic diseases results the prevalence of foregone outpatient and inpatient care among middleaged and elderly people was 1021 and 684 respectively whereas the prevalence of foregone care for physical examinations was relatively high 5788 predisposing factors including age marital status employment education and family size significantly affected foregone care in this population regarding enabling factors individuals in the highest income group reported less foregone inpatient care or physical examinations compared with those in the lowest income group social healthcare insurance could significantly reduce foregone care in outpatient and inpatient situations however these schemes except for urban employee medical insurance did not appear to have a significant impact on foregone care involving physical examinations conclusion in china policymakers may need to further adjust healthcare policies such as health insurance schemes and improve the hierarchical medical system to promote reduction in foregone care and effective utilisation of health services

introduction background explanations for monogamous marriage have centered around the prevalence of this practice in eurasia linking its emergence to the development of idiosyncratic features of societies in the region these include for example the establishment of large nation states and democracy the spread of christianity the onset of industrialization and urbanization and of economic development more generally consistently crosscultural analyses show that societies scoring high on scales measuring societal complexity tend toward monogamous marriage by focusing on the crosscultural distribution of marriage strategies these studies fail to account for their history restrictions on polygynous marriage appear in the earliest historical records long predating the development of aspects of social organization typically associated with eurasian societies and with societal complexity and modernization more generally in this paper i reconstruct the pattern of change in marriage strategies in the history of societies speaking indoeuropean languages using crosscultural data in the systematic and explicitly historical framework afforded by the phylogenetic comparative approach in the companion paper i extend this framework to reconstructing the history of residence strategies in the same set of societies finally this framework is extended in fortunato to investigate the coevolution of monogamous marriage and neolocal residence on this analysis it cannot be excluded that the observed association between marriage and residence strategies is the artifact of a history of descent of these societies from a common ancestor phylogenetic treebuilding analyses of linguistic data support renfrews hypothesis for the origin of the ie language family which envisages an expansion from anatolia with the spread of agriculture starting between 7000 and 6000 bce this scenario involves an early split of ie languages from their sister group the extinct anatolian family which comprises the extinct languages hittite palaic lydian luwian and lycian together ie and anatolian form the indohittite language family the other main competing hypothesis proposed by gimbutas places the homeland of the language family in the pontic steppes north of the black sea and posits an expansion driven by nomadic horseriding pastoralists starting after 4000 bce consistent with the former scenario i use the terms protoindoeuropean for the hypothetical ancestor of ie languages and protoindohittite for the hypothetical ancestor of indohittite languages as well as for the hypothetical protosocieties that spoke them other classifications based on alternative explanations for the origin of the ie language family use pie for the ancestor of ie and anatolian languages to avoid confusion throughout this and the companion paper i have changed instances of the latter usage to the one stated here related research early ie marriage strategies have been reconstructed on the basis of linguistic and ethnographic evidence the linguistic evidence is at best tenuous the correspondence of the middle irish and avestan terms for concubine wanton woman suggests that pih society recognized some form of polygynous mating if not polygynous marriage this interpretation is supported by the use of specialized terms to designate legitimate children a second line of evidence relates to the concept of widowhood while it is possible to reconstruct a pih term for widow there is no corresponding term for widower one interpretation of this pattern is that male widowhood was not recognized in pih society because men married polygynously such that the death of one wife did not affect their marital status implicit in this interpretation are however a number of unrealistic assumptions for example that all pih men married multiple wives and that they rarely if ever outlived their wives both represent demographic impossibilities based on the ethnographic evidence murdock reconstructed an eskimo type of social structure in the prehistory of the indoeuropean peoples the defining features of this type of social organization are the presence of the eskimo system of cousin terminology and the absence of exogamous unilineal kin groups additional typical characteristics include the presence of monogamy independent nuclear families and neolocality but variant subtypes characterized by nonneolocal marital residence may feature polygyny and extended families in the eskimo type of cousin terminology all cousins are equated with each other but differentiated from siblings unilineality refers to kin groups organized around principles of matrior patrilineal descent neolocality indicates residence of married couples apart from the kin of either spouse the reconstruction was inferred from the social organization of five societies speaking ie languages representing four of the major subgroups of the language family specifically the social systems of yankees and ruthenians are of the eskimo type the social systems of albanians and ossets include features suggesting eskimo antecedents while the social system of the kurds is not incompatible with the eskimo type quite apart from the small number of societies upon which the reconstruction was based murdocks approach presents a serious methodological issue according to fox modern ie terminologies for kin and affines tend to show a much stronger bias toward the nuclear family than was the case for early ie terminological systems this brings into question the validity of inferences about past social organization drawn from kinship and affinal terminologies finally fortunato and mace used the ethnographic evidence in a phylogenetic comparative framework to test the hypothesis of coevolution of bridewealth with polygyny and of dowry with monogamy in a sample of 51 societies speaking ie languages this analysis reconstructed monogamy with dowry as the most likely state at the root of a phylogenetic tree representing the historical relationships among the 51 societies in addition the tree included hittite thus the root of the tree corresponded to pih the reconstruction was obtained using the maximumlikelihood phylogenetic comparative method developed by pagel and implemented in discrete this method estimates the evolutionary scenario that is most likely to have produced the observed distribution of states of the two traits across taxa at the tips of the tree the tree was generated through phylogenetic treebuilding analysis of the corresponding 51 speech varieties in dyen et als ie basic vocabulary database using a maximumparsimony optimality criterion as implemented in paup 40b4a this approach finds the tree or set of trees that optimizes the degree of fit to the data however the use of a best tree for phylogenetic comparative analysis is problematic because results are affected by the topology and other parameters of the tree used thus while controlling for the effect of descent on the distribution of cultural practices fortunato and maces reconstruction may be contingent upon the phylogenetic tree model used to represent how the societies are related rationale and objective for the most part previous attempts to infer early ie marriage strategies from linguistic and ethnographic data have failed to use a systematic and explicitly historical approach where such an approach has been taken the available methods did not account for uncertainty in the phylogenetic tree model used to represent population history here i use a phylogenetic comparative method in a bayesian reversible jump markov chain monte carlo framework to reconstruct the pattern of change in marriage strategies in the history of societies speaking ie languages using a phylogenetic tree to represent how the taxa are related phylogenetic comparative methods infer likely evolutionary scenarios that produced the observed distribution of the attribute of interest across the taxa the bayesian mcmc framework uses a single tree or a sample of trees to represent the relationships among the taxa use of a tree sample removes dependence of the inferences upon any single phylogenetic hypothesis this is particularly important for application of the phylogenetic approach to crosscultural data because the reticulate nature of the interactions linking human societies cannot be captured by any single tree model in a similar way the rjmcmc implementation of the approach removes dependence of the inferences upon any single model of trait evolution the model of trait evolution specifies for example whether a trait is likely to be acquired and lost at the same or at different rates this is also crucial in the analysis of cultural traits because the mechanisms of change are usually unknown for these traits more generally the bayesian mcmc framework estimates the degree of statistical uncertainty in the parameters of interest to the comparative question this provides an indication of the degree of confidence that can be placed in any particular inference about the evolution of the trait a nontechnical introduction to the approach is presented in fortunato phylogenetic comparative methods assume that traits are transmitted vertically consequently high rates of horizontal transmission of traits across societies may invalidate their application to crosscultural data recent simulation analyses show however that phylogenetic comparative methods outperform nonphylogenetic methods under a wide range of simulated scenarios and levels of horizontal transmission in any case kinship and marriage systems appear to be conservative features of social organization in the context of linguistic and genetic variation the effect of descent is strongest at the supraregional level while the effect of contact prevails within regions this makes traits relating to kinship and marriage systems especially suited for analysis within the phylogenetic comparative framework data and methods i used data on marriage strategy from the ethnographic atlas for a sample of societies speaking ie languages the crosscultural data were mapped onto a sample of trees representing how the societies are related obtained by pagel et al through treebuilding analysis of dyen et als ie basic vocabulary database finally on the crosscultural data and tree sample i used the phylogenetic comparative method developed by pagel and colleagues to reconstruct ancestral states of marriage strategy crosscultural data the ea is distributed in electronic form through the world cultures journal variable identifiers in this section follow grays ea codebook the data in binary form are in the supporting information file a map of their geographical distribution is in figure 1 the crosscultural sample was collated by matching societies in the ea with speech varieties in dyen et als ie basic vocabulary database as described in the si file i coded societies included in the crosscultural sample as monogamous or polygynous based on ea variable 9 which scores societies on the prevailing form of family organization i collapsed the five categories for polygynous marriage thus ignoring the distinction between limited and general polygyny between general polygyny with sororal and nonsororal cowives and between general polygyny with cowives occupying the same or distinct dwellings this produced a sample with 18 of 27 societies coded as monogamous and 9 coded as polygynous tree sample i used pagel et als posterior probability sample of 750 phylogenetic trees to represent how societies in the crosscultural sample are related by way of descent from a common ancestor trees are present in the sample in proportion to their posterior probability which is the probability of the tree conditional on the data and model of word evolution used in the treebuilding analysis and can be interpreted as the probability that the tree is correct for example the iberoromance speech varieties included in the treebuilding analysis by pagel et al share an ancestor in 84 of the trees in the sample the probability that they are a monophyletic group is thus 084 given the data and model of word evolution used in the treebuilding analysis as discussed below use of a tree sample instead of a single best tree amounts to incorporating phylogenetic uncertainty in the comparative analysis the degree of phylogenetic uncertainty at several of the nodes in the pagel et al tree sample emphasizes the importance of doing so in this case pagel et al inferred the posterior probability distribution of trees from dyen et als ie basic vocabulary database using the bayesian mcmc phylogenetic treebuilding method developed by pagel and meade as described in the si file i obtained the tree sample from mark pagel i pruned the trees to retain only the speech varieties corresponding to the 27 societies in the crosscultural sample plus the outgroup hittite using andrew meades program bayestrees outgroup taxa provide information on the direction of change in the data by virtue of being distantly related to the groups under investigation the ingroup taxa they are used in treebuilding for 1 in the si file colors express the marriage strategy as per figure 4 numbers correspond to taxa in figure 4 and to entries in the relevant column in table 1 in the si file determining ancestordescendant relationships i preferred this pruning strategy over the alternative of generating a tree sample for the speech varieties included in the comparative analysis because the accuracy of phylogenetic treebuilding grows with increased sampling of taxa hittite was retained for consistency with previous work but was assigned no marriage strategy data for the purpose of the comparative analysis comparative analysis reconstruction of ancestral states using the phylogenetic comparative method developed by pagel and colleagues is performed using bayesmultistate available as part of the bayestraits package from unless otherwise specified the information in this section is based on pagel andmeade pagel et al and on the bayestraits manual to which i refer the reader for a more detailed description of the method and its application a nontechnical discussion of the method is in the si file given the crosscultural data and tree sample bayesmultistate uses parameters q mp and q pm to describe the evolution of the trait marriage strategy on a tree q mp and q pm measure the instantaneous rates of change respectively from monogamy to polygyny and from polygyny to monogamy they are used to define the probabilities of these changes the probabilities of the two states at internal nodes on the tree and the likelihood of the data which is the probability of the data given the tree and the model of trait evolution specified by the rates in the likelihood calculations bayesmultistate treats taxa that are not assigned comparative data like the outgroup hittite in this case as taking any state with equal probability in bayesian rjmcmc mode bayesmultistate uses rjmcmc methods to estimate the posterior probability distributions of rate parameters and of ancestral states at internal nodes on a tree and of the possible models of trait evolution specified by the rate parameters four model categories are possible in this case that q mp and q pm take distinct positive values that they take the same positive value or that either one is set to zero while the other takes a positive value the posterior probability of a parameter value is a quantity proportional to its likelihood of having produced the observed data and represents the probability of the parameter value given the data and model of trait evolution schematically the posterior probability distributions are estimated by running rjmcmc chains that sample states in the model of trait evolution in proportion to their posterior probability across trees in the tree sample a state in the model consists of model category and values of the rate parameters and ancestral state probabilities combining estimates over the sample produced by a chain amounts to averaging inferences over uncertainty in the phylogeny in the parameters of the model of trait evolution and in the model itself i performed five sets of analyses each comprising five separate chains started from random seeds one set estimated the posterior probability distributions of states m and p at internal nodes on the consensus tree summarizing the tree sample the means of the posterior probability distributions of states m and p at a given node denoted p and p are multiplied by the posterior probability of the node itself denoted p to produce the combined probabilities of the two states at the node denoted p and p p ϩ p ϭ 1 thus p ϩ p ϭ p this means that if reconstruction of the node itself is uncertain ie if p ͻ 1 the value of p sets an upper limit to the confidence that can be placed in the ancestral state reconstructions for the node as a rule of thumb confidence can be placed in reconstructions with combined probabilities ն070 the other four sets of analyses were used to assess explicitly the relative fit of states m and p at nodes pih and pie for each node one set of analyses was run with the node fixed to state m and one with the node fixed to state p the posterior probability distributions of log e values sampled by the chains reflect how well a given fossil state fits the node a measure called the bayes factor which is used to compare posterior probability distributions provides an indication of the strength of the evidence in favor of one state over the other at the node the bayes factor for state m over state p is denoted b mp 2log e is approximated as twice the difference between log e h for a chain fixed on state m and log e h for a chain fixed on state p where log e h is the natural logarithm of the harmonic mean of the likelihood values in theory values of 2log e ͼ 0 represent evidence for state m and values of 2log e ͻ 0 evidence for state p specifically the evidence for a given state is weak for 0 ͻ ͉ 2log e ͉ ͻ 2 positive for 2 ͻ ͉ 2log e ͉ ͻ 5 strong for 5 ͻ ͉ 2log e ͉ ͻ 10 very strong for ͉ 2log e ͉ ͼ 10 in practice however the harmonic means of likelihood values may vary across runs they are expected to converge to the same value if the chains are run to infinity consequently i take the conservative approach recommended by pagel and meade which disregards any evidence for either state given by ͉ 2log e ͉ ͻ 2 i determined the rjmcmc chain specifications through preliminary maximumlikelihood and mcmc runs all with nodes not fossilized these specifications ensure that the rjmcmc chains sample parameter space adequately and ultimately converge to the posterior probability distribution of states in the model of trait evolution i ran the rjmcmc chains for 10 8 iterations sampling every 10 3 with an additional burnin of 10 6 and rate deviation set to 50 all chains used a uniform prior on the models and an exponential prior on the rate parameters the mean of the exponential prior was seeded from a uniform hyperprior on the interval 0 10 the shape of the prior distribution and the interval of the hyperprior only marginally affected the mean of the posterior probability distributions of log e values and of ancestral states returning qualitatively similar results for each set of analyses convergence to the posterior probability distribution of states in the model of trait evolution was assessed by comparing the samples returned by the separate chains through visual inspection of timeseries plots of log e values the posterior probability distributions of model categories and the average deviation of parameter estimates across runs the nearindependence of sampling events was judged from the autocorrelation of the log e values of successive states sampled by the chains in all cases these diagnostics indicated that the chains sampled the target distributions adequately results for each set of analyses i compared the log e h values for the states in the model of trait evolution sampled by the separate chains at a z denotes rates assigned to the zero class 0 and 1 denote two distinct nonzero rate classes rates with the same value are assigned to the same nonzero rate class for example under model category 1 q mp and q pm are assigned to the same nonzero rate class that is they take the same positive value under model category 2 q mp is assigned to the zero rate class that is it is set to zero while q pm is assigned to a nonzero rate class that is it takes a positive value under model category 3 q mp and q pm are assigned to distinct nonzero rate classes that is they take different positive values b the relative cumulative frequency of a model category is obtained by summing the absolute frequency of sampled points in the model category to the absolute frequencies of sampled points in all preceding categories if any and then dividing by the total number of sampled points in all categories ͓eg 10 5 ϭ 0993 for model category 2͔ convergence i present results for the chain that returned the median value of the log e h below i discuss the ancestral state estimation at nodes on the consensus tree the fossilization of nodes pih and pie largely confirms the ancestral state estimation and is discussed in the si file estimation of ancestral states on the consensus tree at convergence the chain sampled states in the model of trait evolution with mean log e ϯ sd ϭ ϫ1143 ϯ 093 below i example q mp and q pm were assigned to the same rate class in 878 of the 10 5 sampled points over the four model categories rates were assigned to 101 ϯ 008 nonzero classes this indicates that the evolutionary transitions that produced the observed distribution of states of marriage strategy across societies in the sample can be described by a simple model of trait evolution based on only one nonzero rate class nodes pih and pie reconstructed as monogamy with high posterior probabilities under model categories 1 3 and 4 and as polygyny with p ϭ 1 under model category 2 in the latter category transitions from monogamy to polygyny are excluded because q mp is set to zero this forces nodes pih and pie to reconstruct as polygyny under this category any variation in states of marriage strategy at the tips of the tree is the result of transitions from polygyny to monogamy in other words the presence of polygyny at the tips could not be accounted for if pih andor pie reconstructed as monogamy however models in category 2 returned a mean log e value 167 units worse than models in the category that returned the best mean log e value and 147 units worse than the mean log e value over the four model categories this suggests that the evolutionary scenario described by model category 2 is unlikely to have produced the observed distribution of states of marriage strategy across societies in the sample posterior probability distributions of ancestral states over the four model categories nodes pih and pie reconstructed as monogamy with high posterior probabilities the posterior probability distribution is more strongly skewed toward high values for state m at node pie as reflected in the higher value of p at this node monogamy reconstructed with high posterior probabilities through to nodes a and b on the consensus tree summarizing the tree sample but phylogenetic uncertainty limits the confidence that can be placed in these inferences node d and node f reconstructed as monogamy with high posterior probabilities node e reconstructed as polygyny with high posterior probability the uncertainty in the reconstructions at the base of the consensus tree means that a host of scenarios can explain the distribution of states of marriage strategy at the tips polygyny was acquired at least once on the tree between nodes pie and e and possibly a second time in the branch leading to albanian g a minimum of two reversals to monogamy occurred one in the branch leading to panjabi st and one in the branch leading to singhalese discussion the phylogenetic comparative analysis of marriage strategies across societies speaking ie languages provides evidence in support of pie monogamy this pattern likely extended back to pih but the evidence is only suggestive polygyny evolved at least once possibly twice throughout the history of iespeaking societies but uncertainty in some of the deep reconstructions means that alternative evolutionary scenarios cannot be excluded this uncertainty emphasizes the need for an explicitly historical approach when deriving inferences about past social organization from crosscultural data and to crosscultural comparison more generally in turn the uncertainty in the phylogenetic model used to represent how the societies are related by descent stresses the importance of avoiding best tree approaches in phylogenetic comparative analysis as discussed above fortunato and mace used a best tree in the phylogenetic comparative analysis of marriage strategies and strategies of wealth transfer at marriage in iespeaking societies the present findings suggest that their reconstruction of pih monogamy is not contingent upon the phylogenetic tree used further while the outgroup hittite was not assigned marriage strategy data in the present analysis it was coded as monogamous in fortunato and maces this was necessary because the phylogenetic comparative method they used did not allow missing data the present findings indicate that the reconstruction by fortunato and mace is not contingent upon the state they assigned to the outgroup applying a phylogenetic comparative approach to the marriage transfer strategy data in a bayesian mcmc framework fortunato et al showed that the reconstruction of pih dowry is similarly robust to phylogenetic tree model and coding of the outgroup more generally these reconstructions push the origin of monogamous marriage into prehistory well beyond the earliest instances documented in the historical record this implies that the archaeological and genetic evidence for the nuclear family in prehistoric populations may reflect a monogamous marriage strategy on their own the archaeological and genetic data can at best provide clues about a monogamous mating pattern for example haak et al found evidence through analysis of adna samples of genetic relatedness of one adult male and one adult female with two children recovered in one burial at the site of eulau germany a late neolithic community attributed to the corded ware culture they argued that this establishes the presence of the classic nuclear family in a prehistoric context in central europe similarly bentley et al identified a nuclear family comprising an adult male an adult female a mature female and two children through analysis of the isotopic signatures of skeletal remains in the communal grave at talheim germany an early neolithic community attributed to the linear ware culture previous analysis of the teeth had revealed high similarity between the male and the children suggestive of genetic relatedness the corded ware and linear ware cultures are archaeological horizons of northern and central europe associated with populations speaking ie languages the phylogenetic comparative analysis shows that monogamous marriage prevailed among prehistorical iespeaking societies located in europe at least to the extent that evidence from a single grave can substantiate claims such as haak et als this suggests that the burial patterns may reflect the monogamous marriage strategy of the eulau and talheim communities largerscale analyses of ychromosome data provided evidence for a later increase in effective male population size compared to effective female population size across european and worldwide samples one possible interpretation of this pattern is that the difference in effective population size was caused by a regime of polygynous mating which resulted in greater variance in reproductive success for males than for females further dupanloup et al interpreted the delayed increase in the effective male population as evidence for a relatively recent shift from polygynous to monogamous mating based on pritchard et als estimates for the timing of expansion of ychromosome data they linked this shift to the emergence of food production between 10000 and 5000 years ago in europe and asia and more recently elsewhere when nuclear families replaced the polygamous extendedfamily compounds typical of huntinggathering populations dupanloup et al use the concept of nuclear family as synonymous with nonextended and monogamous family organization although in anthropology it is used to designate a family unit comprising parents and their dependent children technically therefore nuclear families exist in societies practicing monogamous and polygamous marriage the reconstruction of pie monogamy presented in this paper with monogamy likely extending back to pih falls within the temporal interval identified by dupanloup et al suggesting that monogamous marriage had emerged in eurasia by that time however dupanloup et als interpretation holds only to the extent that the shift to the nuclear family coincided with a shift from polygynous to monogamous mating with consequent reduction in the variance in male reproductive success the historical and ethnographic evidence suggest that variance in male reproductive success is comparable in societies practicing monogamous and polygynous marriage in any case this pattern is to be viewed against the background of moderately polygynous mating that is believed to have characterized our species evolutionary past based on morphological and genetic data finally and most importantly the phylogenetic comparative analysis confutes explanations linking the emergence of monogamous marriage to the development of features of social organization typically associated with the complex modern societies located in eurasia indeed investigation of the factors resulting in the shifts from monogamy to polygyny identified by the phylogenetic comparative analysis and in the corresponding reversals would be of particular interest shifts in marriage strategies may reflect for example changes in subsistence systems as well as historical contingencies such as the diffusion of religious beliefs recent theoretical work situates variation in marriage strategies in the context of variation in ecological factors linking the prevalence of monogamy across eurasian societies to the development of intensive modes of production diamond has convincingly argued that the relative greater complexity of these societies and their consequent modernization can also be attributed to ecological determinants that facilitated the emergence of food production in the region this raises the possibility that ecological factors act as a confounding variable in the observed relationship between marriage strategies and indicators of societal complexity and modernization an appeal to complexity and modernization as the terminus of explanation amounts to providing a proximate answer to ultimate questions about the evolution of marriage strategies

explanations for the emergence of monogamous marriage have focused on the crosscultural distribution of marriage strategies thus failing to account for their history in this paper i reconstruct the pattern of change in marriage strategies in the history of societies speaking indoeuropean languages using crosscultural data in the systematic and explicitly historical framework afforded by the phylogenetic comparative approach the analysis provides evidence in support of protoindoeuropean monogamy and that this pattern may have extended back to protoindohittite these reconstructions push the origin of monogamous marriage into prehistory well beyond the earliest instances documented in the historical record this in turn challenges notions that the crosscultural distribution of monogamous marriage reflects features of social organization typically associated with eurasian societies and with societal complexity and modernization more generally i discuss implications of these findings in the context of the archaeological and genetic evidence on prehistoric social organizationto access this article as a pdf payperview download via bioone please click here

introduction endometriosis is a chronic multisystemic disease of inflammation affecting approximately 10 of the female population it is defined as the extrauterine growth of endometrial glands and stroma and may present with a variety of symptoms such as pelvic pain and infertility resulting in a significant negative impact on individuals health and quality of life the most widely regarded theory on the origin of endometriosis dates back to dr sampson who postulated that endometriotic implants resulted from retrograde menstruation back in the 1920s although reports of aberrant endometrial tissue growth date back to as early as 1860 historical perspective john a sampson was interested in exploring the reason for infertility seen in patients with endometriosis at a time of social concern regarding declining birth rates among upperclass women in the united states in the context of such societal panic dr j meigs proposed a theory that endometriosis was linked to contraceptive use and delayed childbearing seen most commonly in the welltodo this theory gained ground for several decades substantiated by methodologically flawed research demonstrating increased rates of endometriosis among private white patients compared to the ward black patient a dichotomy ridden with confounding and bias although some evidence to the contrary started to emerge in the 1950s it was not until dr chatman presented his work in the 1970s that the view of low prevalence of endometriosis in black patients began to shift nevertheless by this point a strong bias regarding the impact of raceethnicity in the epidemiology of endometriosis was perpetuated in the medical community evidenced by the narrative in medical education literature suggesting a rarity of endometriosis amongst nonwhite patients present until the twentieth century more recent texts continue to suggest lower prevalence of endometriosis diagnosis in black and potentially higher prevalence among asians compared to white women summary of evidence regarding raceethnicity and endometriosis several publications dating back to the 1920s have investigated the epidemiological risk factors for developing endometriosis including raceethnicity this literature was synthesized in a systematic review and metaanalysis by bougie et al in order to estimate the risk of endometriosis among various racialethnic groups the review included 18 studies and identified that compared to white women black and hispanic woman were less likely to be diagnosed with endometriosis while asian women were more likely to have this diagnosis significant heterogeneity was present in the analysis for all racialethnic groups which may have stemmed from clinical variation of included study participants and definition of outcomes as well as methodological differences in study design two studies were not included in the metaanalysis as they reported outcomes of interest in a format not compatible with data synthesis first missmer et al examined the incidence of surgically diagnosed endometriosis in the nurses health study ii and found that black women had lower rate of endometriosis diagnosis compared to white women whereas asian women had similar rates of disease compared to white women hispanic women had lower rates of endometriosis diagnosis compared to white women although this did not reach statistical significance these findings should be interpreted cautiously as the studied population was predominantly caucasian secondly zhao et al examined the prevalence of endometriosisrelated hospitalization based on the nationwide inpatient sample in 1991 and 1992 in the united states they observed significantly lower rates of endometriosis diagnosis in black hispanic and asian pacific women compared to white women a more recent retrospective cohort study using claims electronic health records estimates that 70 of patients diagnosed with endometriosis were white 6 hispanic 9 asian and 47 nonhispanic black this work highlighted several important themes pertinent to raceethnicity and endometriosis first many of the included studies were of poor methodologic quality and at significant risk of selection bias as well as confounding particularly from socioeconomic status secondly the majority of patients included in the studies were of white racial origin lastly the majority of studies focused on disease prevalence without exploring potential variability in presenting symptoms diagnostic delays or therapeutic response based on race literature looking at uterine fibroids another gynecologic condition suggests that there is significant variability amongst different ethnic groups in terms of symptom burden and clinical presentation not necessarily in alignment with objective measures of disease burden florescaldera et al recently presented the results of their international collaborative crosssectional study 32 which established the phenotypic profile of hispanic latinx patients with endometriosis specifically they identified substantial severity of symptoms particularly dysmenorrhea and dyspareunia high pain catastrophizing scores and overall negative impact on quality of life finally the primary presenting symptom of endometriosis pelvic pain may limit clinical consideration of this diagnosis of this condition amongst nonwhite patients historically medical education has perpetuated stereotypes surrounding black patients and their experience of pain significant racial and ethnic disparities remain across different areas of pain care with minorities receiving lesser quality pain care than nonhispanic white patients these encounters may be rooted in implicit and explicit biases held by healthcare providers including the notion that nonwhite patients have a higher pain threshold similarly when stereotypes surrounding the prevalence of diagnoses like endometriosis are perpetuated within the broader community racialized patients may be less likely to seek medical attention for their symptoms raceethnicity and endometriosis representation in medical education endometriosis and race have been discussed in medical education with heavy influence from the gynecology community the integration of evidencebased medicine has stressed the importance of using highquality evidence to support clinical practice however we must appreciate that there are many longstanding beliefs that are held as mantra in medicine supported mostly by flawed confirmation bias the perception of endometriosis as less prevalent in black patients is widespread amongst foundational textbooks of gynecology including but not limited to williams gynecology blueprints obstetrics gynecology and speroffs clinical gynecologic endocrinology and infertility textbooks are important to examine as they are widely distributed as educational tools based on expert opinions and until the recent shift to online resources formed the foundation of medical education for example an excerpt from the sixth edition of novaks gynecology published in 1961 states there seems no doubt that endometriosis is much more common in the white private patient than in the dispensary clientele by the 16th edition published in 2020 the section states that endometriosis is found in women from all ethnic and social groups whereas novaks revised its content to remove all references pertaining to race and endometriosis other textbooks removed blatant commentary while still alluding to an ongoing controversy other examples of racial bias are more nuanced for instance the 2013 edition of blueprints of gynecology features a corresponding multiplechoice clinical vignette in which her ethnicity is caucasian is correctly identified to increase suspicion for endometriosis similar commentary can be found in other gynecology textbooks dating back to the 1960s with the nature and severity of these assertions changing over time it is of note that many of these comments are made without any appropriate citations the uses and misuses of raceethnicity in medicine the consideration of race and ethnicity in medicine and biomedical research has been a longstanding charged and complex debate there is an established history of racial injustice in medicine and a hesitance to repeat past mistakes there are two general positions either there is strong utility to the inclusion of race in research and medical practice or race has no biological origin and thus should not be included in medicine to understand each side it is imperative to define this terminology which has been used inconsistently race and ethnicity are primarily social constructs they arose through geographical social and cultural forces as opposed to defined biologic constructs race is often classified based on continental origin and historically genetic variation has been related to geographical mating patterns ethnicity is a further construct related to geography but also considering religion culture and language they are often a result of endogamous mating within continents thus they have genetic variation but less than continentally defined groups both race and ethnicity can influence socioeconomic status resulting in unequal access to opportunities and resources and disproportionate morbidity and mortality raceethnicity is often used as a marker for underlying genetics epidemiologic and clinical research often divide endometriosis r37 32 participants into such categories to investigate hypotheses between environmental and genetic risk factors although social determinants of health and access to care must be considered racialethnic differences are often seen despite controlling for such factors for instance in a study by karter et al the rate of diabetic complications was evident despite using the same health maintenance organization and after adjustment for various social determinants conversely while these risks are often reported as intrinsic differences between races they are likely capturing the risk of inequities from exposure to structural racism single gene disorders are an example of successful discovery based on raceethnic considerations noting that certain groups display certain diseases geneticists hunt for a cause leading to discoveries of the genes for taysachs cystic fibrosis and thalassemia mendelian disorders are often traced back to particular groups such as ashkenazi jews french canadians the amish or certain european backgrounds but it should be noted that these groups are not defined by race genetic variation is still more commonly observed within continental populations as opposed to among them common chronic diseases such as cardiovascular disease diabetes mellitus and kidney disease have been seen worldwide confirming that all populations are susceptible and variation is more likely due to environment while race can help target screening for diseaseassociated mutations the only way to diagnose a dnasequence variant is to test for it it should also be noted that despite all the literature on the topic race has not been defined in genetic terms further application of raceethnicity has been in drug responsiveness it is well known that functional variants of genes encoding drugmetabolizing enzymes exist and understanding a patients background can allow clinicians to predict drug responsiveness and tailor therapies accordingly for instance there has been substantial work in targeting racespecific medical therapy in cardiovascular disease the clarification of oral anticoagulation through genetics trial showed a difference between the responsiveness of populations of european and african ancestry with respect to warfarin dosing necessitating a racespecific approach to treatment however researchers must be cautious as other randomized trials were interpreted to show different responses by race but further analysis of the results revealed this conclusion was a type i error these assumptions may lead to clinicians withholding certain medications from certain racial groups thereby exacerbating the differential care seen between groups while the above examples describe positive attempts at using race in medicine there are far more examples of its misuse of which one of the most interesting areas is in diagnostic algorithms used as a concrete proxy for bias this can be seen throughout all fields of medicine vyas et al explored some of the most common diagnostic algorithms by including race in these calculations they suggest that racebased medicine is being propagated guiding decisions that may further direct resources away from minorities one of the most widely described algorithms incorporating race is that of estimated glomerular filtration rate the formula predicts higher egfr meaning better kidney function for black patients this is supported by evidence that higher serum creatinine levels are seen in black people potentially due to increased muscularity this assumption may result in delayed referrals and indeed black people have higher rates of endstage renal disease on the other hand ignoring race in this algorithm may lead to the prediction of worse kidney function in such patients and result in overtreatment and inappropriate drug dosing similarly the kidney donor risk index finds that black donor kidneys perform worse and given that black patients are more likely to receive organs from black donors it is not surprising that they have long wait times for renal transplantation algorithmic inclusion of race can be seen across the medical specialties the vaginal birth after caesarean risk calculator predicts a lower chance of success if a patient identifies as black or hispanic which may deter clinicians from offering a trial of labour indeed nonwhite americans have higher rates of caesarean sections and it is well known that black patients have increased rates of maternal mortality while some algorithm developers do offer sources for these adjustments these are often found to be outdated and biased the racial distinctions seen in large datasets are more likely reflecting the toxic effects of racism such as its physiological consequences discrimination and access to care borrell et al cautions that when using standardized algorithms clinicians should consider whether the inclusion of race would decrease health inequities leading to better health outcomes the consideration of race has also led to knowledge gaps in medical research years of insufficient funding for research in minority populations have led to questionable generalizability of medical advances to such groups for instance less than 2 of national cancer institutefunded clinical trials and less than 45 of federally funded pulmonary research have included minority populations the national institutes of health requires reporting of all racial or ethnic groups and despite this there is a paucity of information and minimal progress in including minority groups in large trials endometriosis is another condition affected by the misuse of race as reviewed above it has historically been viewed as a condition of white women and a systematic review of the literature identified a strong focus of research on white women with minimal data on minority groups while some studies postulate that endometriosis is higher in asian women and lower in black women compared to their caucasian counterparts other studies comparing women of different races with equal indications and socioeconomic status have failed to note a difference it is commonly thought that those women of african descent rarely have endometriosis yet it is one of the most common reasons for african american women in the united states to undergo gynecologic surgery it has also been shown that in private patients admitted for such surgeries the prevalence of endometriosis was similar between african american and caucasian patients interestingly kyama et al reported a significantly lower rate of endometriosis in africanindigenous women compared to african american indicating that race alone is not an explanation and more likely due to lack of awareness lack of access to laparoscopy limited training on diagnosis and treatment lack of research interests and lifestyle factors in their retrospective study shade et al reviewed charts of african american patients that had undergone surgery for endometriosis and noted that 93 of patients demonstrated uterine endometriotic implants although this was a retrospective study without a comparator group the authors suggest that this finding may indicate a variation in disease presentation compared to other racialethnic groups the debate regarding the use and misuse of race ethnicity in medicine is ongoing and fraught with complexities while race is not a reliable proxy for genetic difference we must acknowledge that differences do exist between people of different racial categories and this is clinically meaningful ultimately replacing race with genetic ancestry would result in more informative evidencebased approaches yet this technology is not yet readily available outside the research environment while ignoring race may improve equality it is only through the equity that racial disparities can be tackled phenomics and endometriosis the advent of genomewide association studies has gathered a great amount of information suggesting highconfidence genotypephenotype associations between specific genomic loci and a large number of diseases including diabetes obesity crohns disease and hypertension recognizing the importance of considering phenotypic variation among endometriosis patients vigano et al conducted a comprehensive review of the relationship between morphometric traits and endometriosis they identified some association between bmi and particularly pigmentary trainspresence of nevi and diagnosis of endometriosis more importantly they drew attention to the consideration of genomic contribution to the phenotype of endometriosis although currently the mechanisms underlying genotypephenotype relationships remain only partially explained and must be interpreted in the context of multiple limitations including the inherent variability in quality of published data and the higher order complexity of the genotypephenotype relationship it is easily imaginable that a catalogue of nearly all human genomic variations and their relative impact on human diseases will be available within our lifetime we must appreciate that even with expansion of genomic information that will become available the majority of phenotypic variation seen amongst endometriosis and other medical conditions will stem from genotypeenvironment interaction genetic variation between populations tends to be geographically structured as expected from the partial isolation of human populations during much of their history in this regard race may be considered firstorder approximation to the geographically structured phenotypic variation in the human species the influence of environmental exposure resulting from geographic variation on the development of endometriosis has been suggested conclusions and future work in summary we see that there is a strong historical bias regarding the epidemiological impact of raceethnicity on 32 the prevalence of endometriosis although the summation of current evidence suggests that endometriosis may be less common amongst black and hispanic women compared to white women it is imperative to recognize the significant methodological flaws and bias driving the studies performed to date furthermore it is important to question the relevance of this information in the provision of outstanding and individualized patient care recognizing the narrative on this topic to date we suggest the following clinical education and research priorities moving forward moreover it is important to note that race should not be used as a proxy for biological markers or genetic predisposition for a disease race also should not be used to simplify systemic contributors when teaching around the underlying cause for disparities in diagnoses medical trainees must be taught social determinants of health in order to holistically serve diverse patient populations 3 further investigation into the epidemiologic risk factors predisposing the development of endometriosis should be encouraged in order to identify atrisk individuals and implement early detection and appropriate treatment of the condition research exploring the unique presentation and treatment of endometriosis amongst patients may explore race and ethnicity but needs to include these factors in a sensitive manner reflecting on underlying social constructs any researcher including raceethnicity when studying endometriosis should reflect a priori on the reason and implications of including this factor in their study we advocate for the adaptation of an individualized and patientcentred approach to the management of endometriosis to achieve more equitable and improved care provision for all endometriosis patients declaration of interest o bougie has participated in a speakers bureau and received research grants and consulting fees from bayer pharma allergan hologic and abbvie the authors confirm these sponsorships had no involvement in the study i n and c w have no disclosures author contribution statement all authors contributed to the research and manuscript preparation they all approved the final submitted version

endometriosis is a chronic multisystemic disease often presenting with significant phenotypic variation amongst patients the impact of raceethnicity on the prevalence of endometriosis as well as disease presentation is a question of interest which has been explored for the last century this narrative review explores the historical perspective of endometriosis and raceethnicity as well as the evidence available to date furthermore we discuss the potential implication of the bias perpetuated on this topic specifically in the areas of medical education research and clinical care in consideration of these intersecting realms we suggest priorities for future consideration of raceethnicity as it pertains to the delivery of care for endometriosis patients

introduction family is a very important social institution of the society it is one of the basic institutions of the society which breeds actors of other social institutions no one exists without some form of family it is only in literature that societies are portrayed without families an individuals life revolves around the family at one period or the other during his lifetime the word family was derived from the latin word famulus which connotes servant inference taken from this is that family comprises of people who are meant to serve one another and in a typical african family which consists of a man woman with their children people are interdependent on one another every human society has adopted the family system it is the lowest unit of social organization this has attracted several disciplines such as anthropology archeology history medicine law psycho logy sociology and social studies among others to give special attention to the study of the institution which erinosho described as the bedrock of value the institution of the family formed the basis of social relations and was essential to the survival of the individual in the african traditional societies but it is important to note that as industrialization set in and new institutions came to limelight family roles and relevance were taken up by these emerging institutions although family still remains the basic unit of social organizations but the complexities of societies and the current era of globalization has ushered in several changes and altered the originality of the family structure family defined family is a universal institution and as a result it will be very difficult to give a universally acceptable and applicable definition in the face of diversities in structure and varying cultural practices of societies as such within the context of this chapter family will be defined based on its applicability to african society and easy understanding of students family can be defined as a group of people related by blood or marriage who live together cooperate economically and care for their young ones according to giddens a family is a group of people who are intimately related by kinship and whose adult members are responsible for caring for children a family may also be defined as a small collection of individuals who have facetoface interactions and are linked through kinship or marriage the concept of family exists in society it may also be thought of as a social structure that has impact over society a civilization cannot exist without family murdock defines family as a social group defined by shared housing financial integration and procreation implicit from these definitions given is that the concept of family has something to do blood relation marriage and household overtime with the presence of the threat of divorce single parents unmarried cohabitation and gay marriages several definitions of family have lost their originality and are being threatened by the changing trends functions of family in the society 1 socialization every individuals initial point of interaction in society is with his or her family socialization is the process through which a person becomes an accepted member of society it is frequently stated that home is the first school and the mother is the first instructor an infant learns conventions such as hygiene eating habits and so on from his family members the family via its parents guardians and older relatives assists children in becoming wellintegrated and productive members of society from childhood the children are indoctrinated with societal standards and values in order for the child to fit into anticipated roles and behaviors in society regulation of sexual behaviour each society controls sexual behavior in order to preserve familial organization and personal liberty family systems define standards that govern sexual behavior these norms may forbid premarital sex or describe the qualities of suitable sexual marital partners laws forbidding marriage and sexual interactions between relatives are examples of such standards reproduction function for there to be continuity members of society who die must be replaced family offers a culturally and legally authorized setting for new members to be born and raised in 4 provision of emotional support one of the functions of the family is taking care of the emotional and physical needs of its members irrespective of how old a member of a household is such a member still craves for meaningful social ties to others the human life cycle is such that there is always a stage to be extremely dependent on others in africa people are not only dependent on one another but very interdependent and as such come to one anothers aid when assistance is required 5 social security family provides a sense of security to its members an individual feels secured when he is with his family members in many societies especially in the rural communities any attack upon a person is considered an attack on the entire family and as such all family members stand to defend the person although most families are now nuclear in structure but the ties with other members of the family who are heterogeneously scattered in different communities are still maintained especially in nigeria 6 ascription of status since individuals cannot choose their parents before birth the family into which a child is born confers a genetic and social status on the genetic or biological status a child whose father is a king automatically qualifies to be in the lineage of royalty and as such can become a king also for the achieved status a child who is born into a wealthy family also enjoy the wealthy status of the parents which can serve as a determinant of the childs aid to attain wealth without having to engage in much hard work 7 religious function most times the religious practice of the family into who one is born is always the religious group one belongs until maturity or marriage sets in since the infancy will be socialized by the family into which heshe is born the family has a strong influence in determining the religious practice of an individual 8 economic function since the family is the interphase between an individual and the society the economic aspect of the family is also catered for from infancy family in the traditional societies engaged in joint effort of working and sharing ie every member of the household was an economic asset because the needs and aspirations of every member was jointly provided although the situation has changed and a large number of families now are not engaged in agriculturebased occupation that requires the services of every member but even with white collar jobs several families that reside in the urban jointly cater for the family needs marriage marriage is an institution that results into family marriage is a societal institution that allows individuals to form family system with one another marriage can take one of three forms monogamy polygamy or group marriage marriage practices endogamy this is a practice which requires that mates be selected within certain groups the groups are commonly socioeconomic socioreligious and ethnic based according to oyeneye the practice is prevalent all over the world but some cultures emphasize it more than others in india the indian caste system is an example and in nigeria the osu caste system also exists in the eastern nigeria there are some other instances such as the case of some marriages contracted within relatives among royal families in northern nigeria in order for the royal blood not to be contaminated by marrying from outside the clan exogamy in this practice there is prohibition against the selection of a spouse within certain groups when close relations have sexual intercourse with one another it is regarded as incest taboo this incest taboo prohibits individuals from selecting spouses amongst members of the family and close blood relations according to and shankar rao the rule of exogamy is that individual should look for spouse from another family clan tribe or village oyeneye identified different types of marriage being practiced in africa these include types of contemporary marriage marriage by mutual consent this is an association between man and a woman living together as husband and wife without a formal bond such as approved by any religious institution or family members and because such association exists without the acknowledgement of parents this marriage is usually not stable any of the couple may decide to break the relationship this practice is common among some career conscious individuals in the urban areas such as lagos port harcourt and abuja among others in nigeria trial marriage this is a contracted kind of marriage which is bound to expire at the sight of growing incompatibility it is somewhat similar to marriage by mutual consent but trial marriage is common among students of tertiary institutions and middle class clerical workers in nigeria although this type of marriage is not yet approved in nigeria but it has become a common practice among people to start living together and use the opportunity to closely observe each other if their character can match one another for the relationship to be further cemented people who engage in this practice are referred to as liveinlovers marriage by ordinance this is a marriage contracted in a court of law before a court registrar magistrate or any designated government official who has authority to contract marriages at the end of the marriage certificate is usually issued to the couple but with emphasis that it should be handled by the wife marriage under the ordinance cannot be dissolved until after five years of its contraction and such dissolution can only take place in a court of law marriage by ordinance only permits both couple to have a spouse at a time and because of this clause a lot of couples have dodged contracting their marriages in a court of law some men for the tendency of infidelity few ones for the fear of infertility or inability to produce a male child usually reject this type of marriage christianmuslim marriage in a religious solemnization the families of the bride and groom are represented or present to serve as witness and show approval for the consummation of two consenting adults most christian marriages take place in the church and it is usually referred to as white wedding while the muslim marriage usually referred to as nikhai is mostly done outside the mosque both christian and muslim marriages are mostly combined with the ordinance and as such the dissolution requires that both parties be present or represented in a court of law customary marriage this is a traditional marriage system which permits the groom to perform all necessary rites and dues before being betrothed to his wife under this practice the families of both bride and groom must come into agreement to allow their children marry one another history of sicknesses and diseases moral and social qualities of either family as well as the hard working nature of the groom are factors always considered before the marriage is consummated among the yorubas there is usually provision for an intermediary who sees it all from both families point of view and report any anomaly or foul play noticed in the course of his visitations if nothing is detected in the course of his findings then both families can be united in the bond of marriage among the yorubas once two families are married it is believed that they have become one single family and hence no two members of either family can have any strange feelings of love for themselves it is a forbidden act in the fulani tradition there is a marriage custom called the sharo the purpose is to prove a young mans courage and ability to endure the rigors of a married life if the young man cannot endure the pain of flogging then he is not ready to marry today this system is going fast into extinction escape marriage this type of marriage happens when a woman leaves her husband to marry another man without any formal divorce or payment of compensation to the former husband onwuejeogwu the new husband takes the wife to his house slaughters a cow which symbolizes the validity of the marriage if a woman involved in escape marriage gets tired of her new husband she may decide to return to her former husband or be married to another husband in this type of marriage there is no limit to the number of husbands a woman may take this type of marriage is common among the fulani tribe of nigeria child marriage it is referred to as the koggalpibol it is also common among the fulani tribe of nigeria under this arrangement a girl is betrothed to a boy when they are both still very young or to a much older man in some fulani resident communities the girls father gives her to the father of the boy who in turn takes care of her till she is old enough for marriage this practice is valued because it enhances group integration although this has been negatively interpreted as a lot of families who are into this practice are reported to have jettisoned the place of keeping the young girl for a young boy or at least permitting her to attain maturity before sexual intercourse is introduced infact a lot of old and wealthy men have resulted into capitalizing on this practice to find virgins for themselves in the young girls whom the culture described that they should be nurtured till the level of maturity and the problem associated with the recent arrangement is that should the husband of this young wife die life may become miserable for the woman as there may be no one to cater for her and the kids woman marriage in this case a woman marries another woman pays her bride price and acquires the rights of a husband with respect to wife after the marriage the woman who paid the bride price can betroth the new wife to her husband brother son or close relations although the most popular of all this practice is the one that sees the woman marrying on behalf of her husband to neutralize the effects of the harsh ethnic system which prevents women who have no male children from inheriting part of their deceased husbands property and being part of his agnatic lineage this practice is peculiar to the igbos in nigeria marriage by inheritance this is common in traditional african societies where when a man dies his wife can be inherited by his kinsmen most especially the siblings of the deceased this is mainly to cater for the woman and raise children in the name of the deceased also because marriages in the traditional african societies were usually conducted between families most families see it as a loss when a man dies and his wife is allowed to married outside the family hence one of the kinsmen is chosen to marry the widow in order to cater for her and probably the children of the deceased most especially when the woman is still very young surrogate this involves one woman carrying a foetus produced from the egg of another woman haralambos holborn chapman and moore stated that surrogate is more of a mutual agreement between a woman and a couple or a single parent the surrogate mother is usually contracted to carry the baby from foetus stage to the level of delivery and once the child is delivered it is delivered to the contracted party which may be couple single parent or willing parties smart also noted that this practice is becoming a common phenomenon among same sex partners such as gays and lesbians who also crave to have children in their union without adoption merriamwebster dictionary described that this can be referred to as levirate family and social change a lot of changes are taking place in the institution of family which quite often poses a threat to the very survival of family system universally giddens henslin ferrante and haralambos holboln chapman and moore stated that the following trends have been observed in the institution of family 1 unwed mothers it is gradually becoming a universal culture for some women to voluntarily choose not to marry but have children although some are victims of circumstances such as rape rejected pregnancy teenage pregnancy and children accidentally born out of prostitution these set of women chose not to marry for several reasons some out of the fear of being maltreated past sexual abuse experiences fear of unknown and quest for fame live in relationship between couple without the ceremony of marriage this is often referred to as living lovers or trial marriage this is common among young adults who want to observe one another for a period of time before deciding on marriage it is often practised by students of tertiary institutions although this practice has been on for long because a lot of people who live together as couple and give birth to children without the ceremony of marriage also fall under this category this practice is not only restricted to the youth but also some elderly persons in the society who find the ceremony of marriage very rigorous to undertake a lot of people run from being implicated legally in case they engage in infidelity extra marital affairs this is almost a universal practice in nigeria when a woman engages in this act she is often condemned instantly but the case is not so for the male counterpart who sometimes boast publicly of his potency although the legal marriage system negates this attitude but infidelity is almost normalized in most african countries except for the developed countries that take legal actions against persons who are found guilty in this phenomenon 4 increased rate of divorce this practice is said to be a product of industrialization and the quest for gender equality although most african families curb growing intolerance which may lead to divorce it is important to note that some educated young wives are beginning to develop a new profit making venture in their claim for divorce in most divorce cases reported infidelity growing incompatibility and wife battering among others are factors responsible calhoun light and keller stated that the likelihood of divorce is highest when a the couple lives in a city b they both work but their earnings are low c they got married young c they havent been married for a long time c the wife has egalitarian beliefs on household labor division but the husband does not f neither the husband nor the wife possesses religious beliefs g both the husband and the wife have liberal attitudes h both husband and wife have a negative outlook on life i either one or both parents are divorced or single parents boarding school for children boarding school education for children from a very young age which makes them lose their attachment with the family moreso a lot of caregivers have risen to the occasion people now take it as a job to raise other peoples childrenat the absence of the mother 6 decision not to procreate this tendency is particularly observed among the highly educated couples who feel that they have no time to bring up children or can adopt because of the rigors of child bearing and child rearing this is also common among artists and people who are too dedicated to their profession 7 decision of youngsters to remain unmarried on account of high degree of dedication to profession 8 increasing rate of domestic violence such as child abuse wife abuse and abuse of the elderly 9 increase in employment opportunities for women presently there is a universal agitation for the incorporation of women in organizations because of the perceived level of social inequality more women now have jobs unlike before and as a result of their new status they have lesser time for the family 10 decline of the breadwinner system since the society is encouraging that both spouses work to sustain the family in the face of industrial reality there is decrease in continual dependence on the man as the sole bread winner of the family rather there exists joint effort on the part of the couple to cater for the needs of the family st abraham noted that the breadwinner system is mostly common in the traditional african societies and in an urban area it will not thrive 11 increased life expectancy more members of the family are now conscious of the health status of pregnant women nursing mothers and infants as well as the physically challenged individuals this has helped to save a lot of lives in the family this is partly due to the increasing efforts of the government to improve the lives of every individual 12 decline of arranged marriages a lot of marriages conducted now are based on mutual consent between the couple rather than imposition by the family more people first meet themselves fall in love and then agree to marry one another the involvement of family in marriage is no longer in the area of finding suitable partner for their wards but to only perform ceremonial functions 13 decline in parental authority due to the growing rate of civilization and the increasing number of graduates and elites more youth crave to be personally independent and find their source of survival away from their families their quest for survival has separated them from authority and control of the elderly members of the family and in some cases where the parents have little or no time for their wards who have been conscripted to the boarding schools these wards come back into the family with a separate culture of their own part of which is self dependence and decline in parental control because they have not been consistently in contact with their parents to understand their dos and donts 14 teenage pregnancy and parenthood more teenagers are being put in the family way in recent times some through abuse and others via ignorance or exuberance though teenage marriage is a permissive practice in some part of northern nigeria it must also be emphasized that because most of these teenagers did not prepare for induction into motherhood a lot of them struggle to cater for the children born especially if the child is born out of wedlock also most teenage mothers have some health challenges which might have emanated in the course of the child bearing and such complications threaten either or both the lives of the mother and child structure of the contemporary family according to giddens families in the world are in transition several pluralities have been witnessed and other structures of the society have overtaken the responsibilities of the family for the procreation function of the society the health institution has engineered the establishment of breeding and cloning of the human species animals and laboratorymade materials can incubate premature babies ejected at early stage from their mother sexual gratification is also gotten from commercial sex workers and people nowadays derive pleasure from well defined contractual marital arrangements with expiration periods as well as with multiple sexual partners even though these are not legitimate on the socialization function of the family schools and religious organizations have replaced the family children spend much time with their counterparts and teachers in school than with their parents and as a result of the busy schedules of parents mostly in the urban areas the level of attention mothers give to their children is on the decrease coupled with single parenting and the death of one or both parents in this vein several educational instructions and religious organizations have taken up the task of instilling the norms and values of the society in the children since complexities is beginning to set in into the family the level of closeness of members of the family is also being threatened by industrialization and urbanization the level of ascribed status has reduced because of the economic conditions of most developing society hence a lot of children fend for themselves and learn from their peers instead of being initiated into the societal norms by their family members this partly explains why a lot of social problems have increasingly become part and parcel of so many societies in the world conclusion the primary school of citizenship is the family every person is born into a family grows up in it works for it and dies in it the individual becomes emotionally attached to it the first lesson in social responsibility and acceptance of selfdiscipline is imparted to the kid through parental care the family is the foundation of societal organization it holds a nuclear power status in society however despite the relevance of the family in the society if proper care of the young ones is not taken as priority the family can become an active institution which breeds delinquents and destitute as a lot of functions are neglected by the modern day family and the efforts of other institutions at managing the lapses of the family has not been a perfect job done hence there is need for every family to hold with uttermost importance the place or morals socialization and regulation of individual member of the familys behaviour

given that social institutions are the basis of any society they must ideally operate in unison with functional necessities for any society to function and then flourish the plethora of issues confronting nigeria as a country may be traced back to weak incompetent and dysfunctional social institutions that have failed to alter the status quo according to talcott parsons society is analogous to the human body and in order for the body to thrive all of its elements must collaborate for nigeria to advance all social institutions including family school religion politics and the economy must work together to create repeatable results it is against this background that this paper sought to examine the role of family structure in nigeria and their proactiveness in propelling national development literature was extensively reviewed from relevant publications and journals and it revealed that the family structure in nigeria is gradually becoming weak and dysfunctional this is attributed to a lot of changes that are taking place in the institution of family which quite often poses a threat to the very survival of family system universally it was then concluded that there is need for every family to hold with uttermost importance the place or morals socialization and regulation of individual member of the familys behaviour

how are older people faring postpandemic evidence from the english longitudinal study of aging chair giorgio di gessa cochair paola zaninotto discussant paola zaninotto this session provides insights into the experiences of older people in england postcovid19 pandemic evidence suggests that stayathome and lockdown measures during the pandemic impacted several aspects of peoples lives with detrimental consequences for their wellbeing and mental health particularly among older people little is known however on whether and to what extent there has been a return to normal life since covid19 restrictions were lifted using data from the english longitudinal study of ageing this symposium aims to provide new evidence on the experiences of older english people since the successful and rapid covid19 vaccination rollout and the easing of restrictions in england through the second half of 2021 elsa is an ongoing longitudinal biennial survey representative of individuals aged 50 and over in private households that has collected data before the pandemic during the pandemic and postcovid19 pandemic exploiting the richness of this dataset this symposium will present the most uptodate picture of how older people are faring postpandemic results will focus on mental health and wellbeing social isolation and loneliness employment and financial status as well as social participation abstract citation id igad1041376 social engagement among older people in england since the covid19 pandemic giorgio di gessa university college london london england united kingdom volunteering providing grandparental childcare and provision of family care were quite common activities prepandemic among older people however during the pandemic older people in particular were strongly advised to stay indoors to work from home and to avoid or at least limit interactions with people outside of their immediate household including grandchildren and friends as a result evidence from the english longitudinal study of ageing showed dramatic changes in the level of engagement in these socially productive activities about 10 of grandparents stopped looking after grandchildren altogether during the first 9 months of the pandemic with 22 reporting an overall decrease in the amount of grandchild care provided similarly among those who were volunteering or caring for someone outside their household precovid19 almost two thirds decreased or stopped altogether engaging in these activities with overall negative consequences for their mental health and wellbeing to date though little is known on whether in emerging from the current pandemic

questions were included to explore caregivers feelings of preparedness and family support of all participants 206 family caregivers responded to the openended questions nearly 40 n79 of these caregivers were providing care to a family member with alzheimers disease or related dementia qualitative methods were used to analyze data develop a coding scheme and identify themes findings suggest that most family caregivers are providing care without adequate help support or communication from other family members this lack of support seems to leave dementia caregivers feeling less prepared and more frustrated than other caregivers our findings highlight the importance of family communication about advance care planning and caregiving responsibilities to promote family caregiver preparedness and wellbeing and effective care and quality of life for an individual at the end of their life

introduction physical inactivity can be a fundamental cause of various public health problems especially chronic diseases in countries with fastgrowing economies the decline in physical activity is even more pronounced for example the level of physical activity of 13 billion people in mainland china is experiencing a steeper decline than in any other country the level of physical activity has dropped by 45 in less than a generation 1 numerous studies have shown that regular physical activity can effectively reduce the risk of preventable chronic diseases 2 3 4 5 environmental improvements can provide health benefits by promoting physical activity however the urban form and social environment of chinese cities are significantly different from that of many western cities it is not clear whether the associations between environmental characteristics and physical activity from western cities can be directly applied to china 6 for example previous studies on transportrelated physical activity in china have shown little association with built environment 7 because the most common form of it is the daily commute to workplace 8 besides density might also impede walking and other outdoor sports activities 910 which is not in line with the existing literature extremely high density limits open spaces and parks which could lead to serious traffic barriers safety and pollution problems 611 however evidence of nonmajor chinese cities with lower density than first tier cities is lacking therefore this study provides some insights into the interaction among various factors associated with physical activity and health outcomes in chinese nonfirsttier cities evidence has reported the association between built environment and physical activity with land use mix density and connectivity as pivotal determinants of physical activity 1213 other walkability related factors such as parks and squares and pedestrian infrastructure also affect physical activity 14 besides easy access to parks and other recreation facilities has been associated with more leisuretime physical activity 15 adults tend to be more physically active when they live in higher density mixeduse neighborhoods with destinations such as shops and parks within walking distance however findings have been inconsistent perhaps owing to multiple modes of assessment and overreliance on selfreported measures 13 on the other hand objective environment attributes tend to affect physical activity through peoples perception of the environment according to ecological models of health behavior the results of objectivelyassessed and perceptions of the same built environment do not have high consistency in physical activity 16 as perception may be influenced by personal cognitive and emotional factors 17 only 82 of the environmental factors are related to the same result the influence of perceived environment on physical activity is slightly higher than that of the conceptually comparable objectivelyassessed environment 18 however few studies have demonstrated the mediation and moderation effect of neighborhood environment and physical activity relations research has documented that the association between the number of parks and moderate and vigorous physical activity was mediated by its perceived indicator 19 facility count and population density were associated with neighborhood walking and physical activity via the perceived neighborhood environment 20 while the association between built environment and physical activity varies according to the individual socioeconomic backgrounds such as gender age and education but there is no consistency 21 22 23 higher socioeconomic status may lead to higher physical activity 24 in addition the associations of objective intersection density and land use mix with moderate and vigorous physical activity are moderated by both gender and perceived pedestrian infrastructuresafety 19 plus education and gender moderate the association between safety from crime and meeting high physical activity levels 21 clear relationships between perceived neighborhood features and built environment with physical activity levels remain elusive 1925 in addition to built environment individual and social environment have multilevel interactions with physical activity according to the ecological model 26 social determinants of health also have robust associations with health status including a wide range of elements such as socioeconomic status social networks social support social cohesion social capital and so on 27 social capital is the most used which contributes to various health outcomes 28 and physical activity 2930 previous studies examining the association of social environment on health outcomes emphasize different aspects of the social environment 3132 the social factors that can affect health are the degree intensity and quality of our social connection with others 33 this paper focused on the connections between residents and neighbors however too little work has been devoted to the effect of social environment as a moderator between built environment and physical activity especially in china the interaction among various factors is still the least understood 21 given these considerations this paper aims to explore whether objective measures of neighborhood built environment are directly associated with indirectly associated with physical activity and health outcomes via the perceived environment and whether perceived environment is directly associated with physical activity and health outcomes all controlling for demographic characteristics and taking social environment as the moderator we conduct a series of mediation models to test the crosslevel relationships between the different aspects of built environment and physical activity the results provide an evidence base for community development in dalian china materials and methods study design and participants we conducted the survey in dalian situated in the northeast coastal area of china due to the hilly terrain more than half of the residential communities have different forms of the slope which may lead to obstacles in driving and walking in particular the average topographic elevation range in the study sample reached 40 m the study sample was drawn from the four urban districts including zhongshan xigang shahekou and ganjingzi districts which had approximately 2 million people and covered an area of 600 km 2 the neighborhood is defined as an area within a 1015 min walk from home the study sample was restricted to individuals aged 2264 that had lived in the neighborhood for at least one year university students aged 1822 were not eligible for this study because they tend to live on campus or study in other cities 8 participants also excluded the special age group like people over 65 owing to the different recommended amounts of physical activity to stay healthy 34 materials and methods study design and participants we conducted the survey in dalian situated in the northeast coastal area of china due to the hilly terrain more than half of the residential communities have different forms of the slope which may lead to obstacles in driving and walking in particular the average topographic elevation range in the study sample reached 40 m the study sample was drawn from the four urban districts including zhongshan xigang shahekou and ganjingzi districts which had approximately 2 million people and covered an area of 600 km 2 the neighborhood is defined as an area within a 1015 min walk from home the study sample was restricted to individuals aged 2264 that had lived in the neighborhood for at least one year university students aged 1822 were not eligible for this study because they tend to live on campus or study in other cities 8 participants also excluded the special age group like people over 65 owing to the different recommended amounts of physical activity to stay healthy 34 we developed an online survey that was completed by participants over a twomonth time frame between july and august 2018 the survey was advertised through weibo and wechat public accounts the online survey instrument consisted of four sections general sociodemographic characteristics individuals perceptions of their neighborhoods participation in physical activities and health outcomes in total 890 survey respondents started the online survey data cleaning was the key step to ensure the data quality of this paper including the elimination of missing values outliers and error values only 649 target samples had a particular time of physical activity and eligible dwelling address we developed an online survey that was completed by participants over a twomonth time frame between july and august 2018 the survey was advertised through weibo and wechat public accounts the online survey instrument consisted of four sections general sociodemographic characteristics individuals perceptions of their neighborhoods participation in physical activities and health outcomes in total 890 survey respondents started the online survey data cleaning was the key step to ensure the data quality of this paper including the elimination of missing values outliers and error values only 649 target samples had a particular time of physical activity and eligible dwelling address measures outcome assessment the dependent variables included frequency and duration of moderate and vigorous physical activity frequency and duration of walking and health outcomes the modified version of the international physical activity questionnaire short version was used to measure total walking and physical activity during the past 7 days participants were first asked whether they had participated in at least 10 min of walking moderate physical activity or vigorous physical activity over the past 7 days those who said yes to any of them continued with the questions questions included how many days they walk or do moderatevigorous physical activities and how much time they usually spent on one of those days doing activities response options ranged from 0 to ≥60 minweek further we multiplied activity frequency values by the midpoint of the range of hours reported for a given activity to calculate total physical activity time health outcomes contained both physical and mental aspects body mass index was calculated as weight divided by the square of height sense of community can be an indicator of social capital 35 sense of community had a decisive influence on mental health 36 and was also associated with walking 37 in this paper sense of community was the product of a fouritem likert scale combining two items into one scale including living in my neighborhood gives me a sense of community and i would be willing to work together with others on something to improve the living environment in my neighborhood additionally participants previous chronic disease were included in the questionnaire sociodemographic characteristics sociodemographic covariates were age gender educational attainment economiclevel and car ownership all sociodemographic characteristics were also considered as potential moderators we measures outcome assessment the dependent variables included frequency and duration of moderate and vigorous physical activity frequency and duration of walking and health outcomes the modified version of the international physical activity questionnaire short version was used to measure total walking and physical activity during the past 7 days participants were first asked whether they had participated in at least 10 min of walking moderate physical activity or vigorous physical activity over the past 7 days those who said yes to any of them continued with the questions questions included how many days they walk or do moderatevigorous physical activities and how much time they usually spent on one of those days doing activities response options ranged from 0 to ≥60 minweek further we multiplied activity frequency values by the midpoint of the range of hours reported for a given activity to calculate total physical activity time health outcomes contained both physical and mental aspects body mass index was calculated as weight divided by the square of height sense of community can be an indicator of social capital 35 sense of community had a decisive influence on mental health 36 and was also associated with walking 37 in this paper sense of community was the product of a fouritem likert scale combining two items into one scale including living in my neighborhood gives me a sense of community and i would be willing to work together with others on something to improve the living environment in my neighborhood additionally participants previous chronic disease were included in the questionnaire sociodemographic characteristics sociodemographic covariates were age gender educational attainment economiclevel and car ownership all sociodemographic characteristics were also considered as potential moderators we controlled for demographic covariates that may confound associations between neighborhood environment physical activity and health outcomes perceived neighborhood environment the abbreviated chinese version of the neighborhood environmental walkability survey was used to assess an individuals perceptions of hisher neighborhood that was determined to be valid and reliable in a chinese population 38 after translation newsa and the ipaq were tested for their reliability and validity participants were asked to evaluate their neighborhood by responding to statements concerning various environmental attributes the response format was a fourpoint scale ranging from strongly disagree to strongly agree negative items were reversecoded to match the remaining items which included the following traffic nearby streets steep streets major barriers separated sidewalks by parked cars or grassdirt strip in this study not all parts of the newsa questionnaire items were selected particularly items included those were conceptually comparable to the objective indicators and other aspects social environment factors were also added to the questionnaire including social interaction and social activities objective built environment we measured 10 built environments including land use mix density connectivity accessibility slope construction quality using geographic information systems software the landuse mix was represented by the frequency density of each land use unit land use mix is the most commonly used index land use mix degree can be calculated in three ways accessibility intensity and form 39 frequency density represented the quantity or density of specific destinations and the proportion of different land use within the study area the land use form identification was conducted through baidu poi data describing facility locations the poi data was divided into six types residential commercial and business facilities green space and plaza industrial administration and public service street and transportation depending on chinese land use classification 40 for each functional unit the index frequency density and category ratio was constructed to identify functional properties the calculation formula was as equations and f i n i n i c i f i 6 i1 f i × 100 i 1 2 6 where i stands for poi type n i indicates the number of poi of type i in the unit n i means the total number of poi of type i f i denotes the frequency density of poi of type i in the total number of poi of this type c i refers to the proportion of the frequency density of type i in all types of poi in the unit street connectivity was measured as the number of street intersections and road network density and the number of intersections based on road network data from esri street map intersection count was defined as the number of threeway or greater intersections within the buffer facility count was derived from the baidu poi which included data related to physical activity we assumed that these resources would be correlated with physical activity especially we used the standard deviation of the elevation within the buffer area to represent the variations of the slope with the data derived from google map additionally the average housing price and construction year were used to reflect the general construction quality of the residential unit derived from lianjia we created a 400m radius buffer around each geocoded home address generally most people prefer to walk within 400 m therefore 400 m has been used as the value of acceptable walking distance and features of buffers larger than 400 m have also been linked to walking 41 an individual will walk up to 1600 m to reach a destination but the most proper spatial context is unclear for understanding the relationship between the built environment and health 42 particularly under 400 m scale there were more built environment elements associated with the perceived environment and health results compared with other scales in authors other research accordingly we used 400 m as a radius to establish the buffer zone in this paper data were analyzed using arcgis 105 and process© v31 for spss®v240 statistical analysis data we adjusted the newsa scale to better reliability and validity first bartletts test of sphericity and kaisermeyerolkin factor analysis were performed on the data with the results fitting for factor analysis then we used the principal component analysis method to test validity accordingly we eliminated the items which by themselves created a component and did not load on the unrotated or initial component the deleted item was deadend streets after adjustment the overall reliability of the questionnaire items showed a value of 0806 and five common factors were identified however the five components dimension was not completely consistent with the original dimension in newsa scale next we made the related items in each component into one scale using the scoring system for newsa ultimately perceived neighborhood attributes included accessibility and street connectivity walking obstacles pedestrian environment aesthetics and safety we also calculated zscores of all independent variables for data standardization to be used in regression models besides logarithmic transformation of dependent variables were carried out due to its skewed distribution analysis the data analysis procedures were divided into three steps first oneway anova was used to differentiate the health outcomes and perceived neighborhood environment among different social parties second multiple logistic regression was used to examine the effects of different physical activity behaviors and health indicators on selfreported health outcomes third we used a fourstep mediation regression to analyze the effects of the built environment on physical activity and health outcomes this paper tested mediation with regression analysis in four steps we first and tested the correlations between objectivelyassessed environment variables and physical activities as well as taking the corresponding perceived environment attributes as the mediator variable this process can compare the relationship between the objective and perceived environment and examine the mediation effect we then examined mediation effects controlling for sociodemographic variables in step 2 if mediation effects were identified in step 1 y intercept b e y intercept 1 b 1 b 2 e 1 m ax e 2 y intercept 2 b 3 b 4 b 5 e 3 we took and the social environment variables as moderators for the significant independent variables in step 3 if no mediation effects were identified in the final step 4 of the analyses we regressed physical activity onto the built environment variables and conceptually comparable perceived environment attributes social environment variables and when appropriate the significant sociodemographic variables examined previously as comoderators y intercept 3 b 6 b 7 e 4 y intercept 4 b 8 b 9 b 10 e 5 y intercept 5 b 11 b 12 b 13 b 14 b 15 e 6 all regression models were constructed in three groups we first tested the mediation effect with the objectively assessed environment as the independent variable and physical activity as the dependent variable we then took the perceived environment attributes as the independent variable next we examined the health outcomes as the dependent variable if an effect was not moderated or mediated we removed the nonsignificant interaction term from the model we repeated this process until only statistically significant interaction terms remained we used bootstrap resampling with 95 biascorrected confidence intervals of the indirect effects for those independent variables with no significant coefficient we further explored their associations with the duration and frequency of the physical activity using ordinal logistic regression and nonlinear regression 5 we took and the social environment variables as moderators for the significant independent variables in step 3 if no mediation effects were identified in the final step 4 of the analyses we regressed physical activity onto the built environment variables and conceptually comparable perceived environment attributes social environment variables and when appropriate the significant sociodemographic variables examined previously as comoderators y intercept3 b6 b7 e4 y intercept4 b8 b9 b10 e5 y intercept5 b11 b12 b13 b14 b15 e6 all regression models were constructed in three groups we first tested the mediation effect with the objectively assessed environment as the independent variable and physical activity as the dependent variable we then took the perceived environment attributes as the independent variable next we examined the health outcomes as the dependent variable if an effect was not moderated or mediated we removed the nonsignificant interaction term from the model we repeated this process until only statistically significant interaction terms remained we used bootstrap resampling with 95 biascorrected confidence intervals of the indirect effects for those independent variables with no significant coefficient we further explored their associations with the duration and frequency of the physical activity using ordinal logistic regression and nonlinear regression 1 and and sociodemographic perceived environment and social environment as moderators and of the association between objective built environment and health outcomes the dashed lines and arrows also show the moderated mediation effect that is the potential moderators may influence the mediation effect 1 and and sociodemographic perceived environment and social environment as moderators and of the association between objective built environment and health outcomes the dashed lines and arrows also show the moderated mediation effect that is the potential moderators may influence the mediation effect results sociodemographic factors in general the overweight population was as high as 36 43 only 75 of the residents were obese lower than the national average 44 the discrepancy was likely due to the younger age of the online sample further oneway anova demonstrated statistically significant differences in health outcomes among individuals as shown in table 1 gender age education background and private car ownership all had significant effects on bmi among all participants 48 were men who had higher bmi than women and also higher than the normal level older respondents were more likely to have higher bmis which was in line with previous empirical findings 44 people with a high school degree or lower education level were overweight while gender age and private car ownership also had significant effects on physical activity additionally we tested the impact of sociodemographic groups on soc we found a bimodal relationship between income and soc with both higherand lowerincome respondents having higher soc compared to middleincome respondents additionally we found physical activity had impacts on selfreported health status namely that the mpa frequency duration and the total time of walking related to mental health status physical activity can somehow benefit the phycological aspect finally health indicators were significantly correlated with selfreported health status that is bmi was associated with hypertension and hyperglycemia and the soc had a relationship with mental subhealth we also found most of the residents were physically and mentally healthy but up to 19 chose mental subhealth this index was much higher than the common chronic diseases like cardiovascular cerebrovascular diseases and hypertension which showed that residents mental health was also worthy of attention objectively assessed environment table 2 summarizes the results of the regression model examining the impact of the objectively assessed environment and health outcomes we found four statistically significant independent variables land use mix street connectivity accessibility and net residential density land use mix and road network density was positively related to the duration of vpa additionally the number of public facilities had a positive effect on the total time of vpa but weak correlation coefficient besides number of public facilities was also positively related to walking time in contrast net residential density had a curvilinear correlation with mpa and the interpretation rate of the model was the highest among all built environment fitting models further density and connectivity were inversely associated with the sense of community density included building density and far and the impact of building density was relatively weak compared to far as for bmi the slope was the only indicator that had a significant negative impact however no significant relationships were observed between objective and perceived streetlevel terrain slopes the perceived and objectively measured neighborhood environment were related but distinctly constructed for unique variance in physical activity in the previous studies 45 similarly we found comparably defined variables exhibited low agreement between each other that is the number of facilities road network density and far had associations with the perceived neighborhood environment but not with the conceptual corresponding one more specifically the number of catering leisure facilities and public transit stops had associations with the social environment road network density and far were related to aesthetic and perceived social environment therefore in the mediation test only far was mediated by the social environment with sense of community however sociodemographic variables did not show any significant difference in mediation models perceived neighborhood environment sociodemographic attributes showed a significant difference in the perceived neighborhood environment men had a higher perceived neighborhood environment score than women especially in safety and aesthetics those with a high education background showed lower social interaction with neighbors additionally perceived neighborhood environment total score had a positive association with the social environment implying that residents who perceived higher scores on environment quality tended to have a stronger sense of community results of regression analysis about the perceived environment and health outcomes are summarized in table 3 only aesthetics and safety had a significant impact on physical activity aesthetics was positively related to both frequency and duration in mpa and more frequency in vpa which was mediated by the social environment additionally safety was related to the total time of vpa further perceived social environment mediated the associations of five out of six perceived neighborhood environment with sense of community namely connectivity accessibility aesthetic sidewalk and safety finally we found only connectivity among all the perceived neighborhood attributes was mediated by the social environment on bmi although income had no direct effect on bmi it moderated the effect between connectivity and social environment in the mediation effect discussion direct effect of environment density and connectivity were positively correlated to physical activity but the regression coefficient was weak even statistically significant which was in line with previous studies 46 we found road network density had a positive association with the duration of vpa and the number of intersections was correlated to mpa this was due to the compact land use that can reduce residents daily shopping distance enhance neighborhood commerce and thus promote residential walking 4 in contrast land use mix and connectivity had inverse impacts on sense of community implying that these two characters had more complicated associations between physical and mental health further the number of parks within the community was related to vpa as expected because parks in the neighborhood can facilitate engagement in leisuretime physical activity 47 in addition to the park this study added other service facilities that might encourage recreational physical activity 48 including gyms outdoor sports venues and fitness places which also showed positive associations rather recreational sports venues contributed to physical activity and were the only elements in the objectively assessed environment that were significantly related to the total time of physical activity potentially owing to the extension of the activity choice we additionally took topographic factors into account especially the hilly terrain terrain topography changes in the spatial variability is obvious within the research units however slope exhibited no significant associations with physical activity but negative associations with bmi that is respondents had lower bmi in areas with steeper slopes further no mediation or moderation effects were found between slope and bmi which needs further study on the associations between topography and health outcomes the evidence for the association between built environment and physical activities comes mainly from selfreported environmental perceptions 16 particularly we found aesthetics to play an essential role between built environment and physical activity factors contributing to aesthetic characteristics in our study included night lighting street trees pedestrians architectural aesthetics natural scenery and interesting things within the neighborhood furthermore traffic safety had no significant effect on physical activity but the impact of security safety was significant what we found was partly consistent with the literature was that not all aspects of safety have a significant impact on pa namely that security and traffic safety were sometimes not significant while the main effect of pedestrian safety was significant 25 objectively assessed environment and perceived environment were related that is a higher objective walkability score was associated with a higher perceived neighborhood environment score which in turn was associated with higher odds of meeting physical activity recommendations 20 however our results showed that only land use mix and construction year was significant albeit inconsistently correlated with perceived neighborhood environment score more specifically industrial frequency density had a negative association while the later had a positive impact which was consistent with the practical experience the newly built residential areas had relatively preferable environmental quality but the adjacent industries would discourage the perceptions of the environment indirect effect of environment previous studies have found that perceived neighborhood environment mediated the association between built environment and physical activity in particular the impact of the number of parks on physical activity was mediated by their perceptual corresponding environment the effects of intersections and land use mix on physical activity were moderated by gender and safety 19 additionally gender and educational background moderated the effect of perceived safety on physical activity 21 however our research found no mediation effect of perceived environment which was inconsistent with the existing evidence we found that the number of service facilities was the only objectively assessed environment element significantly related to their perceptually corresponding environment but there was no mediation effect although gender had a significant effect on both perceived safety and physical activity no interaction effect was found the possible explanation was that the news scale had a measurement error in a highdensity situation the research confirmed that the social environment in the highdensity living environment had important significance in promoting physical activity and sense of community sense of community can promote peoples awareness of safety comfort and selfconfidence thereby stimulating positive physical activities in the community and increasing opportunities for social interaction 49 previous study found that low density and abundant commercial land were conducive to sense of community which can promote leisure activities 37 likewise our findings identified a significant positive impact of sense of community on all types of activities however high density negatively affected the sense of community that might be owing the cramped feelings and lack of green space resulted by high density which were key barriers to facilitate social interactions additionally residents with positive perceptions of their neighborhood characters have a better social network well maintained social relationships contribute to the cultivation of sense of community which is beneficial to both physical and mental health strengths and limitations there are several strengths and limitations to our study although great achievements have been made in the study of the built environment and physical activity in the past decades there is not much research on the highdensity environment in china 50 51 52 the built environment we identified significantly associated with physical activity supported previous studies findings 91013 and also provided further evidence on chinese urban environment we found that both objective and subjective environment were positively related to physical activity which is in line with the literature but density and connectivity had inverse impacts on sense of community the study focused on the social environment as the main moderating variable finding that the social environment had essential significance for physical activity and health outcomes we confirmed the importance of social environment in the highdensity living environment in promoting physical and mental health however there were still limitations first the study controlled for individual characteristics but did not provide specific analysis of behavioral differences among population groups therefore it would be useful for future studies to distinguish between different demographic groups in the neighborhood with hilly terrain second we only used the buffer method to define neighborhood boundary and made no distinction between the cognitive distance in the questionnaire and the actual buffer distance which may result in the mismatch between objective and perceived environment finally the demography of the respondents obtained through the internet survey tended to be younger than the local demography and the neighborhood selfselection bias of the respondents remained unresolved additionally the sample size was limited to an acceptable range of errors due to the difficulty in data collection however the study limited the study population within the central districts and focused on those who had convenient access to public social media such as whitecollar adults in urban centers the sampling design and data cleaning process also alleviated the concerns related to sampling error in chinas nonfirsttier cities citylevel data from authoritative databases is not rich and difficult to obtain publicly especially those related to personal information and health for a more comprehensive understanding of the relationship between highdensity living environment and health in china this needs to be further explored conclusions in general this study demonstrated that both objective and perceived environment factors had significant impacts on physical and mental health in dalian the association of density connectivity the availability of service facilities neighborhood quality with physical activity andor walking which has been found to be linked in research in firsttier cities also holds true in dalian especially we found that aesthetics and safety play an essential role between built environment and physical activity this research provides new insights that high density facilitated engagement in physical activity but hindered the sense of community which also had influences with physical activity additionally the objectively measured slope was related to bmi residents living in the neighborhood with more steep slopes had lower bmi indicating that the design of slope might be influential given the complexity of density in chinese neigborhoods especially with hilly terrain we suggest that future work of this nature might aim to identify to what extent density can facilitate both physical and mental health this study is also part of an evidence base that social environment is of equal importance compared to built environment which needs to be well established by local officials or developers in chinese communities author contributions conceptualization ps wl methodology and formal analysis ps ys investigation data curation and writing ps review and editing zg appendix a other chinese cities land use mix 9 accessibility 10 neighborhood quality 6 design features and safety 53 density ingle function adjacent main road 9 western countries land use mix density connectivity accessibility pedestrian infrastructure parkssquares 12 13 14 15 coastshillssceneries wellmaintained neighborhoods aesthetics and safety 54 city sprawl unpleasant vistas illmaintained roads and facilities dirty environment garbage broken glass 54 perceived number of parks parks on physical activity 19 gender and safety intersections and land use mix on physical activity 19 gender and education safety on physical activity 21

neighborhood built environment may influence residents physical activity but evidence of nonmajor chinese cities is lacking we investigated the impact of five sociodemographic characteristics 10 objectively assessed environment characteristics eight perceived neighborhood attributes and social environment on physical activity and health outcomes sense of community body mass index as well as selfreported health status we also examined 1 five conceptually comparable perceived neighborhood attributes as mediators of the relationship between objective environment attributes and physical activity 2 other perceived indicators and social environment as moderators of those relationships using the mediation analysis in regression objectively assessed residential density land use mix street connectivity and accessibility were curvilinearly andor linearly related to physical activity the slope of terrain was inversely associated with body mass index bmi none of the perceived attributes were found as mediators probably due to the weak associations between subjective and objective environments high density facilitated physical activity but hindered the sense of community further the perceived aesthetic and safety were associated with physical activity additionally social environment moderated the positive associations of all perceived environments except for slope and sense of community the present study demonstrated that both physical and social environment attributes significantly correlated with physical activity in dalian

background providing costeffective care for the increasing numbers of complex elderly andor comorbid patients is a global problem facing industrialized and nonindustrialized nations 1 with an aging population and individuals living longer lives healthcare costs continue to rise at rates faster than other parts of the economy 2 in response payers have sought to contain spending growth through healthcare rationing and efficiency gains exacerbating these challenges are the growing numbers of individuals with chronic disease and multimorbidities a proportion of who develop complex health conditions for example in ontario one study estimated that complex patients constitute 1 of the provinces 137 million people but accounted for 34 of ontario health care expenditures 3 similar research has identified the same trend from the united states 4 and the united kingdom and europe 5 costs associated with managing complex care patients have generated a growing sense of urgency due to the increasing emphasis on accountability the sustainability of health care and pressures posed by population aging in many jurisdictions across canada governments have launched priority initiatives to improve the care costs of complex patients these initiatives have been based on the assumption that improved coordination will lead to faster care at reduced costs 6 often these initiatives have called for researchers to develop innovative models that are both patientcentred and cost effective moreover in canada as well as in many other countries one of the main problems identified in the care of complex patients is poor coordination of services 1 poor coordination of services has been described as impeding both good care and efficient use of health care dollars it has been estimated that in the province of ontario better integration of care would result in savings of 4 to 6 billion per year from reductions in redundant services improved coordination and provision of more appropriate services 2 at the same time that ministries of health health services researchers and media are recommending costsaving measures and creation of new and innovative models of care those working in social science have been questioning the nature and framing of these public policy debates many have challenged the hidden assumptions underlying the import and application of performance measurement and accountability principles developed in business settings into health care settings 7 8 9 and have sought to draw attention to the implications of the resultant discourses that are shaping public policy debates they have for example challenged the virtual realities created by systems of accounting based on administrative databases 7 8 9 that produce this notion of high users of health care resources cited above nevertheless these debates are often not wellintegrated into mainstream conversations about health policy and practice 10 in this context our study builds on an innovative canadian institutes of health research funded research program that uses a social science lens through which to view the organization of the care of patients with chronic osteoarthritis pain many of whom have multiple comorbidities 11 it is clear that that there is a need for such research as this is where the majority of patient care takes place and is seen as a key determinant in complex patients need for care 12 moreover this research also seeks to explore how other stakeholders are involved in coordination of care not as separate objects of study but as part of the same patient care system this will be accomplished by speaking with primary care physicians and asking them to describe both what they do and who else is involved in the care they deliver to patients with multimorbidities and chronic pain complex patients are the focus of much debate and concern in the contemporary healthcare context they are defined as those who have more than one of the following five major chronic conditions arthritis diabetes heart disease chronic lower respiratory tract disease and stroke 13 patients with these chronic conditions may also suffer from mental health problems or addictions 13 multimorbidity is even more important as each condition may influence the care of the other condition result in interactions between therapies andor direct contraindications to therapy and thereby limit life expectancy 14 at the patient level multimorbidity has been found to affect quality of life ability to work disability and mortality 15 in addition the process of navigating care across different specialists is burdensome for patients 16 and is a patient safety issue 3 our previous work in patients with osteoarthritis pain suggests discordance between the policy goals of improving patient care and the experience of patients 1718 arthritis specifically oa is one of the most common disabling and costly chronic diseases 19 20 21 it is a degenerative joint disease that most commonly affects the knees hips hands and spine and is characterized by a slow evolution of symptoms and disability over time 22 23 24 arthritis is the most frequent cause of chronic pain which is debilitating to the individual and extremely costly to society primary care is most often the first contact for people seeking symptom relief truly interprofessional care is necessary to provide appropriate evidencebased pain management and selfmanagement support for these patients who are seeking appropriate strategies to ameliorate and limit progression of their chronic pain and resultant disability yet achieving successful ipc often remains an elusive goal in practice 25 several research gaps have been identified in relation to primary care in musculoskeletal care including oa 26 these include wellknown issues such as a lack of comprehensive management that includes exercise and weight loss strategies 27 a focus on other chronic conditions or comorbidities that may be considered more urgent 2829 and low referrals rates to both physiotherapy and total joint arthroplasty 29 there are also ongoing controversies associated with the use of opioid medication to manage pain and concerns with possible medication dependence misuse and addiction 30 31 32 finally at the patient level there are many socioeconomic factors that influence helpseeking referral and treatment with some patients falling through the cracks 33 however despite our knowledge of these various gaps what remains unknown are strategies or models of care that while rooted in primary carethe medical home for most patients 34 are coordinated effectively with other care providers policymakers patients and their families and offer the benefits of ipc primary care is the context for most oa education and management the role of context in health care has been increasingly recognized as important at the local level 35 however context is often described in abstract terms and may refer only to a description of geography or place 36 the need to investigate the empirical context of the primary care setting not as it exists in isolation or in the abstract but as it pertains to other providers in the patient journey is critical in order to improve patient care of oa pain management this will allow for an exploration of how primary health care isor could be betterintegrated with other services that play an important role in health such as housing education and income the patientcentred medical home has been introduced as a chronic care model that can reduce costs 37 it emphasizes the need for care management to be based in primary care and has become increasingly important in canada as well as internationally 38 several studies of care management in primary care show convincing evidence of improving quality 39 40 41 42 43 44 45 these studies measured a variety of quality outcomes including patient satisfaction functional ability capacity to perform basic activities of daily living mortality bed disability days and overall quality of life the results of care management studies in primary care are mixed regarding reductions in hospital use and healthcare costs all of these studies enrolled patients with multiple chronic conditions who were at high or moderate risk of incurring major health care costs each program placed substantial emphasis on training the care manager team keeping care manager panel sizes at reasonable levels forging a close relationship between care managers and primary care physicians and including care manager interactions with patients inclinic and at home by telephone this study will employ the approach of institutional ethnography to investigate how primary care physicians define encounter and manage complex patients who experience chronic pain our overarching research question is how do primary care physicians describe the work they do in caring for patients with complex chronic pain conditions this question will become our starting point rather than the end point to allow our team to explicate how care is put together at the level of the institution with attention to how care is coordinated in local practice using an expanded definition of work will allow us to understand the many types of work that physicians do and also alerts us to how the discourses and concerns of institutions enter into the everyday language of care providers this will achieve the following specific objectives 1 describe carefully and empirically the work that goes into caring for complex patients with chronic pain and multimorbidities beginning from the standpoint of primary care physicians and working outward to capture the often invisible social relations informing patient care 2 follow in each setting the textual informal and formal practices implemented by the providers as their work is coordinated with that of others in different settings this will create a map of the social relations of primary care provision of oa chronic pain management that includes the perspectives of all key stakeholders and will allow for the creationaugmentation of new models of care that are effective efficient and sustainable ultimately improving the patients experience of care 3 provide a link between everyday experience to broader discourses related to health care system inefficiencies integration and patientcentred care these links will be the mechanism by which findings from our work can be replicated and applied to other provinces and internationally methods institutional ethnography was developed by sociologist dorothy smith 46 47 48 49 50 according to smith the social strategy she developed is constrained by the project of creating a way of seeing from where we actually live in the powers processes and relations that organize and determine the everyday context of that seeing 50 ie refers to an approach to inquiry rather than a set of methods it uses peoples everyday experiences as the starting point for an exploration of the often invisible social relations that underpin or organize their experiences 47 48 49 50 based on smiths understanding of the social organization of knowledge it allows for an examination of the complex social relations organizing peoples experiences of their everyday working lives ie makes use of several types of data typically including interviews observations and texts however ie studies may differ in the extent to which they employ the various data collection strategies 50 in this study we will rely on interviews and texts and also observations when possible ethics approval for this study was obtained through the university of toronto research ethics board sampling and recruitment year one understanding the social world requires taking up a specific position as a starting point from which to begin to explore how things are put together the way that they are 50 in this sense ie is sampling an institutional process rather than a population all qualitative sampling is purposive rather than experimental and there are multiple purposive sampling techniques 55 the goal is not to be representative of the broader population but rather to understand a phenomenon or process indepth in practical terms our study will include any primary care physicians working in community and academic hospitals and in any type of primary care organization such as family health teams solo practice and community health centres we will purposively select family physicians from each type of practice model within 4 local health integrated networks one northern one southwestern one downtown toronto and one eastern and within each we will select academic and community hospitals participants will initially be identified through members of our team who in turn are linked to other collaborators across different sites as we embark on our study following reb approval the principal investigator will send out an email with a letter of information and a consent form requesting that the recipient participate in an interview in a location of their choosing and at a date and time convenient to them at the conclusion of each interview participants will be asked to suggest other potential participants whom they identify as being involved in the coordination of their working lives in an ie study sampling while purposive does not follow standard strategies such as maximum variation or theoretical sampling 55 the identification of research sites informants and texts cannot be predetermined but proceeds through the process of inquiry 53 for example primary care physicians refer patients for joint replacement surgery and then care for them postsurgery we might therefore speak to those involved in the referral and repatriation process including orthopedic surgeons and pharmacists this is known as snowball sampling 55 ie researchers follow sequences of action with one informants interview leading the way to the next or to a text for analysis first level data collection interviews we estimate that we will conduct approximately 80 interviews over 18 months estimates of qualitative interviews are classically difficult to determine prior to entering the field given the exploratory nature of the ie approach therefore our estimate is based on presupposing that at a minimum we might interview 5 primary care physicians across 4 different sites andor settings we may interview a greater or lesser number of these participants depending on what they share with us we might interview the same informant twice and may also interview others who we have yet to identify as playing a key role in the social coordination of chronic pain management in addition and as previously noted ie researchers look for something outside of the experiences of key informants which is largely invisible to them and yet that enters into and coordinates their work with those of others of whom they ma y not even be aware exploring relations beyond primary care physicians experience means learning from others who work in related settings hence we will also interview other health care providers policymakers and patients and their family members these interviews will take place in a location that is convenient for the participants and formal written consent will be obtained the content of our indepth interviews will be guided by an emphasis on the actual work that people perform most researchbased descriptions of physician decisionmaking are abstract accounts that are not connected to the actual work they engage in 34 or refer to individual psychological explanations for physician behavior 123536 this concept of work and of work knowledge is what the ethnographer draws on in talking to informants and will comprise the content of the interviews this also opens the possibility of exploring informal aspects of work that are rarely accounted for in professional practice guidelines and of analyzing the role of texts and writing in the work physicians and policymakers perform analysis the procedural steps involved in analyzing data are similar to that practiced in other qualitative research approaches data is transcribed and coded so that it can be analyzed codes identify features of the data that are pertinent to the research questions and organize data into more concise ideas that can be eventually grouped into topics they are often recurrent keywords or concepts that are supported by interview data coding of the first few transcripts will be performed by the pi the interviewer and another member of the research team multiple coding is a useful way of developing reflexivity rather than a tool to confirm the truth of the data 57 reflexivity used in this way refers to the process by which we critically examine our own assumptions about the world 57 through comparison of our developing understanding of the transcript data each member of the coding team has an opportunity to check their own assumptions and ideas the closest equivalent for this type of analytic technique would be thematic analysis 5859 however codes as they are used in ie are not used to develop themes but will reflect our analytic interest in explicating how the work that is performed by an actor in one situation is coordinated extralocally finally we will also hold team meetings in which we will discuss and reflect on our emerging understanding of what is being described the thoughts and comments that result from all meetings will be recorded as extensive marginal notes throughout the interviewing transcription and coding phases with the goal of focusing thoughts around the emerging concepts these meeting notes also become part of the audit trail in which the team keeps careful track of all interpretative and theoretical decisions that are made about the phenomena being studied secondlevel data collection year two text and discourse analysis through interviews and also drawing on our own institutional knowledge our team will identify a series of texts and discourses that are present in the language of participants as they describe their everyday work practices in caring for complex patients texts refer to any document that has a fixed and replicable character and includes any documents that can be become distributed and subsequently used by users in different places and at different points in time texts are activated when they are read completed or filled in higher order texts 52 are those that are not often visible in local settings but become active in the actual settings of peoples work an example of this would be the wait times strategy these higher order texts do not rule by prescription but by establishing the concepts and categories of which what is done can be recognized as an instance of expression of the textually authorized procedure 54 texts then both standardize and mediate social relations 52 our interview data will be analyzed for clues that point us to texts which may help us explain organizational details missing from experiential accounts the genre of text that participants identify cannot be predetermined but may include policy documents related to different sectors such as education or health or clinical documents such as care pathways for example an interviewee may make passing mention of filling out form x in order to accomplish y which we would then follow up by tracking down form x and any associated governing policies 38 tracking a document across various sites helps to create a social map of the various work processes involved in coordinating a particular model of care the documents we seek will be publicly available texts we will assemble the various documents that may play a role in care coordination between primary care physicians and other professionals and across sites in order to better understand the individual accounts being provided to us our preliminary work has led us to identify the several key documents as being central to our analysis but others will be added during the course of our interview textual analysis will also include analyses of relevant discourses our use of the term discourse draws on the idea that language is active that is it has a constitutive function as well as a descriptive one 46 in our work we will analyze the use of several terms in everyday language used by physicians other clinicians and policymakers in order to better ask what is left out by the use of these terms who benefits from these terms what is rendered invisible explicating a social process year three in the third year of our study we will begin the process of mapping the social relations informing care in many research traditions this is described as triangulation the key difference however between a positivist use of the term triangulation and most critical qualitative research approaches is that the purpose of the activity is not to validate a truth claim but rather to extend our understanding of a phenomenon starting with insights gained from interviews we will identify active texts to discover how these texts are used in the work of primary care physicians and that coordinate this work with the work of others in different settings we will also be mapping how the consciousness of individuals is coordinated with those of others for example how do the discourses of efficiency integration and patientcentered care enter the talk of primary care physicians when they are describing their ever yday work caring for complex patients with oa pain does these terms map to a higher order text data management and steps to ensure quality all interviews will be audiotaped and transcribed transcripts will be entered in nvivo software program for data management it should be noted however that while nvivo is useful for managing large qualitative data it does not perform analysisthis will be undertaken by the researchers quality in qualitative research is evaluated differently from the criteria used in quantitative studies while this is an area of some controversy a number of strategies will be employed to enhance the trustworthiness of the findings 54 55 56 including recursive questioning during the interviews and audit trails in much research the researchers presence is treated as a bias that must be overcome 52 as smith 51 notes an ie does not rely on notions of objectivity in order to produce validity however it does strive to produce accounts that are accurate representations of how things actually work smith stresses the importance of remaining faithful to the accounts provided by people of their lived experience while going beyond that experience to explicate how that experience happened as it did 51 with this in mind most qualitative researchers speak of authenticity and reflexivity as central to the goal of getting it right we will make good use of the multidisciplinary nature of our team to enhance our reflexivity as the diversity of our group will provide many opportunities to challenge our own and others assumptions as we proceed through the stages of data collection and analysis discussion the underdevelopment of relationships between sociology and other disciplines as well as between healthcare organizations has been long noted 10 yet there is growing recognition of the potential and need for research that brings together perspectives from a range of disciplines 46 for example current knowledge translation frameworks and empirical research in implementation science 34 cite context as the critical consideration in the effective integration of research evidence into practice however there remains a dearth of knowledge about how to define measure or engage with context 47 on the other hand the notion of situated knowledge is common amongst many sociological traditions and is well described used and applied 48 it is our belief that context and situated knowledge may well be referring to the same phenomenon in order to empirically study situated knowledge we may thus borrow from sociological research traditions studying the health care institution as it is experienced at the level of peoples everyday work means being able to see it in motion 9 and to explore how various texts and competing discourses inform our understanding of the increasingly complex healthcare environment through their work ie researchers are helping to redefine the problems rethink the questions and design and conduct studies that explicate how things actually work in practice 9 conclusion few studies have been able to adequately capture or address the complexity of the care environment in which primary care operates in relation to many other specialties diseases and diverse patient populations our study is novel in that it aims to ground itself in a particular standpoint not to focus on individual subjective experiences or meaning but to begin to locate the social coordination of the work of primary care physicians as it is provided in and across both community and academic health care settings based on primary care physicians responses we will begin to identify the various other provider groups involved in patient care delivery for complex patients both directly and indirectly and during a second wave of interviews we will speak to them this will allow us to identify how the work of coordinating care across multiple settings is accomplished in practice as well as discursively and textually focusing on patients with chronic oa pain will allow us to be specific in our questions while building on our previous work with chronic pain patients further it renders our study manageable in a sense the oa patients will provide the case study for our exploration however as in keeping with the exploratory nature of this approach we will remain attentive and open to physician accounts of other complex patient groups our goal is to map an institutional process of providing care that may be similar and therefore useful across many disease groups our study is poised to make a significant contribution to our understanding of interdisciplinary interprofessional and communitybased partnerships an expected outcome of this study will be the development of new or augmentation of existing models of care that are based in the local realities of primary care practice trial status we are currently in year one of this project key informant interviews have been conducted and transcribed but have not yet been analyzed competing interests the authors declare that they have no competing interests authors information

background patients with chronic conditions and multiple comorbidities represent a growing challenge for health care globally improved coordination of care is considered essential for providing more effective and costefficient care for these patients with complex needs osteoarthritis is one of the most common and debilitating chronic conditions is the most frequent cause of chronic pain yet osteoarthritis care is often poorlycoordinated primary care is usually the first contact for patients requiring relief from chronic pain our previous work suggests discordance between the policy goals of improving patient care and the experience of osteoarthritis patients we plan to investigate the empirical context of the primary care setting by focusing on primary physicians conceptualizations and performance of their work in treating complex patients with chronic pain this will allow for an exploration of how primary health care isor could beintegrated with other services that play an important role in health care delivery methods our study is an institutional ethnography of pain management in family medicine to be carried out in three phases over 3 years from 201415 to 2018 over the first year we will undertake approximately 80 key informant interviews with primary care physicians other health care providers policymakers and clinical experts in the second year we will focus on mobilizing our networks from year one to assist in the collection of key texts which shape the current context of care these texts will be analyzed by the research team in the final year of the study we will focus on synthesizing our findings in order to map the social relations informing care as is standard and optimal in qualitative research analysis will be concurrent with data collection discussion our study will allow us to identify how the work of coordinating care across multiple settings is accomplished in practice as well as discursively and textually ultimately we will identify links between everyday experience of care for patients with chronic pain and broader discourses related to health care system inefficiencies integration and patientcentred care an expected outcome of this study will be the development of new or augmentation of existing models of care that are based in the local realities of primary care practice

background since the declaration of millennium development goals there has been an increased attention on womens health in healthcare research and policymaking as a key indicator of international development mdg 5 was dedicated to the reduction of the maternal mortality rate by 75 by 2015 however progress towards achievement of this goal has been inadequate a mere 34 decline since 1990 and yet uneven across different world regions 1 according to who the developing countries especially those in sub saharan africa and asia share a discriminate burden of maternal mortality which remains the second largest cause of mortality among women of reproductive age in these countries with about 85 of global population developing countries altogether account for about 99 all maternal mortality cases 2 moreover about 97 of all unsafe abortions occur in lmics which contributes to about 15 of total maternal mortality in these countries 3 statistics on the utilisation of maternal health services is equally disheartening in the developed world about 98 women receive adequate number of anc services and skilled birth attendants supervising 94 of the deliveries 4 in the lmics in contrast about half of all women remain deprived of adequate anc services 5 two broad perspectives from which researchers attempt to explain this stark difference include the efficacy of healthcare systems such as quality access and infrastructural barriers 67 and proximate determinants such as economic gender health behaviour and sociocultural barriers 89 among the themes that commonly emerge in the sociocultural context of reproductive health violence against women 10 and male involvement 11 have been two very important and challenging ones in this study we focus on male involvement and aim to explore the factors associative factors among men in bangladesh the issue of male involvement in reproductive care was first pronounced officially in a conference on population development in cairo held in 1994 1 since then the number of empirical studies and demand for contextual evidence on sexual and reproductive health seeking behaviour and their determinants have also grown considerably research evidence from other south asian countries suggests that mens involvement in womens reproductive care has a crucial role to play to increase the uptake of maternal health services and reduce maternal and infant mortality 12 13 14 reproductive health seeking behaviour of an individual has shown to be a psychological construct affected by various proximalindividual 121415 and distalsocial influences 1617 there is also lot to accomplish especially in the areas of universal access to reproductive health services increasing the rate of institutional delivery and adoption of family planning which have shown to be more effective in active presence of male counterparts 1518 in addition to the rate of utilisation of maternal healthcare service male participation is also positively associated with pregnancy outcomes prior studies have shown that male involvement was significantly associated with reduced odds of postpartum depression and improved utilisation of maternal health services 6 in the predominantly patriarchal society as seen across the south asian region women in bangladesh are generally dependent on male counterparts for making decisions on matters as general as their own and childrens healthcare household purchases and visiting relatives 15 being faced with household power imbalance and having minimized control over resources would generally necessitate for even greater involvement of men in womens health issues apart from that the longstanding sociocultural view on sexual and reproductive health is directed in a way that negatively affects reproductive health communication between partners and understanding each others positions regarding such matters 1920 the depth of perception of reproductive health needs among men and women and their srh seeking behavior are strongly influenced by the established meanings of reproduction embedded in the society in which they live 21 in a qualitative study conducted on a group of bangladeshi men participants reported feeling uneasy to discuss reproductive health and stds related issues with their wives accompany them to healthcare centres and avoided dealing with reproductive health related complications with service providers 20 similar studies conducted in other countries have suggested indepth population based studies to explore the underlying causes of inadequate participation of men in reproductive health however studies on this topic in the context of bangladesh is remarkably scare to this end we conducted this research with the intention to enrich the literature and facilitate policy making aimed at promoting male involvement in maternal health in the country methods data source study area and sampling procedure we used the sixth round of bangladesh demographic and health survey data for this study the data is nationally representative crosssectional in nature and carried out in 2011 from july 8 through december 27 data were sourced from the official website of dhs the national institute of population research and training a renowned health research organization in bangladesh 22 conducted the survey the survey is a part of the international demographic and health survey program known as measure dhs which is currently active in about 90 countries and conducted under the auspices of the united state agency for international development and technical assistance of icf international of calverton based in usa the survey employed a twostage cluster sampling method covering the population residing in noninstitutional settings in bangladesh the twostage clustering of the population involved labelling the smallest administrative units as enumeration areas or clusters each consisting of households at mouza or mohalla level firstly selecting eas based on their size proportional to that of the units secondly by selecting household systematically from each ea to ensure effective sampling bdhs 2011 selected 600 eas however only one third were selected for men sample in total 4343 men were found eligible for the survey among which 3997 were finally surveyed more details regarding ethics protocol on biomarkers used in demographic and health surveys are available at subjects study subjects were male participants ageing between 15 and 69 years in total 1196 men were finally included in the analysis variables level of activeness of male involvement in reproductive care was the response variable in this study in order to select the potentially relevant covariates in the context of male involvement in reproductive health an extensive literature review was conducted surrounding the most proximal themes demographic and socioeconomic factors and media use status 2324 secondly based on the availability of variables in the dataset the following items were selected for analysis age type of residency religion educational attainment type of occupation level of earning sex of household head number of members in the household interaction with chws and in community health events and media use measurements male participation was measured based on answers to a composite scoring on three items knowledge awareness and practice each correctpositive answer was assigned score 1 and 0 if incorrectnegative total score ranged from 0 to12 based on the contrast between individual scores and population mean scores male involvement were dichotomized as active and passive 23 age was trichotomised into 3 groups 1529 years 3044years and 4564years place of residency was categorized as rural and urban religion was categorized into islam 1 and others 0 educational attainment of participants were categorized into three groups based on the total number of years of receiving formal education 0 nil 1 primary 3 secondary higher type of occupation was categorized in the following way 1 farming farmer agricultural worker fisherman poultry farmer cattle raising 2 blue collar jobs carpenter mason driver construction worker rickshaw puller brick breaking road building 3 white collar jobs businessman physician lawyer accountant teacher government service holder utilization of paper and electronic media has been shown to be associated with reproductive health behaviour this study included three types of media use tv listening radio newspaper and was dichotomized flowingly 0 not using at all 1 using occasionally regularly statistical analysis the first step in the data analysis was descriptive statistics percentages of study population across the independent variables were calculated cross tabulation was performed to identify the independent variables of significant association with the level of male participation significance of associations was estimated by χ 2 test only the variables which showed statistical significance in χ 2 test were retained for regression analysis all the explanatory variables were entered simultaneously into the regression model data were adjusted for sampling weight and for clustering effects we performed intraclass correlation analysis prior to choosing appropriate regression model as icc value was found insignificant multiple regression method was performed finally we conducted binary regression analysis to sort out the variables which significantly impacted male participation status in reproductive care 2526 results of the regression analysis were reported in terms of pvalues odds ratios and 95 confidence intervals pvalue less than 005 was considered statistically significance in all cases all analyses were performed using spss version 200 for mac results table 1 shows the frequency and percentage of correct answers by participants regarding reproductive issues majority of the men had correct knowledge about requirement of food and necessity of checkup during pregnancy only 23 of the men knew the correct timing of first checkup during pregnancy regarding contraception almost half the men were of opinion that reproduction is womens issue and does not concern men almost half of the men said that they did not have any idea whether or not wife visited any health facility or was visited by a medical person however 702 of them knew if wife received antenatal checkup for during pregnancy about onethird of the participants reported being present during visit by a medical person and 712 present during delivery of the last child 556 men discussed about medical persons with wife and about onethird communicated with medical persons himself baseline information regarding the study population table 2 outlines the basic characteristics of the study population about onethird of the participants belonged to the age group of 3044 years and more than three fifths were of rural origin 889 of the sample population were muslim which is almost the same as observed at country level almost twothird of the participants completed secondary school while onefifth received no formal education 281 of the sample consisted of farming population proportion of both blueand whitecollar professionals were more onethird of the total sample population however only 121 of the total sample reported earning sufficient income to support family more than a quarter of the sample reported having insufficient income level almost all the participants were from maleheaded households and more half of had 58 members about half of the total participants reported having the habit of reading newspaper percentage of respondents watching tv and listening to radio were 92 and 163 respectively only about a quarter of the subjects reported ever hearing about family planning among the three media of information regarding family planning included in this study poster billboard and leaflet combined were the most popular compared to community health workers and community events almost all the explanatory variables were found be significantly associated with the level of involvement in reproductive healthcare and were retained for final regression analysis mean score was of male involvement 57 ± 22 the results show that only 40 of the participants were actively involved in womens reproductive matters the variables which were excluded from regression analysis are age religion number of household members and utilisation of radio factors associated with active involvement of men in womens reproductive health matters table 4 shows that male involvement was significantly associated with type of residency level of education reading newspaper and learning about fp from community health workers type of occupation sex of household head watching tv listening to radio learning about fp from community activities were not significantly associated with active involvement results illustrate that participants with formal education were more likely to have active participation in reproductive care compared to those with no education men who read newspaper were twice as likely to have active involvement though learning about fp from community events and posterbillboard media were found be to be associated with male involvement in chisquare test it showed no significant impact in regression analysis however odds of active involvement were also twofold among men who learned about fp form chws discussion and policy recommendations results of this study showed that only 40 of the men had active involvement in reproductive care and knowledge and awareness regarding reproductive health was remarkably low though most participants knew that women need institutional care during pregnancy knowledge about timing for pregnancy checkup contraception and awareness about utilisation of mhs by wife and rate of physical presence in service utilisation was meagre this result is not surprising given the result that onefifth of the participants had no formal education and only 145 attained secondary or higher level education previous studies have reflected on the importance of husbands education on positive reproductive health behaviour 112227 poor knowledge concerning srh is also shown to be associated inadequate communication about reproductive matters among family members and grow a virtual barrier for crossgender cooperation thereby 28 conversely better communication on srh has positive impacts on reproductive health awareness 29 findings of our study suggest that literacy has a crucial role to play in ensuring male involvement in reproductive care which is consistent with prior studies conducted in other south asian countries 273031 in bangladesh the reserved view towards srh matters exist largely because there is not enough political incentive and civil society motivation to create room for the subject in the tradition health belief systems programs aimed at promoting male participation in reproductive must focus on systematically addressing the social barriers in a culture friendly way to ensure effectiveness and longterm success type of residency also appeared to be a significant determinant of male involvement in reproductive care the urbanrural divide regarding reproductive health behaviour is explainable by the fact that people in urban areas tend to have higher literacy and socioeconomic status enjoy better access to healthcare service and receives greater media exposure all of which are likely to improve health behaviour in general 3233 in our study men who reported having the habit of reading newspaper occasionally or regularly had higher participation in reproductive care therefore newspaper coverage of reproductive health information is likely to generate potential benefits however unexpectedly we didnt find any association between electronic media exposure such as tv and radio this may be due to the increasing number of mobile phone subscribers rapid expansion of internet and social networking sites which made the traditional media less interesting especially among urban residents despite that tv and radio programs remain a source of entertainment and pastime for many in china watching television was found to be strongly associated with adoption of modern contraceptive methods and the number of children desired 33 as the population in bangladesh is predominantly rural the media sector should take innovative actions to design tvradio entertainments more interesting and effective by incorporating health messages into age specific programs to encourage positive attitude towards reproductive health another important contribution of our study is that it found a positive correlation between communication with chws about fp programs and male involvement in reproductive care in bangladesh chws occupy a crucial position in the continuum of healthcare providers especially in remote areas as the country faces huge human resource deficit in healthcare and poses challenges to meet the population health needs 34 involvement of chws has proven the potential for costeffective services in areas as critical as maternal and neonatal care 35 and dots for tuberculosis 36 however their potential remains far from being fully developed and exploited especially in the domain of reproductive care services apart from providing direct healthcare services chws can play a vital role in implementing strategies for changing attitude towards reproductive health in both men and women feeing of confusion and embarrassment in physicianpatient communication is a common thing while discussing confidential matters among young patients chws can bridge the gap substantially since they are usually recruited from the same environment as they already have some degree of understanding and intimacy with the local populace people have the advantage of expressing themselves more easily and thus creating the climate for positive attitude and behaviour towards reproductive health 29 results also indicate that men who learned about fp from chws are more likely to be involved in reproductive care which is consistent with the prior studies showing the association between srh education and positive attitude towards reproductive health behaviour 2037 bangladesh government has made several programmatic efforts to enhance communitybased educational intervention programs to promote maternal and infant health however such programs to enhance reproductive health knowledge would require a different approach to ensure participation of both men and women educational programs targeting womens health education were found to be effective in improving their knowledge besides its contribution to the current literature this study has few mentionworthy limitations firstly we used secondary data which meant that we had no control in selecting the variables and the way they were measured secondly male involvement was measured in terms of performance on knowledge awareness and practice levels which are subjective matters and prone to misreporting by the participant and hence may not represent the actual scenario the dhs survey was conducted in 2011 and prevalence of several factors might have changed since then conclusions the factors that can influence the degree male participation in reproductive care can vary according to the sociocultural environment in which individuals live and interact based on a nationally representative data dhs in bangladesh our study concludes that educational and community level factors play important roles in male involvement in the country given an understaffed and underfunded healthcare system it is suggested that policy makers pay special attention to organizing health education campaigns through engaging chws targeting men especially in rural areas to improve knowledge and attitudes towards reproductive care availability of data and materials bdhs datasets are available through the website abbreviations chws community health worker dsh demographic and health survey fp family planning mhs maternal health services mmr maternal mortality rate sba skilled birth attendants srh sexual and reproductive health competing interests the authors declare that they have no competig interest

background mens active involvement in reproductive healthcare has shown to be positively associated with maternal and child health outcomes bangladesh has made appreciable progress in its pursuance of maternal mortality related goals in the framework of the mdgs however there remains a lot to be accomplished to realise the longterm goals for which active participation of male counterparts in reproductive care is crucial therefore the objective of the present study was to investigate factors associated with male involvement in reproductive health among bangladeshi men methods we used data from bangladesh demographic and health survey bdhs conducted in 2011 study participants were 1196 married men aged between 15 and 69 years and living in both urban and rural households level of male involvement outcome variable was measured based on the responses on knowledge awareness and practice regarding reproductive health chisquare tests and multivariable logistic regression models were performed for data analysis results out of 1196 participants only 40 were found to be active about partners reproductive healthcare chisquare test showed significant association between active involvement and ever hearing about family planning fp in television learning about fp through community health events community health workers and poster billboard results from logistic regression analysis revealed that type of residency p 0004 aor 0666 95 ci 0 5040879 literacy secondaryhigher educationp 0006 aor 0579 95 ci 01650509 learning about family planning from newspaper p 0001 aor 1952 95 ci 14292664 and television p 0017 aor 1514 95 ci 12981886 and having been communicated about family planning by community health workers p 0 017 aor 1946 95 ci 11293356 were significantly associated with active involvement of men in reproductive health issues conclusions level of male involvement was associated with schooling experience type of residency and exposure to electronic media national health policy programs aimed at promoting male involvement in reproductive care should focus on improving knowledge and awareness of reproductive health though community health education programs with a special focus in the rural areas

introduction sharing humors in social media is now a digital phenomenon humor a fundamental aspect of memes typically elicits laughter and induces feelings of wellbeing among individuals 1 although it is often described to be a positive form of communication humors become a gateway for gender stereotypes in social media humor often relies on stereotypes as a foundation which can potentially perpetuate detrimental social norms 12 this aspect raises concerns regarding the potential negative implications associated with such humorous portrayals hence this study wanted to describe how genderbased humors in social media can impact gender mainstreaming campaigns essentially this study aimed to describe possible mechanisms that delimit the mainstreaming of gender sensitivity initiatives in line with the direction of this study linguistic imbalances are important to study because it gives understanding on the concept of inequalities and imbalances in the society this study focused on the dynamics of language use in social media which requires indepth theoretical and narrative analysis the incorporation of humor has been observed to play a crucial role in the communication strategies employed by digital users thereby significantly enhancing the potential of their messages to achieve viral status 3 the prevalence of online memes primarily revolves around the depiction of popular culture and everyday experiences with a notable emphasis on themes related to sex and gender 24 stereotypes play a significant role in humor as they serve as crucial markers for the construction of ingroup identity and the establishment of social boundaries 25 in the initial study conducted by chavez and del prado 6 social media users thought that it is normal or it is part of our lives highlighting the normalization of genderbased humors in social media in certain cases the judgment of normalization has been shown to correspond with the perceived severity of their content such as the degree of harshness insensitivity and potential for causing emotional distress consequently language and social norms are barriers for gender mainstreaming because people reiterate social distinctions and beliefs 67 women are often victims of sexist humor in social media 8 women are frequently subjected to stereotypes and media portrayals that depict them as exhibiting irrationality dependence weakness and emotional instability in comparison to men consequently men are often perceived as the more legitimate and dominant participants in social media 910 it is worth noting that the stereotypical depiction of women in online can potentially contribute to the perpetuation of the patriarchal ideology of women as enemies 11 and the notion of women who hate each other 10 the memes appear to have a notable impact on promoting or at the very least cultivating a disposition of acceptance towards sexism as they effectively diminish the perception of its harmfulness derogatory nature or offensiveness 28 in cultivation theory individuals who are exposed to various forms of media tend to interpret and perceive social realities based on the way these realities are portrayed within the media landscape 12 in early cultivation studies televisions have a stabilizing effect on societal patterns leading to a propensity for resistance to change 1213 this study used this perspective to analyze how discourse markers in genderbased humors served as barriers for gender mainstreaming gender mainstreaming has simple objective ie it …transforms society positively through the elimination of discriminatory laws norms and practices 14 prejudiced norm theory suggests that the use of disparaging humor creates a social atmosphere that supports and encourages prejudice and discrimination through transgression of established boundaries of social acceptability 5 it could be that gender mainstreaming is challenging to achieve online because of language use and reiteration of social norms in social media the presence of humor in communication had a notable impact on reducing the perception of sexist attributes associated with the conveyed message while humors also heightened level of tolerance towards instances of sexual misconduct and sexism 15 this study was an extension of the research conducted by the authors about discourse markers and message patterns of genderbased humors in social media the initial results indicated that perceived inequality was firm to the language and expression of the genderbased humor 6 this study extended the previous study conducted on genderbased humors in social media it is believed that how genderbased humors being reiterated in social media has implications on how people react on gender mainstreaming campaigns gad is an essential concept to be discussed in sociolinguistic perspective this study looked on how linguistic dynamics became a barrier in achieving gender sensitivity initiatives theoretical framework this study used the theoretical perspectives of prejudiced norm theory and cultivation theory in developing the concepts of this study prejudiced norm theory utilization of disparaging sexist humor has the potential to facilitate the manifestation of unfavorable attitudes and the acceptance of violence directed towards women in the realm of social psychology ford and ferguson 5 put forth the prejudiced norm theory wherein they posit that the utilization of disparaging humor fosters an environment conducive for prejudice and discrimination this is achieved by pushing the boundaries of what is deemed socially acceptable thereby providing an avenue for individuals or groups to openly exhibit their biases towards those who are different from them in the context of sexist humor it is observed that such humor establishes a social norm characterized by levity thereby implying the potential acceptability of discrimination and the endorsement of acts of violence targeting women 1617 as ford and ferguson 5 clarified in their overview of pnt …humorous communication activates a conversational rule of levityto switch from the usual serious mindset to a nonserious humor mindset for interpreting the message therefore people are likely to interpret disparagement humor in a nonserious humor mindset unless internal or external cues suggest that it is inappropriate to do so moreover the study conducted by woodzicka et al 18 revealed that the lack of confrontation towards sexist humor can be attributed to its perceived lesser severity when compared to other forms of discriminatory messages conveyed through humor racist statements were found to be perceived as more offensive and confrontational when compared to sexist messages 1617 in their study mallett et al 15 discovered that humor has the effect of diminishing the perception of sexist attributes associated with the communicated message this outcome leads to increased acceptance of the message reduced confrontational responses and heightened tolerance towards displays of sexual harassment and sexism the phenomenon of ingroup identification plays a significant role in moderating the perceived humor of jokes the argument is supported by several studies conducted recently 1617 19 20 21 individuals who exhibited a diminished sense of identification with their ingroup were found to have a greater likelihood for gaining enjoyment from engaging in disparaging humor targeting the said ingroup according to abrams and bippus 22 research conducted in the field of sexist humor studies has revealed an interesting phenomenon specifically women who exhibit a strong identification with their gender are more susceptible to the negative effects of critical messages directed towards them as compared to women who have a lower gender identification 16 this phenomenon suggests that individuals tend to exhibit ingroup biases leading them to prefer humor that belittles the outgroup to a greater degree cultivation theory a few studies looked at how the controversy stoked longgrowing concerns about social medias potential to affect audiences perceptions and conduct instantly and directly traditional media still has a significant impact but social media may have an even greater impact 23 24 25 26 27 28 the concept of cultivation theory posits that the portrayal of a particular subject matter in the media can exert a significant influence on individuals leading them to perceive the issue as more prevalent and representative of the actual world at large this theory recognizes the dynamic nature of medias impact as it has the potential to shape and cultivate viewers perceptions and beliefs about various societal concerns 2729 32 in cultivation studies children who engage in extensive television viewing may internalize the notion that boys are inherently inclined towards exhibiting characteristics of dominance assertiveness and power this phenomenon can be attributed to the frequent portrayal of male characters embodying such qualities on screen 33 as gerbner et al 34 explained …most of those with certain social and psychological characteristics dispositions and world viewsand fewer alternatives as attractive and compelling as televisionuse it as their major vehicle of cultural participation the content shapes and promotes their continued attention to the extent that television dominates their sources of information continued exposure to its messages is likely to reiterate confirm and nourish their values and perspectives most of the literature in cultivation theory were adapted more on mainstream media eg films television and this study is one of the few that integrated cultivation theory in social media especially in the context of genderbased humor in cultivation theory the construction of the value system which encompasses ideologies assumptions beliefs images and perspectives is largely influenced by television 35 in the concept of genderbased humor social media posts could influence how people perceive gender stereotypes cultivation is the process of socialization involves various agents through which individuals acquire knowledge and internalize societal norms in this context media including various forms of mass communication play a significant role in shaping adolescents understanding of gender norms within society 3637 from a media psychological standpoint this shows that certain characteristics of social media could facilitate cultivation processes comparable to those identified in the historical setting of mainstream media 38 research objective the goal of this study was to determine the effects of discourse markers and message patterns of online genderbased humors to gender mainstreaming this study collected narratives on what aspects the genderbased humor exert significant impact on gender mainstreaming discourse markers of genderbased humors include normalization of gender inequality tolerating sexist jokes and promotion of discrimination towards gender these aspects might have social implications in gender mainstreaming 1 assess the effects of the dominant discourse markers and the message patterns of online genderbased humors to the mainstreaming campaign of gender and development 2 determine what aspects of genderbased humors made gender mainstreaming challenging to achieve methods this study explored the effects of genderbased humors in gender mainstreaming campaign this study developed indepth analysis on how genderbased humors in social media could impact the gender mainstreaming campaign through analyzing the narratives of social media users and language teachers this study analyzed the discourses present in social media and extract valuable insights on how its message delimits the gender mainstreaming campaigns population and sampling technique the sampling technique employed in this study was purposive sampling a nonprobability sampling method commonly used in qualitative research 39 40 41 this method involves selecting participants based on specific criteria that align with the research objectives allowing for a targeted and purposeful selection process 42 it is utilized by researchers to deliberately identify and select individuals who possess the necessary knowledge and expertise to provide valuable insights and information pertaining to the specific topic being investigated the individuals included in the sample for this research study were specifically identified as active users of social media platforms spending a minimum of four hours per day to online engagement the participants in this study exhibited diverse gender orientations and profiles which allowed for a comprehensive exploration of the various sources of humor expressions found online this study used several characteristics eg persons in authority gad advocates language teachers these were the main criteria this study used to describe the demographics of the participants there were 14 participants in this study as presented in table 1 they spend at least 4 h a day in social media they actively engage in social media through messages sharing commenting and posting the basic profile of the participants is presented below research instrument the instrument in this study was the guide questions based on the objectives this study carried out focus group discussions to gather the narratives from the participants below table present the research instrument used in this study focus group discussions on dominant effects of discourse markers to determine the effects of the dominant discourse markers and the message patterns of online genderbased humors to the mainstreaming campaign of gender and development the interview guide questions are presented in the table 2 below data gathering procedure to collect data for the study a rigorous data gathering procedure was employed encompassing both focus group discussions and individual interviews the focus group discussions were conducted with a group of participants who were purposefully selected based on their experiences pertaining to the subject matter under investigation the discussions were organized in a structured manner which fostered the opportunity for openended inquiries and facilitated dynamic exchanges among the participants the recorded sessions were carefully transcribed to accurately capture the intricate details and subtleties of the conversations the fgd offered valuable opportunity to explore and gain a more comprehensive understanding of the unique experiences and perspectives of each participant the fgd was conducted with the consent of the participants following ethical standards throughout the research process the focus group discussion was conducted in a conducive setting that was convenient to the participants and allowed them to openly express their experiences the researcher diligently upheld a neutral position during the entirety of the data collection procedure displaying an unwavering commitment to impartiality this was achieved by engaging in active listening and employing probing techniques to elicit additional information whenever deemed necessary data analysis the primary data in this study was the narratives from focus group discussion the transcriptions were reviewed and coded to identify key themes and narrative patterns thematic analysis was used to systematically analyze the data and identify common ideas and responses the findings were compared to other responses in thematic analysis there were six important components that needed to be followedfamiliarization coding generating themes reviewing themes defining themes and writing 43 in this study the responses of the participants were grouped based on their common themes and interpreted narratively this further simplified complexities in their statements and expressions this study also collected data from social media sites to triangulate the narratives with some genderbased humors because this study presented language use and effects it is important to also present some examples of genderbased humors in social media this allowed extraction of valuable language use ethics and standards results objective 1 assess the effects of the dominant discourse markers and the message patterns of online genderbased humors to the mainstreaming campaign of gender and development theme 1 gender stereotyping in career development four of the participants in focus group pointed out their concerns on how genderbased humors in social media can affect how people view career development some participants cited examples like being president or pilot these genderbased humors in social media can impact how most people perceive careers in that sense they believe that humors can direct someone to normalize gender stereotypes of some works it is very evident that we are still not able to achieve equality even in academe there is inequality because we are not able to tackle gender stereotyping and gender biases for example you are a woman you cannot be a president of the university why not participant 2 it is necessary to intensify the gender mainstreaming especially in courses that gender stereotyping is prevalent participant 12 people believed that if a gay will lead the country it will be a great failure for the country these are some of the tolerating sexist jokes participant 3 theme 2 selfperception five of the participants in focus group believe that genderbased humors can influence selfperception of a person this was an important direction for analysis because gad is also focusing on empowering people within communities it turns out that genderbased humors severely impacted how people perceived themselves some participants said that these humors are traumatic and causing people to selfisolate psychological effects of dominant discourse markers like shortterm this could include the perception to oneself youll lose confidence to yourself when these jokes are pertaining to you youll lose your confidence as a person participant 14 in short term youll be angry it has a domino effect because people will believe even if it is not true in that case when you react on these jokes people will keep on doing it participant 8 it is traumatic to the person it can affect how people perceive themselves it has a social effect on them and that they are less likely to socialize they isolate themselves participant 4 theme 3 social characterization five of the participants in focus group pointed out how genderbased humors caused social characterization people in social media developed words that described people as a joke because humors in social media is a dynamic culture it often resulted to new descriptions to people these descriptions are being used oftentimes to make fun of someone on the internet these words have specific connotations to them which people continuously used the humors have characterization people tend to look at these people and create certain ideas related to them they will give them attribution to something say marites name called for a gossiper participant 1 i think that why humor become trending because people can relate to it for example its not wrong being gay so why you will be offended we tend to create image to ourselves about certain gender we stereotype them as this participant 5 when we see males joining with girls we always perceive them as gay even if they are masculine if a male is joining with girls he is gay when a girl we perceive her as tomboy lesbian participant 7 for me jokes really exist its normal we use karen racist or marites gossiper there is also new now raul a name used to bully a gay often spoken with deep male voice so if we dont know the meaning of these words do not use it or might as well dont use it even we know participant 9 objective 2 determine what aspects of genderbased humors made gender mainstreaming challenging to achieve theme 1 humor culture some of the participant explained important contexts of genderbased humors in social media one participant argued that it is difficult to understand humors because people differed their perceptions about it he also emphasized that this is an important concern because it certainly contextualized how genderbased humors are developed discrimination in social media may not be tangible enough to be understood by us how many people are being caught because of cyberbullying like how liable the person is when he jokes some will view it as a joke and some will not that is the time humors have ethical dilemma because it is not clear what are the possible actions that a person should follow participant 10 i think how people act in social media based on what they hear read or see so when a person is frequently exposed in genderbased humor it makes them believe that its normal and that they can also do that participant 6 theme 2 humor dynamics three of the participants expressed their concerns on how genderbased humor is evolving throughout time the humors in social media are dynamic language that has its own syntax and linguistic components some people used humors as a form of insult and this happens even with genderbased humors these aspects of genderbased humors complicate more how gender mainstreaming can be implemented if they see these humors as normal oh its normal to joke like this it has discriminatory undertone so the meaning changes the humors in social media evolve there are explicitly offensive becoming implicitly offensive because you dont know the contextsomeone is insulting you so if we dont stop this if we just allow this to happen it will really delay the success of gad participant 11 if we allow this to happen all the time or occasionally it will really hamper mainstream success whether its small incidental and you let it be tolerate it anyway they are humans it will breed it will connectconnect and will cultivate a culture that is tolerant like its okay participant 13 discussion objective 1 assess the effects of the dominant discourse markers and the message patterns of online genderbased humors to the mainstreaming campaign of gender and development this study yielded important effects of genderbased humors to the gender mainstreaming these effects had several characteristics that needed to be investigate further to develop strategic processes the narratives of the participants opened new discussions on which aspects genderbased humors became prominent and how these can potentially impact the gender campaigns within the community for instance one participant said that we are still not able to achieve equality participant 2 expressing concerns on how prevalent discriminatory speech and language use in social media are genderbased humors became a channel to explicitly express stereotypes because people perceived it as normal notably genderbased humors are form of statements that aim to entertain people but some used it to spread discriminatory statements this study presents table 3 with some of the genderbased humors that are collected from social media feeds posts expression so youre a female doctor females are not fit of being a doctor womens world cup aint nobody got time for that women should not participate in sports table 3 posts expression they say a womens work is never done maybe thats why they get paid less… women are not commitment to their words and deserve to receive low wages gender is a social construct i was born a transgender gender orientation is a choice assessing the effects of genderbased humors was broad process however the narratives from the participants shed light on different angles to be investigated eg career development personal and selfperception and social characterization these aspects appeared to be prominent effects that might delimit people to support gender mainstreaming within communities although gender mainstreaming has been in the system of policy development across the world there was limited assessment done on how it can be implemented in social media one main barrier of gender mainstreaming is patriarchy as cameron 44 argued patriarchal social relations remain deeply embedded in almost all societies and explained language can be an instrument of male power over women used to silence misrepresent belittle and harass in case of media it appears that informative entertainment and promotional content is becoming more sexualized making it harder to achieve gender equity on a daily basis 45 in a smallscale study of anggraheni et al 46 22 of women experienced hate speech in social media at a conversational level individuals employ gender cues as a determining factor in shaping their behavioral responses towards others during social interactions 47 humorous communication is crucial in the establishment of normativity and normality 48 naturally humor changes norms by breaking them and promoting new perspectives 49 bergmann 50 posited that tendentious jokes are dangerous because they perpetuate and amplify existing stereotypes for fun without allowing them to be seriously rethought it is important to acknowledge the power imbalances and structural inequities prevalent in the society when considering the impact of ethnic jokes 5152 these jokes are not only harmful but also have the potential to create divisions within social dynamics specifically individuals who do not find such jokes entertaining may be perceived as outsiders further exacerbating the existing social disparities 51 this explains why genderbased humor in current days become barrier for gender mainstreaming because …they will give them attribution to something participant 1 and it can affect how people perceive themselves participant 4 psychological research in sexist humor which encompasses humor that perpetuates stereotypes and demeans individuals based on their sex or gender substantiates the viewpoints of those who associate humors with adverse social consequences 5354 sexist humors yield consequences on individuals perceptions of others specifically with regards to their gender as well as their likelihood to engage in discriminatory behaviors 5154 therefore it can be inferred that the impact of sexist humor can significantly influence the selfperception of the targeted demographic within the specific social context in which the humor is generated 51 in this study intensity of genderbased humor in social media might hamper the gender mainstreaming for instance it has been determined that normalization of genderbased humors often results to reproduction of this behavior as one participant said …humor become trending because people can relate to it participant 5 it turns out genderbased humors were simple form of statements that become relatable to others oftentimes this mechanism engaged people to develop humorencompassing behaviors this note aligns with previous research 51 52 53 that has demonstrated the adverse consequences of employing disparaging humor which contributes to the development and normalization of inequitable social dynamics the challenge of addressing problematic and stereotyping humor whether it is propagated through institutionally like songbooks in social spaces such as studentrun bars or in everyday interactions like classrooms poses significant barrier for equity initiatives 51 in social media stereotyping humor is severely normalized because of ingroup shared culture for instance group contexts have the potential to cultivate a psychological phenomenon known as a us versus them mentality thereby promoting a sense of bonding among individuals within the group 5556 men form bonds with other members of their group by participating in sexual misconduct against woman if group norms accept it 215657 there were several examples on how people use genderbased humors to characterize someone one humor explains …when we see males joining with girls we always perceive them as gay participant 7 certainly when you react on these jokes people will keep on doing it participant 8 this social complexity further highlighted the challenge on how to manage genderbased humors in social media genderbased humors oftentimes gather people with common norms it became challenging because people share norms which enabled them to be explicitly discriminatory genderbased humor in online spaces can have significant effects on gender mainstreaming campaigns and perpetuate discriminatory attitudes and stereotypes the normalization of genderbased humor can contribute to the reproduction of discriminatory behaviors and hinder efforts towards achieving gender equity the challenge lies in addressing problematic and stereotyping humor as it is often normalized in social media and shared within ingroup cultures reinforcing discriminatory norms managing genderbased humor in social media poses a complex challenge in promoting gender mainstreaming and addressing inequitable social dynamics objective 2 determine what aspects of genderbased humors made gender mainstreaming challenging to achieve this study had important narratives on how genderbased humors made it challenging to achieve gender mainstreaming in social media it was indicated that genderbased humors in essence have specific thematic mechanism that enable people to distribute and expand peoples norm this is an important discourse because it showed how challenging it can be to extend gender mainstreaming in social media because of its saturated gender stereotyping potentials one participant said that …discrimination in social media may be not tangible enough to be understood by us participant 10 although this does not mean that gender discrimination should be normalized it points out how challenging gender mainstreaming to be achieved notably participant 10 was concerned about the complexity of genderbased humor culture in social media that delimits the mainstreaming campaign humor culture in social media has detrimental effects on mainstreaming efforts aside from its capacity to recreate humors that present discriminatory behaviors humor culture cause people to tolerate humors and accept them as part of normal conversations this has major implications on how to deliver mainstreaming campaigns because when people accept something as norm even with policies people would deliberately break these policies genderbased humors made it challenging for gender mainstreaming to be adopted in social media for instance one comment in table 4 said that it is very difficult to be discriminated… because what they say is true indicated discrimination cultivates acceptance of gender normativity social media has the potential to magnify stereotypical portrayals of individuals living in poverty consequently diminishing their prospects in terms of economic and educational advancement the practice of categorizing individuals into distinct groups namely the deserving and undeserving involves evaluating their proficiency in the domain of online impression management similarly genderbased humors also magnify normative expressions eg gays are weak women are dependent to men because people in social media used generalized expressions to share group stereotypes word use like facts reinforce the information about gender while the use of strategic generalization stresses a humor generally applies to people in certain group 64 this is challenging for gender mainstreaming to be achieved because language use is a powerful tool in reiterating gender stereotypes online spaces are known to be an effective grounds of gender stereotypes media content is highly suitable for facilitating social learning processes due to its characteristic inclusion of simplistic and frequently onedimensional models of rules and behaviors that are frequently seen 5859 this has been shown in televisions and media contents whereby exposure to television content elicits the activation of associated schemas in cultivation theory this process of activation leads to the reinforcement and increased accessibility of specific schemas or cognitive frameworks thus impacting an individuals perception and interpretation of the world 59 this explains why genderbased humors will cultivate a culture that is tolerant like its okay participant 13 in this study several mechanisms of genderbased humors emerged as channel for discrimination and stereotyping for instance one participant said that …if they see these humors as normal… it has discriminatory undertone participant 11 this indicates that while genderbased humors remain normalized it cultivates behaviors that reinforce gender stereotypes this note was aligning with previous studies in gender stereotyping and discrimination in social media as lomotey 60 concluded humors …camouflaged and discreetly perpetuated negative stereotypes and ideologies about gender and were therefore morally objectionable philosophically people do not only hear jokes but also reiterate them 61 memes emerge during instances of challenging prevailing narratives through their participatory nature of recreation and mutations memes facilitate the resolution of ideological conflicts and the reestablishment of a normative narrative 62 63 64 the language used in genderbased humors has implications to gender mainstreaming sexist jokes reinforce the existing patriarchal structure within societies thereby perpetuating the unequal power dynamics favoring men over women 6566 language become a tool to infer gender stereotypes and mobilize power dynamics the role of language in the context of humor lies in its responsibility for accurate articulation of the joke and the subsequent delivery of the punch line 67 women are commonly portrayed in material reality as the second sex 68 and that language is meant to maintain gender distinctions 66 this demonstrates why …there are explicitly offensive humors becoming implicitly offensive because you dont know the contextsomeone is insulting you participant 11 humors in social media change because of dynamic language use which cultivates gender normativity message patterns and discourse markers were significant mechanisms of language use in humors because it presents discriminatory undertone the cultivation theory explains how exposure to genderbased humors reinforces specific cognitive frameworks and impacts individuals perception and interpretation of the world thus contributing to the acceptance of genderbased humor as the norm normalization cultivates behaviors that reinforce gender stereotypes and discrimination language plays a crucial role in genderbased humor as sexist jokes and language perpetuate unequal power dynamics favoring men and maintain gender distinctions the use of strategic generalization and discourse markers in humor language reinforces gender norms and presents discriminatory undertones genderbased humor in social media hinders the achievement of gender mainstreaming by perpetuating stereotypes normalizing discrimination and mobilizing power dynamics through strategic language use conclusion the study highlights several aspects that contribute to these challenges firstly genderbased humor has a thematic mechanism that allows for the distribution and expansion of gender norms making it difficult to extend gender mainstreaming efforts the complexity of genderbased humor culture in social media limits the effectiveness of mainstreaming campaigns genderbased humor hampers gender mainstreaming by perpetuating stereotypes normalizing discrimination and mobilizing power dynamics through language use the study emphasizes the need to address these aspects in order to promote gender equality and create an environment that is more inclusive and supportive of gender mainstreaming initiatives the use of humor reinforces the reproduction of discriminatory attitudes and stereotypes which can hinder efforts towards achieving gender mainstreaming efforts managing and addressing stereotyping humor in social media poses a complex challenge in addressing inequitable social dynamics ingroup cultures further reinforce discriminatory norms making it difficult to address and manage genderbased humor effectively however although this study indicated how language use can influence reiteration of gender stereotypes and discriminatory messages through humors there is a need to determine how do language teaching neutralizes the mechanisms of social norms and its cultivation in social media

cultivation of genderbased humor in social media encourages contrarian language to gender mainstreaming genderbased humor posed threat on how to deliver equitable gender mainstreaming campaigns through online the goal of this study was to determine how genderbased humor impact gender mainstreaming campaign in sociolinguistic sense there were 14 participants in the focus group discussion providing collective narratives on proliferation of genderbased humors in social media the participants were language teachers gender and development gad coordinators and gad advocates discourse analysis indicated that language use in social media hampers the delivery of gender mainstreaming campaigns social characterization and social distinctions were prominent components of the humor language which then cultivated gender normativity genderbased humor perpetuate stereotypes promote discriminatory practices and reinforce power imbalances through linguistic means in larger scale humor language influences the reproduction of humor culture in social media gender mainstreaming slows down because of massive cultivation of social belief systems the problem lies on how gender stereotypes are normalized in society through language use

introduction stroke an acuteonset cerebrovascular disease is one of the most critical public health problems worldwide the world health organization reported that 15 million people worldwide are diagnosed with stroke yearly of whom 500 die and another 5 million are permanently disabled 1 in china stroke incidence has been reported to increase by an average of 83 per year 2 and the global burden of disease 2019 study results showed that china has the highest incidence of stroke at 30 3 one study estimated that the number of stroke survivors could increase to 317 million by 2030 4 a total of 75 of stroke survivors are incapacitated while 40 are severely disabled 5 adversely impacting their quality of life however some survivors and their families can recover from adversities gain new advantages and utilise social resources in times of such challenges 6 walsh et al 7 argued that a high level of household resilience helps families withstand the challenges that the disease brings family resilience refers to using resources such as individuals families and communities to support recovery from adverse events achieve positive outcomes and facilitate good family adaptation 8 in china the stroke pathway involves a complex interplay of factors influenced by the healthcare system cultural norms and socioeconomic conditions china faces unique challenges in managing strokes due to the sheer magnitude of stroke cases and the evolving healthcare infrastructure unlike other developed countries the level of medical services in chinas grassroots communities is still in its infancy as a result approximately 80 of patients prefer home care 9 owing to the acute onset of stroke some patients become permanently disabled which allows caregivers to adapt to their unexpected roles as carers with little preparation 10 in addition many family caregivers face significant problems such as financial constraints inadequate rehabilitation knowledge and overburdening 11 the transition from hospital to home is considered the most challenging period for stroke survivors and their families since they must adapt to the distress that the disease brings 12 at present family resilience has been studied in several chronic disease groups such as the families of patients with cancer and those with acquired immunodeficiency syndrome although it is rarely applied in the families of stroke survivors in china 13 family resilience is the starting point and may be an intervention target to promote the adaptation of patients in china after a stroke however research on family resilience is limited 14 15 16 unfortunately they did not identify a specific period that impacted family resilience therefore the purpose of this study was threefold to gain a preliminary understanding of the level of family resilience of stroke survivors in china to explore the factors influencing the family resilience of stroke survivors in china and identify the favorable factors and risk factors and to establish effective coping strategies for patients family members and provide a theoretical basis for strengthening their coping abilities methods study design the study was conducted at a tertiary hospital in central china the researchers used a sequential explanatory mixedmethod approach 17 to expand and strengthen the understanding of the family resilience of stroke survivors in china this approach comprised two main components a questionnaire and interviews the first stage of this study involved a quantitative research methodology this was used to understand the status of the family resilience of stroke survivors explore the correlation between family resilience and selfefficacy in disease management caregiver burden family function and social support and analyse the factors influencing the family resilience of stroke survivors in china to select representative patient families for interviews purposefully the second stage of this study adopted a qualitative research methodology a semistructured interview framework analysed and mined critical themes clarified the factors that act as obstacles in building family resilience of stroke survivors and explored possible favorable factors data analysis quantitative research in the quantitative research stage social support was measured using a general demographic sociological data questionnaire the family resilience assessment scale the selfefficacy for managing chronic disease 6item scale to measure selfefficacy in disease management the caregiver burden scale to assess caregiver burden the family functioning scale to evaluate the family function and the social support rating scale the quantitative data collection process was as follows the questionnaire was distributed by the researcher to the families of patients who had suffered a stroke who met the inclusion criteria in the outpatient ward of the department of neurology of a tertiarylevel hospital in a province in china before the survey the researcher established a good relationship of trust with the patients and their family caregivers informing them of the purpose methodology and content of this study and voluntarily filling out an informed consent form informing them that this questionnaire was limited to this study and would not disclose their privacy the selfefficacy questionnaire was completed by the patients themselves or the researcher read the questions and the patients answered them and then the researcher completed them on their behalf the other questionnaires were completed by the primary family caregiver on behalf of the family after the questionnaires were completed the researcher checked the questionnaires for completeness and if there were any incorrectly filled or omitted options they were corrected and verified on the spot with the study participants and the patients were thanked the survey data were analysed using ibm spss 260 software sociodemographic data and participants characteristics were summarised using descriptive statistics an independentsample ttest or a oneway analysis of variance was used to analyse the differences in family resilience between different sociodemographic data and p 005 was considered statistically significant in addition spearman correlation analysis was used to analyse the correlation between the selfefficacy of disease management caregiver burden family function social support and family resilience finally the variables with p 005 in the univariate analysis were taken as independent variables and the total family resilience score was taken as a dependent variable a multiple linear regression analysis was performed using a stepwise method with the family resilience level as the dependent variable and statistically significant variables from the univariate analysis as independent variables to clarify further the effect of each influencing factor on the family resilience of stroke survivors qualitative research a phenomenological approach was adopted to delve into the lived experiences of stroke survivors and their families this approach was chosen for its suitability in uncovering the essence of these experiences allowing for an indepth understanding of the phenomenon under investigation the recruitment process involved selecting patient families that were representative of the current status of different family resilience levels a representative sample was selected with due consideration of family resilience score age family situation place of residence different stages of the disease degree of illness caregivers literacy level and caregivers work status the interviews were conducted by two researchers one of whom was responsible for conducting the interviews while the other with the consent of the interviewees synchronised the audio recording of the interviews while recording the interviewees reactions and expressions objectively during the interviews the researchers tried to avoid inducing the interviewees with their subjective opinions if there were any doubts about the content of the interviews they would promptly repeat the interviews to the interviewees to confirm the accuracy of the information within 24 hours after each interview the researcher listened to the interview recordings read the onsite transcripts several times and organised the transcripts word by word and sentence by sentence into a word version of the information with nonverbal information such as pauses emotional reactions and body movements in parentheses in the corresponding positions to ensure that the organised information maintained accuracy authenticity and completeness colaizzis sevenstep analysis was used to analyse the interview data specifically it included the following recording in detail and carefully studying all interview materials extracting meaningful statements that echoed the phenomenon of family resilience extracting and summarising the meaning of valuable expressions organising the extracted meanings into themes theme groups and categories linking the theme to a complete narrative of the research phenomenon stating the essential structure feeding the results of the resulting data analysis back to the interviewees to verify the accuracy of the content and finally gradually refining and sublimating the research themes through feedback from the research subjects group discussions and expert confirmation thematic analysis was employed to identify patterns themes and categories within the qualitative data the process involved data familiarisation generation of initial codes searching for themes reviewing themes defining and naming themes and producing the final report reflexivity though not explicitly mentioned was integral to the process with researchers acknowledging and critically reflecting on their assumptions biases and preconceptions throughout the analysis social support score in this study the scores of family social support of patients who had suffered a stroke ranged from 23 to 59 points with an average score of points among which the scores of objective support subjective support and social support utilisation were points points and points respectively the average scores of the three dimensions were ranked from low to high as utilisation of support objective support and subjective support among which 341 of families with patients were at the high level and 659 were at the medium level the results showed that the level of family social support of patients who had suffered a stroke was generally at the medium level family resilience score the mean fras score was which was above the medium level the score of the family belief subscale was and the score of the family strength subscale was the mean score of each item of the family resilience of stroke survivors was 34 among them the degrees of family resilience of stroke survivors with different marital statuses medical payment methods stroke courses caregivers education levels and work situations differed the difference was statistically significant as shown in table 3 for example the families of divorced and widowed patients had lower levels of resilience than the families of married patients the spearman correlation analysis results showed that cerebral apoplexy and the faith and strength of patients families were positively correlated with selfefficacy scores disease symptom management efficiency common disease management efficiency social support objective support subjective support and the degree of support utilisation but they were negatively correlated with family function and care burden the multiple stepwise regression analysis results showed that eight variables entered the regression equation and the researcher concluded that family function was the strongest influencing factor on family resilience other variables are shown in table 5 qualitative results theme 1 loss of independence and certainty subtheme 1 loss of independence stroke impairment causes the loss of independence and normal activities of daily living it directly impacts the daily lives of family members particularly the loss of independence and autonomy and the ability of the primary caregiver to plan their daily work and life appropriately some of the participants statements are reproduced below s1 he suddenly became incapable of doing anything his right arm couldnt be lifted and eating and going to the bathroom were difficult in order to take care of him you do not have to do anything else yourself you can only do that at home s7 my son rarely travels on business and sometimes he wont go out for drinks or food with friends since his mother is ill no way i am older i cannot handle her alone my son can only come back early from work and give me a hand s12 as soon as i graduated i went straight to shanghai to work now i have resigned from my job and returned to my hometown because my mother needs my help to take care of her father subtheme 2 full of uncertainty patients who suffer strokes have no way of knowing whether the disease will recur or what life will be like once they leave hospital and return home some of the participants noted the following s6 it is hard for me to go out in an emergency when my mother is home alone because i am scared that she may fall s9 in the beginning he recovered very well and i could return to work normally however he suddenly developed epilepsy when he was doing rehabilitation exercises and now he is walking worse than before s14 now whatever you plan is futile just count the days and dont ask for too much theme 2 facing threats and challenges subtheme 1 heavy economic burden a long rehabilitation process and high medical expenses are associated with stroke which places enormous financial pressure on families moreover some family caregivers have to reduce their working hours or even leave their jobs to care for patients the financial impact on the family was mentioned by some family caregivers s9 my salary wasnt great and now i have to change shifts or take time off to take care of him when he was healthy our family relied heavily on him to work so that the kids could attend school and support the family but now that he is sick if i absolutely need money i borrow from friends and family subtheme 2 poststroke negative emotions most stroke survivors are left with sequelae coupled with the uncertainty of stroke recurrence owing to the high disability rate of the disease patients experience negative emotions such as anxiety depression stigma anger and mood disorders at the same time heavy caring tasks also bring negative psychological experiences to family caregivers such as anxiety fear depression role strain and fatigue participants expressed the following s1 he has a strong personality although he has told us all his psychological words i can feel his heart is still sad why should it happen to him s10 sometimes while lying in bed at night a person will often shed tears i am often anxious and nervous afraid that he will relapse subtheme 3 heavy care burden the fatigue of longterm care work and the lack of professional care knowledge impose a heavy burden on family caregivers mental strain reduced social interaction physical fatigue sleep disturbances and memory loss are common symptoms of family caregivers participants expressed the following s3 i often get a little dizzy a little overwhelmed and i often have to take medication s5 i often have dreams or insomnia at night i cant sleep well i have no energy during the day and my memory is not as good as before theme 3 utilising family resources subtheme 1 internal family support after the onset of the disease families face unprecedented pressure for instance family members need to utilise their own resource advantages including family members personality traits health status education level care ability and beliefs about illness to help families adapt to the new changes one participant said the following s4 this happened to my mother all of a sudden its no use being sad for us as children we should still be positive and optimistic subtheme 2 relationships within the family this mainly refers to the quality of the relationships between family members or family caregivers and patients before onset a family with a good relationship will naturally support each other in all aspects to help the family adapt to difficulties better and faster one participant said the following s1 we have always had a good relationship and our son is very dutiful he works very well and he cant accept that this happened but i am glad that he was able to speak up and not keep it to himself subtheme 3 support from external resources after a stroke various forms of support from relatives friends and community health services coupled with adequate social interaction can effectively improve the resilience level of families to a large extent participants expressed the following s7 the community hospital near our house is very good it has rehabilitation equipment and the doctor is extremely professional every afternoon i push my wheelchair to take him to do rehabilitation s8 i will not let him stay at home every day every day i push him to the community below to see others play chess and cards ah to let him have more contact with the outside people are happy theme 4 adopting coping strategies family coping is a gradual process in which families use existing family resources to continuously generate and develop new behaviours to strengthen their ability to adapt to stressful events family members must redefine their roles adjust the division of labour and adapt to the new environment family caregivers turn to others for help learning about nursing and rehabilitation rebuilding their daily habits and changing their mindsets some of the participants expressed the following s6 my husband used to only go to work and do nothing at home now i have to take care of my mother so i can only change him to cook for the child every day the child said that he did not like to eat what he did and he did not want to do it but there is no way i do not know what good way s9 every day i go online to learn some simple movements and to help him do rehabilitation activities professional movements cannot be learned as there is no one to teach ah i can only learn to do a little bit better than no activity figure 1 shows the themes and subthemes extracted from qualitative content analysis discussion in this research we found that the family resilience of stroke survivors was above the medium level and was correlated with positive family functioning other factors that influenced family resilience included adaption experience uncertainty about the future financial burdens and negative emotions family functioning was the most important component of family resilience the requirement for adjusting to daily routines to care for the rehabilitation of a family member after a stroke demonstrates the presence of one of the qualities of family resilience in overcoming problems 18 the quantitative results did not allow for the understanding of how families adapt to changed living conditions when dealing with an adverse situation but our qualitative results generated information pertinent to some phenomena of interest in the chinese context and the quantitative findings support the discovered themes the loss of independence felt by stroke survivors affects caregivers independence but filial piety and some family values may support family members in overcoming their negative experiences a strong interpersonal relationship after a stroke is important for the wellbeing of both patients and family caregivers the findings of other studies highlight areas to consider in promoting strong relationships between patients and family caregivers cohesion and a strong emotional connection between family members support them in facing and overcoming such challenges in this study most caregivers were spouses a good marital status was a protective factor for family resilience and the marital relationship was an important link to maintaining the harmony and stability of the family relationship spouses provide unconditional care strong psychological comfort and motivation for patients the subtheme of relationships within family systems in the qualitative research section seems to explain this phenomenon however studies have shown that around 54 of families of stroke survivors experience relationship problems and nearly 38 of couples experience open conflict 19 without supportive intervention relationship problems tend to increase after a stroke deteriorating relationship quality over time 20 to reduce or eliminate the negative emotions of patients and family caregivers medical staff and community healthcare providers should promptly discover and inform them of selfregulation methods such as mindfulness therapy music therapy and diary writing 21 informal caregivers describe their poststroke lives as having been turned upside down 22 caring for stroke survivors frequently burdens unpaid informal family caregivers because of the rapidly progressive nature of the disability and the ongoing frequent and unpredictable nature of stroke recovery 23 participants in qualitative studies described financial psychological and care burden threats and challenges they faced in adjusting to illness stress which was also confirmed in quantitative studies not only did the caregiver burden affect family resilience but family resilience was worse when medical care had to be paid for family caregivers regularly bear the substantial costs of stroke survivors for a long time and in some cases they even forego treatment because they cannot afford such expenditure 24 which significantly increases the risk of delayed recovery and even stroke recurrence this study found that multichannel economic support can adjust the impact of diseases on families which is similar to the research findings of lopezespuela 25 and kariyawasam 26 among others therefore it is necessary to advocate for government departments to continue to implement medical insurance policies for serious diseases formulate corresponding healthcare policies and promote reemploymentrelated measures to address the financial burden and employment status of family caregivers studies have shown that while coping with disease the effectiveness of the coping strategy is directly related to whether a patients family can achieve a good level of resilience mobilising resources and adopting positive coping strategies can reduce the vulnerability of families to cope with stress and enhance their resilience 27 at the individual level patients should be encouraged to promptly perform selfpsychological counselling and family members should repeatedly encourage patients to enhance their sense of selfefficacy and selfworth at the same time family members particularly caregivers should be encouraged to perform timely selfregulation to maintain good physical and mental states in addition this study found that similar to the research results of lietz 28 and weitzel et al 29 strong and powerful social support was a protective factor for the family resilience of stroke survivors involving community and other resources to help families cope with challenges obtain information and access emotionalinstrumental support this study lays the groundwork for future research in understanding and enhancing family resilience among stroke survivors in china subsequent investigations could delve into developing targeted interventions addressing the identified challenges such as financial burdens and negative emotions exploring the effectiveness of support systems both internal and external on family resilience would be valuable additionally longitudinal studies tracking the evolution of coping strategies and their impact on family wellbeing over time could provide insights for intervention development further examination of the cultural nuances influencing family dynamics and resilience in the chinese context would contribute to a comprehensive understanding overall future research should aim to inform practical strategies and policies that enhance the adaptive capacity of families facing the complex repercussions of stroke limitations this study recognises certain limitations that warrant consideration first the chinese version of the family resilience assessment tool may have contributed to participant fatigue and potentially impacted response accuracy given the extended questionnaire and investigation events while efforts were made to minimise these effects future research should focus on refining the assessment tool and developing a specific scale tailored to the context of stroke survivors to enhance the efficiency and ethical robustness of data collection additionally the crosssectional survey in the initial phase introduces a potential bias and longterm followup may have influenced participants work experiences particularly among nursing staff longitudinal studies are recommended to establish causal relationships between study variables moreover future research should explore additional factors and identify family strengths contributing to a more comprehensive understanding of family resilience in the context of stroke survivors conclusions this study used mixed methods to help healthcare workers better understand the adaptation process of the families of stroke survivors and the factors influencing family resilience including dominant resources and risk factors among these family function was found to be the strongest influencing factor eliminating risk factors from a patients life is practically impossible but increasing their ability to cope with and adapt to difficult conditions despite increased risk factors is very important therefore we suggest that clinical personnel focus on family strengths and conduct family resilienceoriented interventions to facilitate the adaptation recovery and growth of the family as a unit as well as its individual members in the process of stroke rehabilitation and to reduce the burden on caregivers ethics participants provided written consent and were explicitly informed that anonymised responses may be published as part of the study findings participants retained the right to withdraw from the study at any time personal information and relevant data were anonymised and coded to ensure confidentiality and privacy results general information about the patients a total of 258 questionnaires were distributed 242 of which were recovered yielding a 938 successful recovery rate fourteen primary caregivers took part in phase ii of this study with sample sizes determined by data saturation patients who responded to the questionnaire were predominantly male married and the breadwinner of the family the predominant disease type was ischemic stroke mean age 6186 ± 876 years most family caregivers were women and were aged 59 years mean age 5362±749 years participants in the qualitative study were aged 3068 years and eight were the spouses of stroke survivors the participant information for qualitative research is shown in table 2 quantitative results disease management selfefficacy score the chronic disease management selfefficacy scale was used to evaluate the selfefficacy of patients who had suffered a stroke in this study the total score ranges from 0 to 10 points the total average was points showing a mediumlow level the average score of disease symptom management efficacy was and the average score of disease commonality management efficacy was among them 247 were at a low level 673 were at a medium level and 78 were at a high level family caregiver burden score the family caregiver burden score was in which the personal burden score was and the responsibility burden score was the burden of family care for patients who had suffered a stroke accounted for 320 at the severe level 475 at the moderate level and 265 at the noor mildburden level indicating that most of the caregiver burden in the families of patients in this study was at the moderate level disclosure the authors declare no potential competing interests

background stroke is a critical public health issue in china that necessitates a closer examination of family resilience defined here as the collective capacity of individuals families and communities to effectively navigate challenges recover from adverse events and foster positive adaptation amid rising stroke incidence this study addresses the dearth of research on family resilience among stroke survivors in china aiming to assess its level identify influencing factors and establish coping strategies for family caregivers methods this mixedmethods research employed a sequential explanatory design questionnaires were distributed to 258 stroke survivors and their family members at outpatient followup visits in the first stage ie the quantitative research stage the research tools for data collection included a general demographic sociological data questionnaire the family resilience assessment scale fras the selfefficacy for managing chronic disease 6item scale the caregiver burden scale the family functioning scale and the social support rating scale quantitative data were analysed using ibm spss 260 software utilising descriptive statistics for summarising sociodemographic characteristics and conducting analyses such as independentsample ttests oneway analysis of variance and spearman correlation analysis the second stage ie the qualitative research stage involved complementing and validating the data developing a quantitativequalitative interview framework and selecting participants for interviews colaizzis sevenstep analysis was applied to analyse interview data in the third stage the quantitative and qualitative research results were integrated and a comprehensive analysis was performed to obtain an accurate conclusion results a total of 242 families responded to the questionnaire response rate 938 in total the mean age of stroke survivors was 6186 ± 876 years old and 698 were male the quantitative results showed that the fras mean score was 18533 ± 2478 which was above the medium level the multiple linear regression analysis confirmed that family function was the strongest influencing factor on family resilience β 0948 p 001 the qualitative analysis revealed four themes of family adaptation experience loss of independence and certainty facing threats and challenges seeking family advantage resources and adopting coping strategiesthis hybrid study sheds light on the adaptation process of the families of stroke survivors revealing family function as the primary influencer of resilience recognising that eliminating risk factors is challenging our suggestion is for clinical practitioners to emphasise family strengths and implement resilienceoriented interventions focusing on enhancing coping abilities and fostering adaptation within families can aid in the rehabilitation process promoting the wellbeing and growth of both the family unit and individual members while alleviating caregiver burden

introduction depression and anxiety have become major mental health concerns in lowincome middleincome and highincome countries and their lifetime risk has been increasing steadily over the past few decades 1 2 depression has been projected to be the first cause of burden of disease by 2030 globally and has become a leading cause of suicides in china 1 previous evidence indicated that women were more likely to have higher incidence of depression and anxiety than men and that there was a modest peak in prevalence in the fifth and sixth decades of life in both genders 1 35 it has been estimated that 260 and 126 of chinese women aged 4060 years suffer from depressive and anxiety disorders respectively 6 depression and anxiety are associated with functional impairment reduced quality of life and increased likelihood of cardiovascular risk factors and mortality with the increase in ageing population and social transitions china is set to strengths and limitations of this study open access experience more severe health burden caused by depression and anxiety particularly among middleaged and older chinese women hypertension has been considered a main risk factor for cardiovascular disease and premature deaths globally and its prevalence has been increasing over the past decades 7 in 2018 the national chronic disease and risk factor surveillance conducted in 298 countiesdistricts in china reported that the prevalence of hypertension in chinese adults was 275 308 in men and 242 in women 8 a body of evidence indicated a link between hypertension and depressive and anxiety disorders a previous metaanalysis including six studies reported a positive association between depression and hypertension in elderly populations 9 previous studies also reported that individuals with hypertension were more likely to experience depressive disorders 10 11 while depressive disorders were correlated with increased odds of hypertension in middleaged and older adults 12 13 different socioeconomic status leads to different degrees of social cultural political and economic conditions among populations which may then affect health outcomes education and income are widely used as generic indicators of ses in epidemiological studies since education is considered to reflect the knowledgerelated assets of individuals while income is thought to estimate material resources and affordable healthcare 14 urbanrural residency is another important indicator of ses in china as rural and urban areas have considerable disparity in lifestyle environment occupation and social structure economic level and healthcare delivery 15 16 previous evidence showed that low ses was associated with higher prevalence of depression and anxiety and worse prognosis outcomes 17 18 19 further a previous metaanalysis suggested that low ses was linked with hypertension and this relationship was especially evident in different levels of education 20 however little is known whether the relationship between hypertension and the risk of depressive and anxiety disorders may be affected by ses this study therefore aimed to investigate the association of hypertension with depressive and anxiety disorders in middleaged and older chinese women and to further assess whether the association was influenced by ses methods study design and participants this crosssectional communitybased study of women was carried out in six provinces of three socioeconomic regions of china western central and eastern the capital of each province was treated as the representative city and one urban area and one rural area were selected randomly as survey sites in each city women aged 1070 years were recruited by a multistage stratified random cluster sampling in all the survey sites 21 specifically townships streets in each survey site were sorted according to the distance from the countydistrict government location and were equally divided into two layers one township street was randomly selected from each layer as a sample townshipstreet in the second stage in each sample townshipstreet mentioned above villagesneighbourhood committees were sorted according to the distance from the road where the town governmentstreet office is located and were equally divided into two layers one villageneighbourhood committee was randomly selected from each layer in the third stage all women who met the inclusion criteria were recruited from the survey villagesneighbourhood committees facetoface interviews were conducted by welltrained health service workers to collect information on demographic characteristics medical history lifestyle factors and depressive and anxiety disorders we assumed that the prevalence of depression or anxiety was 5 in women aged 4070 years according to the formula used to calculate the sample size for crosssectional studies 7600 women were required finally a total of 12 000 women aged 4070 years were invited to participate in this survey we received questionnaires from 10 103 women of the 10 103 women 9900 were included in the current analysis participants meeting the following criteria were excluded incomplete data on hypertension or depressive disorders or anxiety disorders all participants provided written informed consent assessment of hypertension hypertension was defined as participants selfreport of having been diagnosed with hypertension by a doctor andor currently taking antihypertensive medications assessment of depressive and anxiety disorders the chinese version of the patient health questionnaire9 was used to assess depressive disorders 22 which has been proven to have adequate validity and reliability 23 participants were required to rate each of the nine disorders from 0 to 3 within the past 14 days with a total score of 027 based on the sum of the phq9 scores participants were classified as having depressive disorders or no depressive disorders 24 the cronbachs α of the phq9 in this study was 086 anxiety disorders were examined using the chinese version of the generalized anxiety disorder7 consisting of seven questions during the last 14 days with a total score of 021 25 participants were classified as having anxiety disorders or no anxiety disorders according to the sum of the gad7 scores 26 the cronbachs α of the gad7 in this study was 087 open access assessment of covariates covariates for this study included age place of residence education employment status marital status average monthly household income drinking smoking physical activity body mass index diabetes and dyslipidaemia bmi was calculated as the weight in kilograms divided by the square of height in metres and classified into four groups according to chinese standards underweight normal weight overweight and obese 27 data on diabetes and dyslipidaemia was obtained according to previous diagnosis reported by the participants statistical analysis characteristics were presented as numbers and percentages for categorical variables and χ 2 tests were conducted for comparison between participants with hypertension and without hypertension nonnormally distributed variables were described as median and iqr and were examined between the hypertension and nonhypertension groups using mannwhitney u test first univariate logistic regression models were performed to calculate the or and the 95 ci of hypertension and the odds of anxiety and depressive disorders in addition multivariable logistic regression models were conducted to estimate the association of hypertension with the odds of anxiety and depressive disorders adjusting for age place of residence education employment status marital status average monthly household income drinking smoking physical activity bmi diabetes and dyslipidaemia stratified analyses were carried out according to place of residence education and average monthly household income analyses were conducted in sas v94 software p values are twosided with p 005 regarded as statistically significant patient and public involvement patients andor the public were not involved in the design or conduct or reporting or dissemination plans of this research results characteristics of study participants of 9900 women 185 reported having hypertension while 209 and 153 experienced depressive and anxiety disorders respectively the prevalence of depressive disorders was 285 and 192 in women diagnosed with hypertension and without hypertension in addition216 and 138 of women who reported hypertension and those who did not report hypertension experienced anxiety disorders table 1 shows the characteristics of the study participants according to hypertension women with hypertension were more likely to be older and reside in rural areas have lower levels of education and average monthly household income have higher odds of obesity diabetes and dyslipidaemia and less likely to be employed and married association of hypertension with depressive and anxiety disorders table 2 illustrates the association of hypertension with the odds of depressive and anxiety disorders in the unadjusted model women diagnosed with hypertension were more likely to have depressive disorders than those without hypertension after adjusting for age place of residence education employment status marital status average monthly household income drinking smoking physical activity bmi diabetes and dyslipidaemia the association of hypertension with the odds of depressive disorders remained significant in the unadjusted model women diagnosed with hypertension were more likely to have anxiety disorders compared with their peers without hypertension after multiple adjustment women with hypertension had 148fold elevated odds of anxiety disorders than those without hypertension association of hypertension with depressive and anxiety disorders by ses online supplemental table 1 exhibits the ses of the study participants according to depressive and anxiety disorders women living in rural areas and having lower levels of average monthly household income were more likely to experience depressive and anxiety disorders stratified analyses were subsequently performed to evaluate the associations of hypertension with depressive and anxiety disorders by place of residence education and average monthly household income after adjusting for potential confounders hypertension was significantly associated with increased odds of depressive disorders in women living in rural areas with lower levels of education and with average monthly household income ¥3000 while the associations were not statistically significant in women living in urban areas with higher levels of education and with average monthly household income ≥¥3000 moreover after multiple adjustments hypertension was significantly correlated with higher odds of anxiety disorders in women living in urban and rural areas with lower levels of education and with average monthly household income ¥3000 and ≥¥3000 whereas the association was not statistically significant in women with higher levels of education we also reported the association of hypertension with depressive and anxiety disorders by place of residence education and average monthly household income in the eastern central and western regions of china respectively in eastern china hypertension was significantly associated with increased odds of anxiety disorders in women living in rural areas with lower levels of education and with average monthly household income ≥¥3000 in central china hypertension was significantly associated with increased odds of depressive disorders in women living in rural areas in western china hypertension was significantly associated with increased odds of depressive disorders in women living in rural areas with lower levels of education and with average monthly household income ¥3000 whereas hypertension was significantly associated with increased odds of anxiety disorders in women living in urban and rural areas with lower levels of education and with average monthly household income ¥3000 and ≥¥3000 discussion in this crosssectional study of 9900 chinese women aged 4070 years we found that women diagnosed with hypertension were more likely to experience depressive and anxiety disorders than those who did not have hypertension furthermore the positive association between hypertension and depressive disorders was observed in women residing in rural areas and in those with lower levels of education and average monthly household income while hypertension was associated with higher odds of anxiety disorders in women with lower levels of education open access one of the principal findings based on 9900 middleaged and older chinese women is that hypertension was associated with increased odds of depressive and anxiety disorders consistent with our findings a previous metaanalysis including 3578 and 5833 individuals with and without hypertension from six studies reported a significant association between hypertension and depression in elderly populations 9 another systematic review and metaanalysis summarising more than four million participants from 59 studies also indicated a significant association between hypertension and anxiety in both crosssectional and prospective studies 28 additionally a recent survey of the china health and retirement longitudinal study based on 6273 adults also reported that individuals with hypertension had 112fold increased odds of depressive disorders compared with peers without hypertension 16 the potential pathophysiological mechanism underlying the link between hypertension and the odds of depressive and anxiety disorders might be partly because microvascular lesions on the prefrontal and subcortical regions could lead to vascular depression and anxiety 29 moreover recent evidence suggested that hypertension and depressive and anxiety disorders shared candidate genes that might result in oxidative stress lowgrade inflammation and hypothalamicpituitaryadrenal axis dysregulation 30 in addition we also found that the impact of hypertension on depressive disorders was only observed in women residing in rural areas and with lower levels of education and household income in line with our findings a recent study based on adults aged 45 and older also reported that the association of diagnosed hypertension with an increased risk of depression only occurred in individuals with rural residency and with lower levels of education and household income 16 moreover previous studies exhibited that poor ses was not only associated with higher prevalence of hypertension but also with higher risk of mental problems such as depression and anxiety 17 20 our results also supported these points by demonstrating that women living in rural areas and having lower levels of education and household income were more likely to have hypertension and depressive and anxiety disorders the possible explanations underlying the influence of ses on the relationship between hypertension and mental problems might be as follows first of all people with different ses may be exposed to diverse social environment for example individuals with lower levels of household income are more likely to experience higher levels of psychological stress and less likely to have access to advanced medical resources which might lead to increased risk of mental disorders 31 in addition individuals with different ses may have different lifestyles and behaviours people living in urban areas and having higher levels of education and household income may acquire more health knowledge and have healthier lifestyles including a wellbalanced diet and regular physical activity which might help prevent or manage physical and mental diseases such as hypertension depression and anxiety 16 our findings may have some public health implications as they indicate that hypertension was associated with increased odds of depressive and anxiety disorders highlighting the importance of detection and management of hypertension and mental health in addition this study also emphasised the significance of socioeconomic inequality in mental health disparities by demonstrating that women with hypertension were more likely to have depressive disorders but only in those with lower ses the who also recommends monitoring and evaluating open access socioeconomic inequalities in health behaviours as one of the social health determinants 32 furthermore poverty education geographical and cultural factors have been reported to be associated with poor utilisation of health services 33 prior research also suggested that inequality in health status might be avoidable via adjustable factors including economic and education status and living facilities 19 therefore health education on the prevention and management of hypertension and mental disorders should be more focused on women with relatively low ses in order to minimise inequality in depressive disorders furthermore policymakers should recognise and assess the relationship between hypertension ses and mental health and develop effective strategies and interventions to decrease mental health disparities with different geographical locations and diverse levels of education and income moreover expanding access to health insurance is critical to early identification and treatment of hypertension and mental disorders especially among low ses populations which might help women with low ses improve their mental and physical health this study has several strengths first the sample size was relatively large second the study used validated instruments to assess disorders of depression and anxiety third the study comprehensively adjusted for potential confounders there are also several limitations to be noted first our study cannot evaluate the causality between hypertension and the odds of depressive and anxiety disorders due to its crosssectional design and the study only focused on women second we only used urbanrural residency and levels of education and household income to measure ses and did not include other indicators however in china these three indicators have been considered the most important predictors of ses and are widely used to assess ses 16 finally we used selfreported hypertension and did not classify drinking and physical activity in detail conclusions in conclusion our study found that hypertension was associated with increased odds of depressive and anxiety open access disorders among middleaged and older women additionally this study indicated that the impact of hypertension on depressive and anxiety disorders was more evident in women with poor ses which emphasises the important role of ses in the relationship between hypertension and depressive and anxiety disorders effective strategies and actions for identification and management of hypertension and depressive and anxiety disorders should be developed and implemented in middleaged and older women especially in lower ses populations further studies are needed to testify our findings and illuminate the potential mechanisms underlying the link between hypertension and mental health contributors conceptualisation xuew xz and bs methodology xuew software xuew investigation dg and xuw data curation xuew and dg writingoriginal draft preparation xuew writingreview and editing xz and bs project administration xz and bs xz is overall guarantor for the study and has access to the data all authors have read and agreed to the published version of the manuscript competing interests none declared patient and public involvement patients andor the public were not involved in the design or conduct or reporting or dissemination plans of this research patient consent for publication obtained from patient ethics approval this study involves human participants and the protocol was approved by the ethical review committee of the chinese center for disease control and prevention 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 upon reasonable request data are available from the corresponding author on reasonable request supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

objectives to investigate the association of hypertension with depressive and anxiety disorders in middleaged and older chinese women and to further assess whether the association was influenced by socioeconomic status ses design nationwide crosssectional study setting six provinces of the eastern central and western regions of china participants women aged 4070 years were included by a multistage stratified random cluster sampling in 2018 n9900 primary outcome measures depressive and anxiety disorders were measured by the patient health questionnaire9 and the generalized anxiety disorder7 respectively logistic regression models were used to evaluate the or and 95 ci for hypertension and the odds of depressive and anxiety disorders results 185 of participants reported having hypertension 209 and 153 of women experienced depressive and anxiety disorders respectively after adjusting for potential confounders women diagnosed with hypertension were more likely to have depressive or127 95 ci 111 to 145 and anxiety disorders or148 95 ci 128 to 171 than those without hypertension stratified analyses demonstrated that hypertension was significantly associated with higher odds of depressive disorders in women living in rural areas or134 95 ci 113 to 159 with lower levels of education or128 95 ci 112 to 146 and with average monthly household income ¥3000 or133 95 ci 112 to 159 while hypertension was significantly correlated with increased odds of anxiety disorders in women living in urban or141 95 ci 112 to 179 and rural areas or153 95 ci 127 to 184 with lower levels of education or147 95 ci 127 to 170 and with average monthly household income ¥3000 or145 95 ci 120 to 175 and ≥¥3000 or149 95 ci 118 to 186 conclusions hypertension was associated with increased odds of depressive and anxiety disorders among middleaged and older women especially in those with low ses effective strategies and actions for identification and management of hypertension and depressive and anxiety disorders are needed ⇒ this is one of the largest crosssectional studies of middleaged and older women n9900 from six provinces in china ⇒ this study examined the association between hypertension and the odds of depressive and anxiety disorders while adjusting for potential important confounders ⇒ the study also evaluated the impact of socioeconomic status on the relationship between hypertension and the odds of depressive and anxiety disorders ⇒ depressive patient health questionnaire9 and anxiety generalized anxiety disorder7 disorders were measured by validated instruments ⇒ due to the nature of a crosssectional design this study cannot evaluate the causality between hypertension and the odds of depressive and anxiety disorders

public health must necessarily be concerned with social conditions at the root of many inequities public policy that seeks to achieve sustainable improvements in the social determinants of healthincome education housing food security and neighborhood conditions can contribute to positive health outcomes one approach lies in building capacity for communities to increase their participation and effectiveness in civic engagement to generate collective action and to engage private and public institutions to create systems that protect health community health workers are members of the communities they serve have intimate knowledge of community needs and resources and are considered leaders among their peers while recognized for their role in impacting health downstream there is evidence that chws can also successfully facilitate community efforts to impact social and structural issues related to health in fact advocating for individual and community needs is a core competency of chws in the us this report describes preliminary results from acción para la salud an intervention that relied upon chws to engage community members in three arizona border communities in pursuing public policy contributing to sustainable health improvements the arizona border population is much poorer attends fewer years of school and suffers a higher rate of unemployment than the population of any state not surprisingly these conditions translate into greater health risks which are exacerbated by the lack of insurance and health care resources theoretical background two theories guide acción the first centers on the importance of community engagement in addressing relevant and meaningful policy change the second postulates an avenue through which chws can engage communities in the policy process community engagement gaventa and barrett presented the results of an international metacase study that surveys types of citizen engagement analysis of 100 studies from 20 countries found that people engaged civically through local associations social movementscampaigns and as members of formal participatory spaces such as advisory committees outcomes with implications for public policy development include 1 construction of citizenship 2 strengthening practices of participation and capacity for collective action 3 strengthening responsiveness and accountability of states and institutions and 4 development of inclusive and cohesive societies acción used this framework to describe ways chws engage their communities as precursors of changes in social determinants of health policy development kingdons conceptual framework for policy change envisions three streams problem policy and political which operate independently in the problem stream issues are identified and defined based on various indicators or events the policy stream represents solutions generated about an issue the political stream describes factors that bring a particular problem into focus or favor a specific policy solution such as national mood policy change most likely to occurs when conditions in all three streams are interconnected kingdon calls this alignment a policy window change agents can act to open policy windows andor take advantage of those that have opened in acción chws serve as catalysts for change on a local level in all three streams in the problem stream they interact with community members to identify salient issues in the policysolution stream they engage them in creating ideas to improve their community in the political stream they develop relationships and advance the communitys policy agenda with such entities as school districts health care delivery system or municipalities thus chws both create and seek to capitalize on policy windows in diverse systems methods members of an academiccommunity partnership community action board developed acción through a communitybased participatory research process the five partnering organizations which have chws as core to their health efforts included two community health centers a county health department a grassroots clinic and a grassroots organization each agency identified experienced chws on their staff to work on acción the eleven acción chws had at least five years of experience intervention the cab training committee developed the acción community advocacy curricula guide using strategies from existing advocacy and leadership tools the 18month training consisted of four participatory and reflective workshops with the acción chws and their supervisors the chw supervisors were strategically included to ensure that the chws had organizational support for advocacy activities activities to foster community advocacy were initiated during the training in which acción chws were asked to talk to community members about issues and identify existing power structures within their communities after the first year the chws began to identify community advocacy projects based on needs they identified in their contact with clinic patients and participants in chw prevention activities during outreach efforts and in community conversations and meetings in ongoing technical assistance chws were then assisted in using strategy maps to identify steps to their desired policy outcome acción chws met regularly with their supervisors and engaged in monthly peer network conference calls to share challenges and successes with their colleagues data collection acción data collection instruments were determined through a participatory process with partners the data were primarily qualitative and collected systematically across all five intervention sites to capture the span of their activities acción chws used encounter forms to document conversations and meetings with community members groups and local officials on the forms they described the issue being discussed their next step in addressing it and which of kingdons streams they were working in the strategy maps identified the advocacy outcome and corresponding strategies corroborating data sources included quarterly program narratives and technical assistance notes analysis three members of the research team were responsible for analysis information on the forms was validated using program narratives and technical assistance notes the description of the encounter was used to verify whether the chws had categorized it in the correct stream among the 211 encounter forms approximately 29 was recategorized as individual advocacy community programming or education leaving 150 forms for analysis content from the encounter forms and strategy maps was coded to types of community engagement results the remaining 150 encounter forms across the five partner agencies were analyzed to ascertain the extent to which chw advocacy activities were related to kingdons theory the number of forms per agency was 1755 chws most often reported working only in the problem stream reflecting the first step of engaging community members in identifying issues of importance many of these encounters were conversations between the chws and community members during normal job activities in clinic visits health education classes and support groups and reflected concern over a broad range of issues such as the adequacy of public services community safety and cleanliness and activities for youth over time the encounter forms documented a shift from individual to group encounters in the problem stream eg chws brought community members together in house meetings or community forums to discuss a problem encounters in the problem stream were coupled with the policy stream in 20 of total encounters reflecting activities in which chws began identifying and working on solutions to a previously identified problem a small percentage of policy encounters were activities not connected to a problem identified through acción the policy stream and political stream overlapped in 3 of encounters all of which occurred in one organization in which chws had the opportunities to discuss organizational policy change not directly connected to a previously identified problem in 3 of encounters chws began engaging in all three streams taking their communitygenerated solution to decisionmakers in their agency or town the remaining 3 of total encounters were political in which chws in one agency held informational meetings with political or organizational leaders critical to the acción intervention is community engagement to address the power relationships that underlie disparities in the social determinants of health to describe strategies chws used to involve community members in the policy development process we also analyzed encounters by type of engagement most often chws used local associations to strengthen practices of participation typically by engaging their clients in conversations about the wellbeing of their community and what might be done to improve it the chws also involved community members in efforts to increase access to services and to make systems more accountable to community needs for example through petitions and group meetings with public officials in two instances chws engaged in activities related to the construction of citizenship one informing community members of their rights under immigration law and the other discussing the potential impact of proposed state redistricting on community members finally the strategy maps further documented advocacy strategies and desired outcomes including plans to address transportation infrastructure clinic hours safe routes to schools the safety net for domestic violence victims and sales of energy drinks to minors discussion using theories of community engagement and policy change acción sought to empower chws and their communities to advocate for sustainable change targeting underlying social determinants to varying degrees across organizations acción chws encouraged community members to think ecologically about their health and identify advocacyoriented solutions to improve neighborhood conditions enhance community opportunities and increase access to services in three organizations acción chws initiated activities in the political stream in several cases directly involving community members in looking at types of community engagement chw advocacy activities most often focused on strengthening practices of participation and the majority of these took place within the problem stream our findings indicate the value of longterm testing of effectiveness of acción in identifying specific advocacy activities leading to policy development and potential policy and environmental changes impacting community health in the future it will be important to investigate organizational factors that facilitate or discourage chw advocacy and determine optimal conditions for successful chw public health advocacy activities chws community advocacy activities in the kingdon

objectives public policy that seeks to achieve sustainable improvements in the social determinants of health such as income education housing food security and neighborhood conditions can create positive sustainable health impacts this paper describes preliminary results of acción para la salud a public health intervention in which community health workers chws from five health agencies engage their community in the process of making positive systems and environmental changes methods acción chws were trained in community advocacy and received ongoing technical assistance in developing strategic advocacy plans acción chws documented community advocacy activities through encounter forms in which they identified problems formulated solutions and described systems and policy change efforts strategy maps described the steps of the advocacy plans results findings demonstrate that chws worked to initiate discussions about underlying social determinants and environmentalrelated factors that impact health and identified solutions that improve neighborhood conditions create community opportunities and increase access to services

introduction preexposure prophylaxis is emerging as an important tool for controlling the hiv epidemic and a recommended element of combination hiv prevention strategies including consistent condom use risk reduction counseling and hiv testing 1 oral prep has been shown to reduce hiv infection risk by 92 2 to 100 3 prep may be especially useful for populations most at risk for hiv including men who have sex with men and sex workers prep is recommended for use among atrisk msm in developed countries including by us government agencies 4 and professional bodies in the uk 5 in 2014 the world health organization issued recommendations and guidelines for prep use among msm in developing countries 6 in india although antiretroviral treatment is available for free in public hospitals antiretrovirals are not licensed for prevention and prep is not yet provided through public hospitals nevertheless private practitioners and nongovernmental clinics in india are prescribing prep for patients especially for seronegative partners of hivpositive heterosexual spouses 7 anecdotal evidence suggests that prep is already used by some educated higher socioeconomic status msm in india who pay outofpocket for prep with prescriptions from private practitioners 7 as awareness of prep increases among msm in india demand also may increase and prep could serve as a significant addition to combination prevention this is especially important in that amidst an estimated 57 reduction in new hiv infections nationally in the previous decade 8 national average hiv prevalence among msm remains 12 times higher than among the general population furthermore this national average among msm masks substantially higher hiv prevalence of 1015 documented among msm in several hiv sentinel serosurveillance sites of the national aids control organisation with a trend of increasing prevalence in chandigarh delhi goa and maharashtra including mumbai910 msm in india continue to be at disproportionately high risk for hiv infection in order to assess readiness for prep and to support future implementation strategies to promote prep uptake and adherence we conducted a qualitative study among msm in two major indian cities to understand their perspectives on facilitators and barriers to prep use methods from september to december 2014 we conducted 10 focus groups among a purposive sample of five subgroups of msm kothi doubledecker panthi gayidentified and bisexual11 participants were recruited through communitybased organizations working with msm in chennai and mumbai we did not screen participants by hiv status however we conducted targeted recruitment at meetings and events designed for hivnegativeunknown status msm rather than at clinics or support groups for people living with hiv study inclusion criteria were being age 18 years old or above selfidentified as msm and able to provide informed consent research staff employed at the cbos recruited potential focus group participants by word of mouth key informant interviews were conducted with health care providers and msm community leaders in chennai and mumbai the study protocolwas approved by the institutional review boards of the university of toronto and the humsafar trust data collection we developed a semistructured focus group interview guide to explore and assess awareness and acceptability of prep among msm domains explored were participants prior knowledge of prep willingness to use prep perceived barriers and facilitators to future prep uptake preferences for prep access and anticipated impact on condom use focus groups and key informant interviews were conducted in participants native language a few key informant interviews were conducted in english each focus group participant received inr 300 as compensation for his time written informed consent was received from all focus group participants and key informants after assessing focus group participants prior knowledge of prep the group facilitator provided a standard explanation of prep using a pictorial card in participants native language participants were encouraged to ask questions and misunderstandings were clarified information provided in prep factsheets developed by aids vaccine advocacy coalition 12 and the us centers for disease control and prevention 13 were used by focus group moderators to respond consistently to participant queries based on results from iprex 23 participants were informed that if taken daily prep provided greater than 90 protection against hiv infection data analysis focus groups and key informant interviews were digitally recorded transcribed and translated into english research staff randomly selected 20 of transcripts to check for accuracy in comparison with their respective audiofiles focus group and interview data were explored using narrative thematic analysis with techniques adapted from grounded theory 1415 we developed a codebook based on a priori codes derived from the focus group and key informant interview guides and existing literature on prep acceptability inductiveemergent codes and categories identified from the text were then added to the codebook and used in further coding and categorizing of the data differences in coding were discussed among two data analysts and senior investigators and resolved by consensus the analytic focus was on identifying factors that may impede or facilitate prep acceptability member checking 16 was conducted by discussing findings and interpretations in meetings with field research teams in research sites with attention to differences in perspectives on prep between key informants and msm focus group participants results participant characteristics focus group participants mean age was 26 years a majority completed high school with an additional 328 college graduates most were employed and unmarried with 623 living with parents or a wife and 311 living alone participants were roughly equally divided among kothi panthi doubledecker gay and bisexual sexual selfidentifications among the 10 key informants six were msm community leaders three physicians and one a peer counsellor prep acceptability the majority of msm reported they would use prep if it became available over twothirds reported consistent condom use in the previous month table 2 summarizes facilitators and barriers to prep acceptability among msm in india across eight themes which are described below along with illustrative quotations awareness about prep none of the focus group participants had heard of the term prep nor were they aware that art could be used to prevent hiv infection four participants who initially reported that they had heard of prep were later found to have mistaken postexposure prophylaxis for prep when asked whether they knew of any medication to prevent hiv infection some participants expressed hope that such a medication would be available and expected 100 protection against hiv many participants believed that their sex partnersother than cohabiting male or female steady partnerswould not find out about their using prep the potential for covert use of prep was seen as especially beneficial in situations where a casual or paying partner may not want to use condoms in contrast msm who lived with their parents or wife or who lived with a steady male partner anticipated problems in keeping their prep use a secret a kothi living with his parents explained it will be a big issue in the family they will think that i am hiding something from them and thats why i am taking medicine i cant tell them that i am doing such and such thing and so i am taking tabletsif i dont tell them they may even ask the medical shop persons by showing the tablets participants were concerned about feeling shamed if their prep pills were discovered and further that it might create misunderstanding and maritalrelationship discord or that they might be mistaken as hiv infected as a married participant said if current use of condoms was consistent prep was seen as an additional burden despite its high efficacy some participants expressed that condoms alone were sufficient why to use bothprevention pills and condoms good quality condoms offer better protection… preventive pills are not necessary some participants however accepted the combined use of condoms and prep perceiving prep as additional protection in case a condom breaks or slips as a kothi in sex work said we are already using condomsbut taking pills prep is useful because condoms sometimes rupture if i take intimacy and love participants reported that prep would be particularly useful for msm in hiv serodiscordant relationships they reasoned that hivnegative msm in such relationships would want to have sex with their hivpositive steady partners without apprehension as prep could protect against hiv infection even if a condom breaks or slips even persons who are hiv positive have the right to love but if we are not hiv positive then we will be scaredi mean i shouldnt get hiv so i will take pills then fgd6 panthi mumbai participants further reported differing attitudes toward using prep depending on the hiv status of their steady partners revealing ones prep use to an hivpositive steady partner was not considered to be an issue such disclosure was expected to decrease fear or guilt among hivpositive partners that they might infect their hivnegative partner in this case prep use signals concern and supports intimacy however hivnegative participants were concerned about adverse consequences if a male steady partner of unknown or hivnegative status found out about their prep use as they might be judged as promiscuous or their fidelity questioned if your regular partner sees you taking this he will think that my partner goes somewhere else… and because of this msm would not want to take this pill thus in the latter case prep use may engender mistrust and detract from intimacy attitudes towards prep users participants perceived that prep would be particularly useful to msm who engage in high risk behaviors accordingly they reported that sex workers and msm who have multiple sex partners would be more likely to use prep those who are in regular sex trade those who want sex daily can definitely take this some participants further reasoned that being on prep then means one admits to engaging in high risk behaviors as a result there is a risk of being looked down upon by others as a panthi reported if my friends come to know i am taking prep they will think with how many people he has sex they will start looking at me differently in order to destigmatize prep use participants suggested that it be promoted as an hiv prevention pill for everyonenot just for highriskmsm for example a doubledecker said prep should not be branded as useful formsmalone they are for anyone who is sexually activethere is no need to declare my sexual behaviorjust say that this tablet is to prevent hiv so that anyone can use conversely msm participants who were open about their sex work and particularly those whose livelihood primarily depended on sex work did not express concern about stigma related to using prep in fact a few reported that being on prep would help them to get more clients and that clients might be willing to pay more to sex workers whom they considered to be safe and responsible if tablets are released they will sell very wellthey are for safety right msm in dhandha sex work will ask for more money from their clientswill ask for 2000 rupees instead of 1000 rupees i am safe now they will say like that prep cost and access participants preferred having subsidized or free prep distributed through cbos as they argued that most atrisk msm including msm in sex work are of lower socioeconomic status government has to distribute it prep through cboscondom programming is a good example of it if it comes through government it will be for free and if it is distributed through cbos it will not be wasted key informants thought the government could provide free or subsidized prep through cbos based on their experiences with existing governmentcbo partnerships in contrast some participants preferred prep to be provided through government health care settings as they were concerned that if prep were provided through cbos then other msm might be more likely to find out about their using it and label them as promiscuous while many participants wanted prep to be available in private pharmacies as well they noted that potential high pricing of prep sold through pharmacies may pose barriers in access to even middleincome msm some participants expressed further concern that pharmacies might distribute fake prep to increase profits thus the quality and potency of prep sold in pharmacies was potentially suspect participants also expressed concern about fear and shame in that pharmacists or others might consider prep buyers to be hiv positive promiscuous or msm and that this would prevent msm from buying prep we may encounter problem in getting the prep pills from medical shopsany of our neighbors can visit the medical shop they might ask us why are you taking this medicine… he can inform any of my family members about that even the chemist may wonder why i am taking this prep characteristics and side effects once participants were made aware that prep if used consistently was highly effective in protecting against hiv infection many expressed that it would be worth taking the trouble to initiate and adhere to a daily prep regimen a few participants including a key informant however remained suspicious of the reported high effectiveness of prep as effectiveness data are not yet available from studies conducted in india the high effectiveness was also perceived to be associated with a high probability of severe side effects participants believed that prep may affect ones appearance or major organs ones virility or may result in sickness and thus loss of wages including income from sex work i feel that after all it is a drug so it will have side effects if it prevents more than 90 of hiv infections then it will have some side effectsmany people will think about thatwhat are its side effects and how major they are and whether my virility will be affected if it has little side effects then we may take while some participants believed that they could adhere to a daily regimen others were worried that daily use would be taxing and may detract from prep acceptability among many msm accordingly some participants reported preferences for less frequent dosing or eventdriven dosing around times of anticipated increased sexual activity some participants questioned why prep could not be taken intermittently for short periods of timefor example only for those periods in which they engage in sex work which they reported tend to occur when they travel outside their home city some msm reported a preference for longacting injectable prep administered monthly or every two months an additional advantage of injections was expressed in that it would solve storage problems ie where to safely store prep tablets at home or how to carry them during travel a participant equated injections with longterm prepaid cell phone cards and dailyregimen prep with shortterm cards injection is similar to having a topup prepaid card for a large amount i can talk up to three months pills are like 10 rupees topup card it needs to be often purchasedit will last only a day or two dilemmas due to lack of art access community leader key informants articulated concerns about efforts to make prep available for wider use in india one community leader for example questioned how msm will be provided with subsidized or free prep through the national hiv program when many people living with hiv still do not have access to free art a physician key informant warned about possible emergence of art resistance due to nonadherence among prep users a community leader although he supported free prep availabilitywonderedwhether the government would be able to provide it and wanted msm not to wait for the government but to buy it on their ownalthough this begs concerns about ability to pay government is already providing lubricated condoms for free we cant insist government to provide this prep for free or spend money on this but if they are giving it for free i welcome it or else community should come forward and buy it… they have to invest money for their health risk compensation both msm participants and key informants anticipated decreases in condom use among prep users for example a panthi reported if these pills are available in market then i will stop using condomsafter taking these pills the happiness and fun that we will have while having sex with others will be different this is like a shield whatever comes from outside it has to keep outside only fgd6 panthi mumbai similarly a doubledecker said msm will think i have already taken the tablet so i dont have to use condomsso many will avoid using condoms some participants also reported that prep users would increase their number of sexual partners or anal sex encounters a few participants expressed broader concerns that the availability of prep might result in relaxation of established and long fought for community norms that support consistent condom use they feared the weakening of safer sex norms might lead to decreases in condom use even among msm who do not use prep discussion in this qualitative study with diverse msm in two major indian cities none had previously heard of prep that only key informant physicians and community leaders were aware of prep may reflect that it has neither been tested nor licensed in india importantly once prep was explained however the majority of msm reported they would likely use it this suggests that prep may be an acceptable hiv prevention strategy among some atrisk msm in india nevertheless a variety of facilitators and barriers to prep acceptability emerged some of which may be particularly relevant to prep implementation in the indian context our study adds to the limited evidence base on factors influencing willingness to use prep among msm in developing countries 17 18 19 20 among the facilitating factors the potential for covert use of prep thus not requiring partner approval or negotiation was highly valued among a variety of msm this included those engaged in sex work msm who have multiple sex partners and married msm the particular importance ascribed to covert use may be understood in the context of the reported reluctance to use condoms on the part of clients of male sex workers and broader challenges among msm in india in talking about condoms or hiv status with steady male or female partners 1121 for msm who were open about engaging in sex work or having multiple partners procuring prep through cbos did not emerge as a concern in fact msm in sex work reported that they would proudly announce their using prep thereby indicating to others that they are responsible and safe and even increasing their business msm in sex work identified additional advantages of prep use given frequently reported instances of forced sex by ruffians or policeeven more so after the recent recriminalization of samesex sexual behavior in india 22 among both those engaged in sex work and not the desire to protect ones steady partners also supported prep acceptability given widespread sexual and hiv stigma in india 2324 it is not surprising that msm expressed concern about prep use being discovered by their family members wife or male steady partner fearing negative consequences such as marital and relationship discord and being ostracized to the point of posing threats of divorce or being ejected from their family home msm expressed further concerns about being labeled as hiv positive or promiscuous by their peers as well as by pharmacists who might dispense prep msm in the present study were also concerned about prep users facing stigma from other msm similar to that reported in other contexts 2526 qualitative investigations among msm enrolled in a phase i prep trial in kenya 18 and among msm participants in the iprex study in thailand 26 identified stigma as an important barrier to prep acceptability and usage broadbased strategies to reduce stigma associated with prep are crucial to its acceptability 27 both within msm communities and among the general public among msm in our study prep acceptability emerged as higher among those who use condoms inconsistently with prep seen as a backup plan or a condom substitute some msm also described concurrent condom and prep use as an added burden data from the us prep demonstration project among msm similarly indicated a positive association between risk behavior and prep acceptability higher risk was a significant correlate of study enrollment 28 a general preference was expressed among msm in our study for intermittent prep use which was perceived as less burdensome than a daily regimen similar to preferences expressed among msm and male sex workers in kenya 18 the recent ipergay trial supporting the high efficacy of intermittent prep suggests eventdriven prep 29 may be a plausible option for msm in india who do not use condoms consistently tailored education and implementation strategies for msm particularly those of low socioeconomic status sex workers and married msmeach of which face particular challenges in uptake and adherencemay help to support prep rollout in india a notable concern arose among community leaders who lamented that over a decade of hiv prevention work promoting consistent condom use among msm as a community norm would go to waste community leaders and health care providers also expressed challenges for prep rollout in the face of suboptimal availability of art for people living with hiv in india such concerns in india appear to be shared as in a recent international aids conference a top indian government health official reported that india was not ready for prep as the focus needs to remain on improving treatment coverage not on providing art for prevention we are aware of only one unpublished qualitative study from india 30 that explored prep acceptability among msm in pune nonuse of condoms wanting a stressfree sex life and fear of condom failure emerged as reasons msm might use prep in addition to these factors which similarly emerged in our study we identified the pervasive role of stigma as a potential barrier to prep uptake stigma manifested in wideranging concerns about how to store and conceal prep from family members ones wife or steady male partner and in fears about procuring prep from cbos due to stigma from other msm and from pharmacies a multicountry survey that included 128 msm from india found that 75 reported wanting to initiate prep the top two attributes that influenced potential uptake were route of administration and the need for periodic hiv testing 31 our qualitative findings complement these results in that diverse msm reported preferences for intermittent dosing and injectable prep however the pervasive concerns about stigma that emerged in our study suggest the importance of contextualizing ostensibly productspecific concerns within the sociocultural milieu that is preferences for intermittent dosing longacting injectables and concerns about from where and from whom to access prep may be best understood in the sociocultural context of widespread stigma associated with hiv and msm in india and the enduring centrality and often proximity of family including the prevalence of heterosexual marriage among msm our previous research with msm in india similarly identified stigma as a significant barrier to hiv testing 32 and extensive fears about hiv status disclosure 11 unfortunately the 2013 indian supreme court decision recriminalizing samesex behaviors in india reversing a delhi high court order that had decriminalized homosexual acts since 2009 is likely to exacerbate these challenges to prep implementation and to hiv prevention for msm more broadly 1133 limitations and strengths the use of qualitative methods and purposive sampling limits the generalizability of the findings however our focus was on exploring issues that may emerge around prep implementation among msm in the indian sociocultural context in which prep usage remains largely unexplored the results are more likely to be transferrable to other similar settingscities with diverse msm and with longstanding hiv preventive interventions another limitation is that study participants were primarily recruited through communitybased organizations the acceptability of prep may be different for msm unaffiliated with cbos serving msm communities general acceptability of prep in the present sample was expressed despite lack of any previous awareness nevertheless concerns about stigma and disclosure of samesex sexuality and of preps automatic association with hiv may be even greater among msm who are not affiliated with community organizations also as this was a small qualitative study we cannot characterize wholesale differences between different msm subgroups however we have indicated possible differences that emerged and the diversity of the msm sample is a strength in the breadth of issues explored including those among married msm and msm engaged in sex work implications given the established effectiveness of prep 23 and the who recommendation that prep be provided to msm in developing countries 6 it may be beneficial for india to consider providing free or subsidized prep to high risk msm prep could be provided through existing government outlets in the national hiv program possibly in a separate wing within existing governmentrun art centers however concerns about being perceived to be hivpositive a barrier to prep uptake that arose in our study suggest the importance of providing alternate sites for prep administration which might include msm communitybased organizations a current successful model of indian governmentfunded targeted hiv preventive interventions employs licensed medical doctors to visit cbos at regular intervals to prescribe medication for opioid substitution treatment for people who inject drugs with nurses and outreach workers on site who follow up patients an analogous model of prep administration through cbos for msm may help to mitigate predictable barriers to uptake the use of government art centers and msm cbos also may reduce administrative costs that might accrue with an entirely new infrastructure for prep administration prep is already in use in india through private practitioners and a few nongovernmental organizations to prevent hiv infection in hiv serodiscordant heterosexual relationships 7 explicit guidelines for provision of prep to msm and other atrisk populations should facilitate quality delivery of prep through private and nongovernmental clinics a recommendation previously issued in the national consultation on prep organized by the population health foundation of india and who in october 2013 7 importantly adherence has been identified as the achilles heel of prep 29 data from clinical trials of prep conducted in north america and resourcelimited settings 21829 have established a clear association between systemic drug exposure and preventive efficacy 234 there is a compelling need for intervention research to identify effective modes for supporting prep adherence in real world settings 35 in addition to education and clinical support to prepare physicians for prep administration 36 effective interventions however are likely to vary across sociocultural contexts 35 indicating the importance of qualitative research conducted in situ findings from the present study suggest that appropriate provision of prep should involve exploration with msm of practical issues that may be expected to impact on adherence how to safely store prep at home in light of concerns about confidentiality and how to navigate disclosure of prep use to ones male partner wife and family our findings also suggest that culturally appropriate interventions to engage community stakeholders 35 and train peer educators 17 may constitute key elements in supporting prep acceptability and adherence among msm in india when prep becomes available in india both health care providers and community educators need to be aware of concerns that may influence uptake and adherence preprelated education should be tailored to address clients needs and concerns such as hiv risk perception relationshipmarital status partners hiv status and attitudes toward condom use of particular relevance to prep rollout among msm in india gatekeepers such as msm community leaders and select health care providers that serve msm communities should be engaged in discussion of the benefits and potential risks of prep to the community as important as is navigating practical concerns the appropriate engagement of community stakeholders may constitute a key element in reducing the stigma associated with prep use and normalizing its role in health promotion for msm importantly we also identified ethical considerations among community leaders related to prep rollout in a resourcelimited setting in which many persons living with hiv do not have unfettered access to art these concerns need to be openly discussed and addressed 37 endorsement from these leaders may be critical to the successful initiation of community focused prep promotion campaigns and inculcation of positive peer norms about prep use future survey research among msm and other key populations in india may help to identify and quantify factors that influence prep acceptability and adherence policyoriented research such as examining costeffectiveness and the potential number of hiv infections averted may also be useful in informing policymakers and public health officials about the contribution of prep to decreasing the hiv epidemic a simulation study conducted before the release of the iprex study results estimated a substantial positive public health impact of prep use in southern india 38 investigations to understand health care providers awareness and willingness to prescribe prep to msm also may be helpful in the indian context 3940 prep demonstration projects among msm to support implementation and thereby maximize preps effectiveness and usefulness in india are also needed 641 to date a prep demonstration project among sex workers through the acclaimed sonagachi project has been awaiting approval from the health ministry of india 42 in conclusion this qualitative investigation suggests that diverse msm in india may find prep an acceptable hiv prevention option understanding perceived barriers to prep use that emerge at the socialcommunity level and the individual level may facilitate the development and implementation of strategies by the government and community agencies to promote prep acceptance and adherence as recommended by who 6 the government of india and communitybased organizations should seize this opportunity to implement evidenceinformed prep programs within a comprehensive hiv prevention package to decrease the sustained hiv burden among msm communities in india

acceptability of hiv preexposure prophylaxis prep and implementation challenges among men who have sex with men in india a qualitative investigation aids patient care and stds 29 10 569577

background marital bereavement and separation or divorce are among the most stressful critical life events in later life both events imply a dissolution of social and emotional ties this deeply affects the attachment system and requires acceptance of the loss as well as the formation of a new identity and a new perspective for the future both events involve the adaptation of daily routines which can be even more challenging when social physical and financial resources decline in later life 1 grief and psychological distress after bereavement or divorce are normative reactions for most people grief intensity weakens to a manageable degree within several weeks or months after the most intensive period grief is still present but the loss becomes gradually integrated and no longer hinders the processes of ongoing life however some individuals are less able to cope with bereavement or divorce and show severe prolonged grief symptoms or adaptation problems lasting more than 6 months 2 3 4 5 some individuals even develop a persistent complex bereavement disorder which is characterized by separation distress frequent or disabling cognitive emotional and behavioural symptoms such as avoidance of reminders of the loved one difficulties moving on with life and functional impairment 67 several theoretical models describe factors that are crucial for an adaptive adjustment to bereavement the task model identifies four tasks of mourning namely accepting the reality of the loss experiencing the pain of grief adjusting to an environment without the deceased person and withdrawing emotional energy and reinvesting it in another relationship 8 the dualprocess model of coping with bereavement posits that a dynamic coping process oscillating between lossoriented tasks such as grief work and restorationoriented tasks such as attending to life changes is essential for adjustment 9 coping with lossoriented tasks involves positive reappraisal versus rumination revisions of personal goals positive and negative event interpretation and expressing emotions toward the deceased restorationoriented coping is focused on attending to life changes engaging in new activities distracting from grief and finding new roles and identities these models also provide a theoretical background for interventions ranging from selfhelp groups and pastoral care to psychotherapy cognitivebehavioural interventions for complicated grief are often based on three components exposure eg the confrontational technique of revisiting the deceased person or telling the story of the loss cognitive reappraisal or restructuring of individual dysfunctional thoughts associated with the loss and integration and restoration 1011 internetbased interventions increasingly complement grief counselling or therapy 12 13 14 15 the majority of internet interventions combine the presentation of a webbased selfhelp programme with minimal but regular therapist contact in a recent metaanalysis this internetbased guided selfhelp approach has proved to be as effective as facetoface therapy for depressive symptoms social anxiety disorder and other psychological or somatic disorders 16 furthermore internetbased interventions have advantages over facetoface therapy benefits of internetbased approaches are low threshold accessibility flexible usage independent of time and place usage at a selfdetermined pace a high level of autonomy and privacy and lower costs 17 these factors may be especially relevant for older adults however challenges of internetbased interventions include technological problems and lower computer literacy or unease using computers which may be more prevalent in old age exposure cognitive reappraisal and integration and restoration as treatment components have also been implemented and evaluated in two randomized controlled trials of internetbased selfhelp interventions for complicated grief after bereavement one 5 week internetbased intervention consisted of two writing assignments a week of approximately 45 min 12 after every second assignment participants received an email from a therapist with personal feedback and further instructions this intervention addressed individuals who experienced symptoms of intrusion avoidance or maladaptive behaviour after the death of a significant other the average age of the 55 participants was 37 years all were women 61 had lost a child and 10 their spouses effect sizes for the comparison with the waiting group ranged from 096174 for different outcome measures followup measures at 18 months confirmed the stability of these effects 18 another internetbased intervention comprised five structured confrontational writing assignments for individuals who experienced the death of a firstdegree relative and who were significantly distressed 13 the average age of the 757 participants was 43 years 94 were women 43 lost a child and 30 their spouses effect sizes ranged from 019 for emotional loneliness to 030 for positive mood for shortterm followup and 025 and 023 for longterm followups these effects were mediated by lower rumination however grief and depressive symptoms did not improve risk and baseline distress were not confirmed as moderators in contrast with these two studies litz and colleagues evaluated an internetbased intervention focusing on selfcare social reengagement and goalfocused activities 14 no formal exposure or cognitive reappraisal was included their randomized controlled trial targeted participants between 3 and 6 months after loss and aimed at exploring whether their intervention could prevent prolonged grief disorder the intervention consisted of 18 sessions covering about 6 weeks an initial phone call and periodic brief emails from a therapist the average age of the 84 participants was 55 years 68 were women 78 lost their spouses the intervention resulted in cohens d of 110 for the reduction in prolonged grief 071 for depression and 051 for anxiety finally a recent study compared an internetbased exposure and behavioural activation treatment 15 the therapistguided interventions consisted of six homework assignments over 68 weeks and a short feedback after each assignment the 47 participants were randomly allocated to the two active treatment conditions and a waiting control group the mean age was 46 years 92 were women 40 reported the death of a partner and 60 reported other losses both interventions reduced complicated grief posttraumatic stress and grief rumination but only exposure had an effect on depression and brooding levels relative to the control group effect sizes ranged between d 007 and d 12 the effects of both interventions were maintained at the 3month followup assessment to the best of our knowledge no internetbased selfhelp intervention has been evaluated for divorced individuals objectives based on the task model of mourning and the dualprocess model of coping with bereavement we developed a guided internetbased selfhelp intervention called livia this intervention addresses individuals who experienced marital bereavement or divorce at least 6 months prior to enrolling in the study and are seeking help for coping with prolonged grief symptoms psychological distress or adaptation problems in daily life this study adds to existing knowledge by evaluating an internetbased intervention specifically designed for spousal bereavement and its consequences testing whether this intervention is equally effective for individuals who suffer from grief and psychological or behavioural adaptation problems after a separation or divorce and by including lossoriented tasks ie exposure and cognitive reframing elements as well as restorationoriented tasks ie selfcare social reengagement and goalfocused activities the combination of both components may increase effect sizes compared with previous studies the severity of grief symptoms is not a criterion for taking part in the study but will be analyzed as a moderator variable we assume that the internetbased selfhelp intervention leads to beneficial effects across the severity dimension of distress individuals who have already developed a prolonged grief disorder but who are not willing to see a counsellor or therapist may benefit from the comprehensive internetdelivered intervention for individuals with less severe distress a timely intervention may help to prevent the progress from a normal grief or separation reaction to a prolonged grief disorder the objectives of the study are methods study design this study is a randomized controlled trial with an internetbased selfhelp intervention and a waiting control condition figure 1 displays the study flowchart the study population are adults who experienced marital bereavement or a separation or divorce more than 6 months prior to enrolment in the study the selfhelp intervention is embedded in a larger swiss populationbased longitudinal study on relationships in later life the lives study ip 212 19 the study coordinator uses two separate lists for widowed and separated individuals to allocate participants to one of the conditions based on computer generated random numbers using randomorg 20 participants in the waiting control group receive access to the intervention 12 weeks after the baseline interview sample size we specified the sample size needed for the different analyses conducting a power analysis based on a probability level of 005 and a power of 080 with g power 21 and a power analysis calculator for structural equation models 22 to test the efficacy of the intervention compared with the control condition we expected a large effect of d 080 power analyses indicated a necessary sample size of 42 individuals for this most basic analysis for the analysis of several predictor variables as well as moderation and mediation effects using structural equation modelling we assumed moderate effects of r 030 power analyses resulted in a sample size of 138 participants anticipating a dropout rate of 40 at the 6 month followup we aim at recruiting between 72 and 220 participants at baseline recruitment recruitment is based on the lives longitudinal study and internetselfhelp forums all participants who reported difficulties with adjustment after marital bereavement or separation or divorce in the lives study receive an information letter about the selfhelp programme with a link to the study website from the lives study coordinator additionally information about the intervention with a link to the study website is posted on several internetbased selfhelp forums eligibility criteria all interested adults are required to complete baseline screening questionnaires and a telephone interview for assessing eligibility prior to randomization inclusion criteria are 1 experience of marital bereavement or a separation or divorce more than 6 months prior to enrolment in the study 2 seeking help for coping with prolonged grief symptoms psychological distress or the psychosocial adaptation to a life without the partner 3 having access to an internet connection 4 mastery of the german language 5 provision of informed consent exclusion criteria are description of the intervention the intervention is a guided 10week internetbased selfhelp programme during the work with the textbased sessions participants receive email support by psychologists of the department of clinical psychology and psychotherapy of the university of bern these weekly emails acknowledge and motivate participants in their work with the selfhelp programme and provide a weekly structure and support for technical problems participants can contact their supporters anytime with questions via a contact button in the selfhelp programme the emailsupporters are supervised by a fully trained psychotherapist measures figure 2 gives an overview of the measures with the timing of the assessment all selfreport questionnaires are completed online baseline measurement is at t 0 postmeasurement t 1 is 12 weeks after the start of the programme or waiting condition postmeasurement t 2 is after 24 weeks and the followup measure t 3 will be completed only by the waiting control group 24 weeks after their start of the intervention ie 36 weeks after baseline primary outcome measures grief symptoms are assessed using the german version of the texas revised inventory of grief 23 the texas revised inventory of grief is a widely used measure to assess the severity of grief symptoms a recent factor analysis identified three factors for emotional response thoughts and nonacceptance regarding a loss 24 the german version of the texas revised inventory of grief is a 16item measure to assess the severity of grief symptoms from 1 completely true to 5 completely false psychopathological distress is assessed using the german version of the brief symptom inventory a widely used 53item measure to assess a broad range of somatic table 1 outline of the 10 selfhelp sessions of the internetbased intervention psychoeducation information about the selfhelp intervention grief reactions reactions to separation predictors and treatment of complicated grief 2 assessment of current situation information about and assessment of emotions in the context of the interpersonal loss changes in life since the loss and obstacles for a positive adaptation 3 fostering positive thoughts and emotions information about emotion regulation and cognitivebehavioural strategies to promote positive thoughts and emotions protocols for practising these strategies in daily life 4 finding comfort suggestions for selfsoothing strategies and exercises to promote positive feelings 5 selfcare checklists for current physical emotional and practical selfcare formulation of selfcare goals and suggestions for implementing selfcare behaviour in daily life 6 accepting memories and pain writing tasks to integrate painful memories of the loss into the autobiographical memory and to be able to tell the story of the loss 7 unfinished business identification of unfinished business and regrets writing tasks to formulate unfinished business and to find ways to put issues at rest 8 creating a new life without the partner identifying changes in daily life since the loss and sources of support and strengths before and after the loss information about posttraumatic growth identifying and activating resources in daily life 9 social relationships clarifying current relationships using a sociogram defining goals related to social relationships eg changing relationships building up new social contacts and suggestions for promoting social wellbeing 10 redefinition of the relationship to the lost partner writing a farewell letter to the lost partner saying goodbye and telling the lost partner about the future importance of the loss and how the participant will continue life without the lost partner and psychopathological symptoms within 7 days prior to completing the questionnaire 25 factors include depressed mood somatic symptoms information processing deficits and interpersonal insecurity 26 answer categories range from 0 not at all to 4 very much depressive symptoms are assessed with the german version of the beck depression inventory ii 27 this measure consists of 21 items on a scale from 0 to 3 secondary outcome measures loneliness is assessed using the de jong gierveld short scale for emotional and social loneliness 28 this is a sixitem scale with answer categories from 0 no to 5 yes embitterment is assessed with the short version of the embitterment scale which consists of six items rated on a scale from 0 i do not agree to 4 i agree 29 life satisfaction is assessed with the german version of the satisfaction with life scale 3031 it consists of five items with answer categories from 1 completely disagree to 7 completely agree sessionrelated outcomes we included nine items related to specific sessions of the intervention eg selfrated knowledge about grief symptoms selfcare selfsoothing strategies satisfaction with social relationships or the current life situation items are rated on scale from 1 very little to 10 very much satisfaction with the selfhelp programme six items assess the evaluation of the quality of and the satisfaction with the intervention and six items assess effects of the intervention related to mechanisms of change ie mastery experiences clarification predictors and moderators computer literacy is assessed using the first seven items of the computer literacy scale for older adults 32 they assess experiences with the computer and the frequency with which participants engage in different computerrelated tasks demographic variables include sex age education overall selfrated health and details about the marital history and the loss of the partner or the separation or divorce criteria for a persistent complex bereavement disorder according to the diagnostic and statistical manual of mental disorders 7 are assessed in the telephone interview suicidality is assessed in the telephone interview using the suicidality questions of the brief psychiatric rating scale 33 adherence and completion data as well as data on the duration and the intensity of the use of the selfhelp intervention are collected within the platform data collection and management data are assessed using onlinequestionnaires programmed in qualtrics 34 data integrity is enforced through a variety of mechanisms ie referential data rules valid values range checks and consistency checks the option to choose a value from a list of valid codes and a description of what each code means is available where applicable checks are applied at the time of data entry into a specific field in addition data on the use of the selfhelp sessions are collected within the platform all data will be saved in an anonymous way only identified by a code that is not related to the participants identity servers are protected by highend firewall systems only the researchers directly involved in the study have access to the data statistical analysis analysis will be conducted according to the intentiontotreat paradigm firstly we will analyze the extent of missing data explore the missing data patterns and determine the type of missing data if the missing mechanism is missing at randomization we will use multilevel regression analyses which allow a different number of measurement points per participants and are thus less sensitive to missing data we will include time group event and interaction terms as predictors of the outcome variables cohens d will be calculated as effect size for all observed outcome variables to analyze the longitudinal interplay of predictor variables we will conduct structural equation models analysis will be conducted in spss and mplus discussion the results of this study will provide insight into the acceptance and efficacy of an internetbased selfhelp intervention for adults who experience grief symptoms psychological distress or adjustment problems in daily life after marital bereavement or separation or divorce the outcomes for bereaved and separated or divorced participants will be compared the analysis of other moderator variables may further aid future selective indication and adaptations for different needs limitations of this study include the selfselectivity of the sample it may be possible that older adults who are willing to take part in an internetbased selfhelp intervention have more cognitive resources and a higher education level additional file additional file 1 spirit 2013 checklist recommended items to address in a clinical trial protocol and related documents authors contributions jb participated in the design of the study and the development of the intervention and drafted the manuscript tb participated in the design of the study and the development of the intervention and programmed the selfhelp intervention hjz conceived the study and participated in its design and the development of the intervention all authors read and approved the final manuscript authors information none competing interests the authors declare that they have no competing interests trial status

background marital bereavement and separation or divorce are among the most stressful critical life events in later life these events require a dissolution of social and emotional ties adjustments in daily routine and changes in identity and perspectives for the future after a normative grief or distress reaction most individuals cope well with the loss however some develop a prolonged grief reaction internetbased selfhelp interventions have proved beneficial for a broad range of disorders including complicated grief based on the task model and the dualprocess model of coping with bereavement we developed a guided internetbased selfhelp intervention for individuals who experienced marital bereavement separation or divorce at least 6 months prior to enrolment the intervention consists of 10 textbased selfhelp sessions and one supportive email a week the primary purpose of this study is the evaluation of the feasibility and efficacy of the intervention compared with a waiting control group the secondary purpose is to compare the effects in bereaved and separated participants furthermore we aim to analyze other predictors moderators and mediators of the outcome such as age psychological distress and intensity of use of the interventionthe design is a randomized controlled trial with a waiting control condition of 12 weeks and a 24weeks followup at least 72 widowed or separated participants will be recruited via our study website and internet forums primary outcomes are reductions in grief symptoms depression and psychological distress secondary outcome measures are related to loneliness satisfaction with life embitterment and the sessions discussion the trial will provide insights into the acceptance and efficacy of internetbased interventions among adults experiencing grief symptoms psychological distress and adaptation problems in daily life after spousal bereavement separation or divorce findings will add to existing knowledge by 1 evaluating an internetbased intervention specifically designed for spousal bereavement and its consequences 2 testing whether this intervention is equally effective for individuals after separation or divorce and 3 suggesting adaptations to improve the efficacy of the intervention selective indication and adaptations for different needs

introduction on december 31 2019 the first cases of the international rapidly expanding sarscov2 virus were reported to the world health organization which until then was defined as a pneumonia of unknown origin after migrating beyond chinas borders the who established that it was a pathological outbreak caused by the severe acute respiratory syndrome coronavirus 2 virus which caused severe acute respiratory syndrome months later on 11 march 2020 the who declared a pandemic since the virus had spread exponentially to countries all over the world brazil became the third most affected country in the world in terms of cases and second in deaths from covid19 during the sarscov2 pandemic social and economic factors shown evidence for national and global social disparities lowerincome populations suffered most from the systems employed for combating the pandemic eg difficulties in maintaining social lockdowns due to employment and income factors and less access to health care and basic sanitation brazil is an extremely important country for carrying out impact study on the covid19 pandemic since it had a serious outbreak given its social and economic circumstances and its complex racial composition the objective of this study was to statistically verify the mortality rates of patients hospitalized during covid19 infection based on their economic social and epidemiological characteristics and by comparing the main findings with other international studies on the theme baqui et al presented a crosssectional study with data from the same database source used in this study when brazil had 3254 deaths it gave results on the mortality factors for covid19 including symptoms age sex ethnicity and comorbidities subsequently the lancet suggested that research on mortality from covid19 should consider social and biological factors but also pay attention to ethnic and socioeconomic disparities among patients emphasizing that the lack of associations between ethnicity and mortality from covid19 is of great concern highlighting a research gap to contribute to this concern the main issue in this research is to answer the question in addition the comorbidities were social factors important determinants of the covid19 mortality in brazil this study analyzed variables like comorbidities age gender ethnicity and geographic region of residence separately similar to the cited works data were collected from the hospitalized severe acute respiratory syndrome database managed by the ministry of health when brazil had 331435 covid19 deaths from february 22 2020 to may 10 2021 additionally this study carefully analyzed social factors we used indices for level of education gender age and race considering the natural divisions made up of brazilian states provided by the ibge automatic recovery system from data from the national household sampling survey we were able to obtain evidence related to social factors and covid19 the importance of the subject is that it may reveal disparities among a patients social condition and the probability of the disease progressing to death methods data collection brazilian ministry of health maintains a system called influenza epidemiological surveillance information system that contains a public dataset about hospitalized severe acute respiratory syndrome from both public and private hospitals in this study we collect data from february 22 2020 when the first case of hospitalization for covid19 was registered in brazil to may 10 2021 when brazil had a total of 1956350 epidemiological patient records for people who sought hospital care at all brazilian states at that time brazil had 331435 covid19 deaths from that dataset were collected some variables that are age gender ethnicity education level comorbidities case evolution the city and the state where the patient lives srag database also contains patient symptoms in addition to the aforementioned information to compose our dataset we collected indicators on social factor from the national survey by sample and householdspnad that were characterized by age race gender and education per state these indicators were assigned to each patient according to their demographic characteristics and place of residence registered on sivepgripe the dataset created allowed us to consider not only health factors to the analyze but also social study design after the data collection some variables were processed for this study we created a new variable to set up the region where the patient lives and classified the ethnicity according to the registered data regarding the brazilian states and regions although brazil is divided into five regions the country was divided into two macroregions in this study using their characteristics similar to the approach by baqui et al the northern macroregion encompasses the northern and northeastern regions and the centralsouth macroregion covers the centralwestern southeastern and southern regions this regional division was done for modeling and data analysis purposes for the chosen statistical models there is a proportionality between the number of covid19 cases the number of hospitalized and deaths with the population of the territorial macroregion north and centralsouth so they can be compared using descriptive statistics also this division was considered quite natural by baqui et al since the socioeconomic factors are similar to analyze the odds of mortality among races patients were grouped into two classes as white or nonwhite for the descriptive statistics we used the names for races as defined by the ibge defines as white black asian indigenous or mixedrace thereafter there were some selections in the databases to avoid null records following some criteria also the social database do not have data about people under 14 years old figure 1 shows data clippings from the initial database and the dataset used in this study of the total number of patients selected 394 had died of the 1956350 records collected from the sivepgripe srag 1223330 patients were classified with covid19 1056906 records had variable evolutions filled in 852403 records had correctly registered ethnicity 852299 listed genders 840201 patients were aged between 14 and 100 years from the resulting database 840201 patients 640916 were from the centralsouth macroregion and 199285 were from the northern macroregion statistical analysis we used statistical data to quantify the impact of the covid19 pandemic on the number of deaths in brazil our main question is to demonstrate the differences between regions ethnicities ages and comorbidities of patients recorded in the database the model shown the mortality rates based on variables with a fixed effect for the patients which were comorbidities and social factors for this analysis we used the logistic regression since the central question of this research is related to a dichotomous variable whether the hospitalized individual evolved to death or not the prediction analysis was based on the study by rodrigues and parreira logistic regression is a useful tool for answering the odds of an event occurring it can predict the binomial outcome of a dependent variable using one or a set of independent variables binary categorical variables are often used in empirical research in health sciences such as history of abortion yes or no food security status insecure food or secure food and food stability 3 times or 3 times posttraumatic stress disorder yes or no the logit model is usually used when the dependent variable is binary fundamentally to measure the probability of a given phenomenon as the response of interest to the dependent variable the binary logistic model can be represented as shown in formula 1 p i e e b0b1x1ibnxni 1 e b0b1x1ibnxni the maximum likelihood was used to estimate the probabilities of deaths of individuals hospitalized with covid19 the objective was to maximize the likelihood function that is to obtain the values of the model parameters in what way the probability of observing the values of yi is the highest possible in logistic regression the sample size is fundamental to apply the model is also relevant to consider some aspects related to the statistical design the method is sensitive to multicollinearity and the most common solution to overcome this limitation is to expand the sample the function is defined by logit and is related to the probability of patient cases evolving to death considering their comorbidities and social factors ie using the relative income index the p risk is calculated below the values are applied in the formula logit p ln p 1p and the odds of death is found as 1p using this method we calculated coefficients that indicate risks for covid19 case with wald confidence intervals at 99 for the odds ratios results the patients were registered in the system according to their city of residence the absolute numbers are shown in figure 2a and the numbers of cases per 100000 people are shown in figure 2b based on research from baqui et al tables 12 show the demographic and comorbidity data between survivors and nonsurvivors and their ethnic composition at each stage of the progression of covid19 regarding patients that have comorbidities there were more registered deaths in the north macroregion in all comorbidities compared to the centralsouth anova test suggesting structural health disparities even with a different number of hospitalized patients and death in the regions the previous quantities are relative to their population which makes the comparison statistically plausible the older patients had a greater mortality percentage especially in the north in that region the nonsurvivors people over 51 years old are 558 and in centralsouth they are 449 table 2 shows a higher proportion of hospitalized deaths in the north than centralsouth suggesting a regional effect anova test shown in the supplemental material in addition there were higher proportions of black ethnicities in deaths in the centralsouth region suggesting an ethnic effect anova test shown in the supplemental material with the tukey test result figures 3ab show comorbidity prevalence calculated considering patient ethnicity and region in this case the figure 2 distribution of absolute number of cases among brazilian states and the federal district and number of cases per 100000 inhabitants cases 840201 ac acre al alagoas am amazonas ap amapá ba bahia ce ceará df distrito federal es espírito santo go goiás ma maranhão mg minas gerais ms mato grosso do sul mt mato grosso pa pará pb paraíba pe pernambuco pi piauí pr paraná rj rio de janeiro rn rio grande do norte ro rondônia rr roraima rs rio grande do sul sc santa catarina se sergipe sp são paulo to tocantins northern or centralsouth for both covid survivors and deaths one can see that there is substantial asymmetry between the results with more deaths in the north furthermore black brazilians without comorbidities had the highest death rates in both the north and the centralsouth for groups with comorbidities in the north most deaths were among indigenous ethnicities in the centralsouth when patients had one or more comorbidity most deaths were among the black people the distribution of nonsurvivors by age and ethnicity that was higher for patients aged above 51 in the north and centralsouth as shown figures 3cd for patients aged 1450 there was greater probability for survival in both regions analyzing only the descriptive data one cannot determine large disparities in survival rates among racial groups according to number of comorbidities and age group the statistical model allowed us to observe which variables and to what degree they influence the individuals odds of mortality based on the coefficient obtained the validity of the model is shown in table 3 with p 00001 for all variables showing that they are explanatory for calculating the probability of an individual not surviving the disease one can infer that the probability of a patient not surviving are greater for patients with some comorbidities arranged in order of least to greatest in table 3 the three worst factors are neurological diseases renal diseases and immunodeficiency disorders among the social variables analyzed separately illiterate patients are more likely to die from the disease along with patients aged over 50 patients residing in the northern macroregion have coefficients that indicate a probability of mortality relative to patients in the centralsouth regions along with women relative to men the relative income variable relevant and central to this work indicates that the higher the index the lower the chance of patient death figure 4 shows the odds ratio for each variable statistically significant at a 99 confidence interval according to these indexes the three comorbidities that most lead the patients to death are neurological disease renal disease and immunodeficiency disorders increased by 199 197 and 169 times respectively one can see that social factors are very significant in increasing risk of death among hospitalized patients for individuals with lower relative income for example odds of death increased 245 times also regional factors are relevant since patients residing in the north and northeast regions of brazil are 137 times more likely to die possibly associated with the urgent care and emergency hospital conditions available to patients discussion this paper presented a study on patient mortality for hospitalizations with covid19 in brazil to the best of our knowledge this study gives the highest number of deaths from covid19 from both health and social factors using brazilian data we were able to verify that social factors were very decisive in determining covid19 mortality in brazil even higher than the comorbidity factors this analysis allowed us to observe that patient survival is higher for younger females with fewer comorbidities in line with results worldwide also other important and new trends for social factors were found in brazil similar to baqui et al significant regional variations were found both in terms of case characteristics and results são paulo minas gerais and rio de janeiro states had the most absolute cases amazonas rio grande do sul and santa catarina sates had the most cases per 100000 inhabitants these states are important gateways to brazil the distribution of hospitalized patients with covid19 ie the north at 24 of all patients and the centralsouth at 76 is disproportional with the population sizes of these regions the north holds 36 of the brazilian population and the centralsouth region 64 this difference highlights national heterogeneity and we can therefore hypothesize that hospitalization rates in the north are lower than the centralsouth although this considers disproportionate increases of patients with covid19 in amazonas in january 2021 in a new wave of cases following a new variant of the virus leading us to infer that the hospital structure in the north was inadequate in attending patients some substantial index variations were observed in each region states in the northern macroregion tended to have higher risk factors than states in the centralsouth region in alignment with the highest percentage of deaths in the north according to was even greater than the main comorbidity found additionally individuals living in less populated regions located further north of the country were also more likely to die when they required hospitalization this information led us to conclude that it is essential to strengthen the conditions of highcomplexity care in the public health system especially for the poorest individuals besides it is important to consider in the public health system planning more equitable distribution of equipment and medical support this study had some limitations especially regarding to the existing database to avoid missing information we clipped 435 from the initial database these records were about evolution ethnicity and gender besides the social database does not consider people under 14 years old which exclude the possibility to analyze this group we suggest that in future studies this could be better explored and considered data availability statement publicly available datasets were analyzed in this study this data can be found at bdsrag2021 identify themselves as mixedrace according to the analysis both ethnic groups share highrisk factors and high death rates of all patients diagnosed with covid19 who died in brazil the centralsouth region has the highest mortality rate per 100000 inhabitants however when the mortality rate is calculated for hospitalized patients only the numbers are different the logistic regression results suggested that risk of death is 137 times greater in the northern macroregion than in the centralsouth macroregion when a patient is admitted to hospital with covid19 it strongly indicates the high complexity health system in the centralsouth macroregion that macroregion is the richer part of the country despite also have great incoming and poverty inequality additionally the study corroborates information stating that the brazilian risk group comprises the elderly with comorbidities furthermore it has been demonstrated that hospitalized brazilian black or mixedrace patients or those who live in the north are at greater risk of death from covid19 in short relative income associated with race illiteracy and regional issues are relevant indicators for social aspects related to the covid19 pandemic in brazil measures to contain the spread of the virus were managed by local cities however concerns about mortality rates are still growing especially after confirmation of the first case of a new variant from india in maranhão state on may 22 2021 which is 50 times more communicable across the country urgent political attention is required directed toward the importance of vaccination in preventing covid19 mortality especially when the official number of deaths has surpassed the 600000 mark in brazil the estimated relative income index was the most intense result in the statistical model performed demonstrating that the worse the socioeconomic conditions of the individuals the greater their chance of death when hospitalized with covid19 this index ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent from the participants legal guardiannext of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements supplementary material the supplementary material for this article can be found online at 2022856137full supplementarymaterial conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher copyright © 2022 rodrigues da costa frizzera trevisan prata reis and resende this is an openaccess article distributed under the terms of the creative commons attribution license the use distribution or reproduction in other forums is permitted provided the original author and the copyright owner are credited and that the original publication in this journal is cited in accordance with accepted academic practice no use distribution or reproduction is permitted which does not comply with these terms

on may 10 2021 brazil ranked second in the world in covid19 deaths understanding risk factors or social and ethnic inequality in health care according to a given city population and political or economic weakness is of paramount importance brazil had a seriousness covid19 outbreak in light of social and economic factors and its complex racial demographics the objective of this study was to verify the odds of mortality of hospitalized patients during covid19 infection based on their economic social and epidemiological characteristics we found that odds of death are greater among patients with comorbidities neurological 199 and renal diseases 197 and immunodeficiency disorders 169 while the relative income 245 indicates that social factors have greater influence on mortality than the comorbidities studied patients living in the northern macroregion of brazil face greater chance of mortality compared to those in centralsouth brazil we conclude that during the studied period the chances of mortality for covid19 in brazil were more strongly influenced by socioeconomic poverty conditions than by natural comorbidities neurological renal and immunodeficiency disorders which were also very relevant regional factors are relevant in mortality rates given more individuals being vulnerable to poverty conditions

a introduction this paper will discuss the altruistic motives of actors implementing social welfare programs originating from the utilization of islamic philanthropic funds during the issue of identity politics in indonesia islamic philanthropy is included in social community funds collected based on religion and used to achieve prosperity maftuhin writes that philanthropy has two elements voluntary action which means caring for others through efforts to create welfare and the public interest which means action or giving for humanitarian purposes or organizations that provide humanitarian assistance islamic philanthropy aims to uphold human dignity for the welfare of the people previous research has discussed idealistic motives which have been described in firlis research on humanitarian assistance by the international committee of the red cross and another study by atmeh explaining motives in the corporate social responsibility program latief discusses the contribution of islamic philanthropy to the development of islamic education in indonesia studies on the politicization that occurred in religion during the indonesian presidential election in 2019 no previous research study material discusses the altruistic motives of implementing community welfare programs funded through islamic philanthropy and occurring during a period of identity politics fauziah mentions three philanthropic activities in islam zakat almsinfaq and waqf until now the power of islam in indonesia is still large as seen from the potential for driving the communitys economy through the obligation of zakat indonesia has the largest muslim population as many as 209120000 based on the zakat potential mapping indicator indonesias zakat potential in 2020 is recorded at idr 3276 trillion or equivalent to 212 of gdp in 2020 idr 154342 trillion zakat is a significant funding potential for community development originating from religious movements managed by one of them nonprofit nongovernmental organization or the amil zakat institution according to pujiatis research the concept of zakat management can be adopted from tax management to make it more effective because of its great potential to assist funding development the islamic philanthropic management organization is a thirdsector institution outside the government and private sector and a nonprofit organization based on religion according to hasibuan an organization is a process of determining grouping and managing various activities needed to achieve common goals nonprofit organizations aim to serve the community without prioritizing profit for themselves with three characteristics organizational resources from donors producing goods and or services without the aim of cultivating profits and no ownership nonprofit organizations engaged in managing islamic philanthropic funds are shaded by religionbased organizations to welfare the social life of muslims however the current condition of religious movements is being politicized and used as a political weapon of power which invites division and gives rise to egoism in religion and organization the 2019 indonesian presidential election has succeeded in creating hate politics due to the contestation and tugofwar of religious symbols namely muslim identity and clerical identity the politicization of religion that occurs most frequently at this stage is the politicization of language religious symbols and narratives leading to religious selfishness and identity politics religious egoism according to quintan wiktorowicz in islamic activism a social movement theory approach is more triggered by efforts to maintain religious symbols for the benefit of the existence of the group or itself in fact according to wiktorowicz the emergence of egoism in religion is a side effect of a fight between religious actors such as fighting for influence before the community of followers occupying positions of power social positions and others politics is synonymous with power in an area to develop carried out by competition between individuals and groups the struggle for positions of power is related to egoism that occurs in politics so politics has to do with egoism identity politics arises because of differences between individuals and on the other hand creates rigidity in individuals who can trigger actions to elevate themselves and place their interests above the interests of others or are called selfish kh yahya cholil staquf stated that many religious groups still view interreligious relations as political competition so religion is used as a political weapon to fight for power if actors in religious organizations adopt a selfish attitude in managing islamic philanthropic funds they have violated the goals of islamic philanthropy to achieve just prosperity in society according to auguste comte in taufik in giving help humans have two motives altruism and selfishness selfish helping behavior aims to seek benefits for oneself or takes advantage of the person being helped while altruistic helping behavior is helping solely for the good of the person being helped comte calls this helping behavior altruism the issue of identity politics which highlights the relationship between power politics and religion impacts the scrutiny of religious organizations in indonesia which continues to this day there are differences in identity between islamic religionbased organizations tasked with managing islamic philanthropy funds in indonesia the perpetrators of islamic philanthropy should not mix philanthropic goals with politics because they are not in accordance with philanthropic goals which should be based on altruism altruism is defined by myers as a motive to increase the welfare of others by utilizing islamic philanthropic funding that the people and returns for the welfare of the people collect the community forms the amil zakat institution in indonesia to collect distribute and utilize zakat one of the large nationalscale lazs in indonesia is baitul maal hidayatullah under the auspices of the hidayatullah organization hidayatullah is a large religious organization in indonesia but until now has not been directly involved in practical politics in indonesia since long ago hidayatullah did not allow his cadres to engage in practical politics hidayatullah wants his cadres to focus on the real sector of good deeds business charity dawah charity tarbiyah social economic development of the people and so on stressed the secretary general of pp hidayatullah abu ala abdullah politics is for worship politics is not just about fighting for power husaini caretaker of attaqwa college hidayatullah depok west java 2021 hidayatullah has made tarbiyah and dawah the main areas of jihad educating the nations life educating the public and enlightening the ummah with islamic teachings the values of monotheism and the principles of the one and only god are essential parts of jihad said dr nashirul haq of the central executive board hidayatullah this study is based on the motives that actors should have in implementing social welfare programs that utilize islamic religious philanthropic funds that uphold fair welfare altruism motives reflect the goals of islamic philanthropy which prioritizes helping others for the welfare of the people who are deserving of those engaged in welfare programs this discussion is important because of the conditions in indonesia which face issues of identity politics that bring the islamic religion into politics which negatively impacts the mentality of the people because of political interests that do not reflect religious goals b method this paper was written based on the results of field research regarding the motives of community economic empowerment actors in the utilization of islamic philanthropy in the hidayatullah organization in east java province the research used a qualitative approach emphasizing meaning reasoning and definition and prioritizing the process rather than the result the conditions could change according to the conditions in the field the research subjects were conducted on humans empowerment actors in the east java baitul maal hidayatullah environment as an institution that utilizes islamic philanthropy to become a community welfare program the objects in this study are empowerment actors from religiousbased social organizations who carry out islamic philanthropy and manifest it as community empowerment hidayatullah the research data comes from primary data obtained from interviews with empowering actors in baitul maal hidayatullah secondary data from magazines and publications of baitul maal hidayatullah and documentation data from literature studies of books and journals informants who become data sources are divided into several categories and positions as follows motive analysis was conducted using discourse texts from interviews with informants from hidayatullah and baitul maal hidayatullah and expressions derived from published media interviews the analysis was carried out by connecting the theory and the data results in the field to produce conclusions regarding altruism as a motive for implementing community welfare programs through islamic philanthropic funds c results and discussion philanthropy is one of the three approaches to promote welfare including poverty alleviation namely the social service social work and philanthropy approaches compared to philanthropy based on islam becoming islamic philanthropy is the concept of religious obligations religious morality and social justice the essence of the goals of philanthropy and religion is social justice to prevent the concentration of wealth and create a circulation of wealth to maintain the level of economic equity the potential for zakat obligations of the indonesian people is a potential for national development funding that can be utilized to carry out community economic development programs that the community can manage through the amil zakat institution philanthropy is also interpreted as voluntary action for the public good or voluntary action for the public interest maftuhin writes that philanthropy has two elements voluntary action which means caring for others through efforts to create welfare and the public interest which means action or giving for humanitarian purposes and or organizations that provide humanitarian assistance the mandate of zakat law no 11 of 2011 states that the primary goal of the national philanthropic management institution is to participate in poverty alleviation with specific targets the mandate was assigned to hidayatullahs baitul maal hidayatullah unit by carrying out fundraising managing funds to utilizing funds the utilization of islamic philanthropy funds is closely related to community empowerment activities in the long term the concept of philanthropy in islam is firmly based on a paradigm that human dignity is fundamental to be maintained and even fought for in line with empowerment activities that aim to increase the dignity of layers of society who are currently unable to escape poverty and underdevelopment the empowerment carried out by baitul maal hidayatullah is carried out by individual actors who run community welfare programs resulting from the utilization of islamic philanthropy actors in this activity have the urge as humans to carry out an act of welfare activities to achieve community empowerment goals on a certain basis every human being has a motivated action or acts with an urge to achieve a goal including human activities in empowering fellow human beings must have a motive motives cannot be observed directly but can be explained by looking at their behavior through stimulation encouragement or power generation for the emergence of a certain behavior motive actions are actions taken by humans because of a perceived need so that the action aims to achieve a goal the aspects contained in motifs are based on the definitions of motifs from bercloon and steiner and wa gerungan is an urge from within humans to perform a behavior that is useful for achieving goals three keywords describe motives psychological drives behavior and goals not all of these three aspects can be seen in real terms to determine the motives of an individual aspects that can be seen and expressed are the behavior and goals of an individual figure 1 three aspects of human action motives the motive in individual psychology is not easy to see but can be identified through encouragement in behavior as described in attribution theory by fritz heider attribution theory explains the causes of individual behavior and the basis for individuals to perform an action or decide to act in specific ways according to heider in observing social behavior the first thing that needs to be determined is the cause of individual behavior external causality and internal causality figure 2 aspects of motives based on the causes of encouragement to behave according to heider attribution is divided into internal or dispositional attribution and external attribution or environmental attribution internal attribution is behavior from the person concerned caused by traits or dispositions external attribution is a persons behavior that comes from the situation of the placeenvironment or outside the person concerned based on the text analysis of the interview results it can be seen the tendency of the informants answers with the following data based on the results of discourse analysis from the interviews with informants some of the motivations behind the informants became drivers of the welfare program carried out by baitul maal hidayatullah internal motivation comes from the psychology of everyone who in this discussion has a position as people who participate in empowerment they consciously state that the encouragement widely expressed is a soul calling related to conscience as a human being to choose to do something in addition to having a calling there is also encouragement from a sense of empathy for others and aspirations within oneself in carrying out empowerment for certain goals in addition to internal drives whose causes cannot be inferred from the naked eye but can be identified from the informants expressions there are also drives whose causes can be identified because they come from outside the perpetrator external encouragement comes from the environment around the empowerment actor which causes an individual to carry out empowerment activities for the community the mandate of the hidayatullah organization as the main organization of the baitul maal hidayatullah is the most frequent expression and is often conveyed by informants hidayatullah is a religious organization that upholds religious values in every activity movements acting in the name of religion have a holy purpose of serving god without any reason by practicing religious teachings that humans must be patient helpful not hateful not divided and have no grudges the movement carried out by baitul maal hidayatullah has a religious goal islam which is oriented towards preaching to the community so that the lives of indonesian people are directed by religion every program driven by hidayatullah is carried out to support the organizations vision to build islamic civilization with the aim of preaching religion in accordance with the discussion of the theoretical basis religion has a role in the emergence of motives for empowering actors in hidayatullah the teachings of islam are realized in the formation of hidayatullah cadres according to its mission to produce quality cadres in the sense of islamic and social qualities hidayatullah uses the systematic method of revelation a method that refers to the events of the revelation of the quran which were given to the prophet muhammad saw sequentially so it is a method or way of educating people in hidayatullah so that they can become true muslims ustadzah retno interviewed head of mushida east java tuesday 23 august 2022 people in hidayatullah are first educated to know the systematics of revelation or how to fully embrace islam as a provider before engaging in congregational life in society motives are determined based on the goals and actions carried out by humans because motives are related to actions carried out with the encouragement of a goal the motives of the perpetrators of empowerment in hidayatullah can be seen through two elements the purpose of utilizing the results of islamic philanthropy and the actions in operating the results of islamic philanthropy activities in philanthropy which means love others which comes from the rules of the islamic religion are zakat infaqalms and endowments which are encouraged to achieve the goal of just human welfare religion encourages philanthropy by religion to love one another by assisting in the form of property and facilities to those in need but not as compassion but as a process of selfpurification and peace of mind for zakat payers guided by the alquran an take alms of their wealth wherewith thou mayst purify them and mayst make them grow and pray for them lo thy prayer is an assuagement for them allah is hearer knower surah at taubah 103 the islamic funding instrument in the form of zakat can support community development in accordance with philanthropic goals voluntary action for the public good which is designed for social change that has a massive impact on social justice with good management of zakat management institutions baitul maal hidayatullah which participates in the management of islamic philanthropy funds sees zakat as perfecting the human creed to realize the goal of cleansing the soul defeating lust and lust that comes from the love of wealth and protecting humans from becoming selfish humans who only think about enriching themselves actions carried out by baitul maal hidayatullah for the welfare of the community are carried out with programs for providing consumptive funds and using productive funds which are realized through empowerment programs the third aspect of motive is the goal because every behavior has a goal charles n cofer explained the direction of behavior because every behavior activity has a goal to be achieved the goals discussed in this chapter are the goals of the perpetrators of empowerment in hidayatullah which are based on philanthropic funding so that the goals of the actors can be broken down into three the goals of empowerment the goals of islamic philanthropy and the goals of individual actors individuals in carrying out empowerment following are the results of the analysis of information interview data as an empowerer at hidayatullah six levels of heading are allowed as follows give help to others harus ada kemauan untuk memberikan sebagian keuntungannya untuk sesama selain itu juga adanya panggilan jiwa dimana allah menyuruh kita untuk saling berbagi dan menolong sesama infaq dan sedekah adalah penguatan umat salah satu bentuk taawun saling membantu sesama umat pemberdayaan yang bersifat membantu sesama adalah tugas manusia didunia untuk membantu sesama tanpa disuruh membantu pun kita harus saling membantu masyarakat yang harus dibantu mana yang membutuhkan roda penggerak dibidang dakwah pendidikan ekonomi dan sosial kemanusiaan agar bisa berbagi bersama umat agar mampu membantu masyarakat menjadi berdaya karena ini adalah tugas kami ditugaskan sebagai manusia ini seharusnya menjadi tugas kita ketika kita membantu hajat orang lain maka allah akan membantu hajat kita di akhirat nanti sebaikbaik manusia adalah yang memberi manfaat kepada orang lain source 2022 interview results based on the discourse text of the interview results in the table it is known that informants often mention the goals of individuals as actors in community welfare programs to help others and carry out tasks and orders these goals become the basis for actors to move and act to carry out empowerment activities the results of the objective analysis can become data to find out the motives of the actors in baitul maal hidayatullah as individuals who participate in the utilization of islamic philanthropy hidayatullahs view as the parent of baitul maal hidayatullah regarding the management of zakat is the basis of the spirit of the actors because this religious basis is the basis for moving towards the goal hidayatullahs view of the purpose of zakat in human life and indonesia is as follows 1 zakat funds are a form of taawun or help to the good done by muslims to help their brothers and sisters in accordance with islamic religious law 2 utilization of zakat funds becomes a real action to help society towards just welfare 3 achieving blessings through the zakat funding process for community welfare the first basic goal of an empowerment actor being able to move about carrying out empowerment activities is because of assignments and orders these tasks and orders can be psychological and theological psychologically humans feel they have a duty to help others and theologically humans have a duty in this world as caliphs khalifah can be interpreted as the role of humans as gods representatives on earth who are given the mandate to administer manage and utilize the earth and all its contents while remaining submissive and obedient to the rules set by allah swt humans have tasks that are ordered on a socioreligious basis as caliphs and other tasks come from orders from the organization that oversees the empowerment actors hidayatullah is an organization that has empowerment actors who are regenerated by instilling organizational goals to become the basis for the movement of empowerment actors the purpose of assisting others can be interpreted as a form of helping individuals to other individuals or a group in need the word fellow is addressed to muslims or fellow muslims therefore the purpose of helping that is expressed aims to benefit other people who are still in one bond of the islamic religion in accordance with the teachings of islam the best human being benefits others other the purpose of giving help and help is also explained in altruism voluntary action to improve the welfare of others without thinking about selfinterest individual motives in humanitarian activities or helping the community can be distinguished into two categories altruism and egotistical opposites altruism motives are voluntary actions to improve the welfare of others without thinking about selfinterest while motives based on selfinterest think about selfinterest the theory of altruism put forward by auguste comte stated that there are three categories of altruism psychological altruism behavioral altruism and ideological altruism the term altruism was coined by the french philosopher and sociologist auguste comte derived from the italian word altrui meaning to others or belonging to others altruism was introduced as an antonym of egoism to refer to the totality of instincts about others in humans the concept of psychological altruism concerns the motives that people have for acting the way they do helping others does not count as altruistic unless the perpetrator has the welfare of others in mind as the ultimate goal in contrast the concept of evolution or behavioral altruism concerns the influence of behavior on survival and that increasing the fitness of others at the expense of their fitness is altruistic sober and wilson believe that altruistic and egoistic tendencies are adaptive for survival the concept of altruism can be identified by knowing the act of helping others and the goals for the welfare of others based on sober and wilsons description of altruism the motives of empowering actors in hidayatullah can be analyzed according to the description of the data as follows figure 3 aspects of altruism in the baitul maal hidayatullah bmh carries out zakat utilization activities through two schemes providing consumptive funds and productive funds through empowerment activities in order to achieve community welfare bmh designed an empowerment program that was believed to be able to alleviate poverty in society through synergistic work however not all programs can be aimed at community empowerment because basically our society still needs assistance in the form of consumptive funds an example of charity activities carried out by bmh is the muharram bangkit program bmh provides compensation packages to orphans and poor people this program is a direct gift but is carried out on a regular basis and gives priority to children whom bmh or children assisted by hidayatullah empowers even though bmh conducts charity programs bmh continues prioritizing trust for welfare through community empowerment programs the implementation of the empowerment program by baitul maal hidayatullah is always enshrined in articles and news both from the bmh website and from the media this news shows openness to muzakki regarding the mandate of the philanthropy fund given to bmh to be managed into a program that helps the community transparency or openness positively affects the trust of zakat management institutions including the disclosure of information submitted to the public regarding programs that have been implemented as a duty and responsibility figure 5 implementation of the productive zakat fund utilization program source website bmh 2022 baitul maal hidayatullah shows actions and goals that tend to help the community toward welfare these goals and actions can work because there are actors in them the basis for acting in the welfare program is not derived from political goals but goals as human beings and program implementers according to what auguste comte explained in the law of three stages the actors run the program because of their belief and intellectual encouragement to behave currently we are trying before our activities to intervene first in the dawah program so we educate them we understand that the bmh of our institution is not political party funds not funds that depart from sudden funds no our funds are in a process the funding there is a mandate from donors muzak which we have to use so we have to deliver these funds in a right target trustworthy and successful way results of ustadz muslim interview east java representative bmh program 27 september 2022 the theological basis is the primary key in baitul maal hidayatullah because it must adhere to islamic religious rules as an islamic religious institution religious belief predicts longterm altruism as reflected in volunteering and charitable contributions gallup brett pelham and steve crabtree very religious people tend to have donated some money and have also been reported to have done social work and helped foreigners religion is the center of generosity frank emerson andrews attitudes toward giving 1953 frank emersons words show that faithbased philanthropy can become a center of generosity that is not only temporary but sustainable according to latief philanthropy is interpreted more broadly namely not only related to the giving activity itself but to how the effectiveness of the activity of giving both material and nonmaterial can encourage collective change in society zhao states that religious people are more altruistic than nonreligious people because all central religious teachings explicitly encourage good behavior toward all beings therefore the basis of religion without politics can create human motives as a driving force for empowerment programs to produce actions that can realize peoples welfare altruism is the basis of the actors in baitul maal hidayatullah as philanthropic administrators to carry out their duties with the aim of helping others and the welfare of the people religious organizations that prioritize the welfare of the people will act based on altruistic motives because of their moral responsibility as religious people d conclusion the motives of the perpetrators of community welfare programs when associated with a religious basis have a relationship between religious philanthropy and religious goals which reflect altruistic motives therefore in terms of altruism starting from the encouragement actions and goals of the actors in baitul maal hidayatullah they have similarities that lead to community welfare selfreligious and psychological encouragement enables the actors implementing the community welfare program at baitul maal hidayatullah to act and behave to help the community achieve prosperity with empowerment programs welfare is a longterm goal of empowerment and a goal that is an aspect of the altruistic motive the primary foundation of hidayatullahs organization has a strong role in instilling the basis of religious and organizational rules so that people within hidayatullahs environment cannot practice politics the absence of interest in politics makes the goals of altruism more achievable and embedded in welfare program implementers bibliography adi i r psikologi pekerjaan sosial dan ilmu kesejahteraan sosial dasardasar pemikiran jakarta grafindo persada

the amil zakat institution laz is an institution that serves the community for the welfare of society through islamic philanthropy funds but the laz program is not yet compatible with other welfare goals there is an issue of politicization that befalls religious organizations so that the focus of amil zakat institutions tends not to lead to community development this paper will discuss the altruistic motives of implementing social welfare programs amidst the issue of identity politics in indonesia this research is based on a study of the motives for helping altruism in accordance with the goals of just social welfare reflecting islamic philanthropys goals the research uses a qualitative approach with motive analysis using discourse texts from interviews with informants from hidayatullah and baitul maal hidayatullah bmh linked to theory to produce conclusions the study results explain that aspects of altruism starting from the encouragement actions and goals of the actors in bmh have similarities that lead to community welfare so that altruism motives reflect what they do as implementing welfare programs based on the islamic religion hidayatullah does not carry out practical politics as a basis for actors in the empowerment process to focus on community welfare

introduction personal networks develop and evolve continuously throughout the life course some scholars suggest that network size is bellshaped as a function of age on average the size of the network initially increases with age peaks at young adulthood and decreases monotonically after middle adulthood however others claim that the network dynamics in later life can be more complex to capture such complexities one needs not only to examine the structure of older adults personal networks but also to investigate the social backgrounds and contextual factors that help shape these networks life course transitions and changes in social context result in exceptionally high network turnover rates for older adults however peripheral ties are especially likely to dissolve as individuals age as compared with inner ties this illustrates an important phenomenon namely that different types of social ties have different likelihoods of dissolving as the social context shifts this motivates my research questions how do the size and structure of personal networks evolve as individuals age to what degree do social disadvantage and contextual factors matter for network dynamics in later life a wellconnected and wellstructured personal network contributes to an individuals wellbeing but people of different sociodemographic backgrounds have different chances of building and maintaining such a network empirical studies have shown a positive association between advantageous personal networks and other life outcomes including lower mortality risk and better physical health and emotional wellbeing the supporting role of personal networks becomes more substantial in later adulthood as older adults tend to rely on close ties for social support especially once their health substantially declines social disadvantage is associated with less desired network positions as well as less favored network characteristics however both these lines of research are faced with the problem of reverse causality is it that a good social relationship leads to advantage in health living situation and economic standing or do those same factors contribute to both a good social relationship and other positive life outcomes in other words the success in social relationships and other life outcomes could be the result of some other social factors such as favorable sociodemographic background or contextual factors moreover social contexts and networks could coevolve as adults age one way of compensating for this is to incorporate existing social disadvantage indicators and dynamic contextual factors simultaneously in the analysis among the relevant factors the residential working and health contexts are often considered to play a key role in shaping personal networks therefore i include all these factors in my models this paper has two main parts first i present how older adults personal networks change over a tenyear period specifically i show how the size composition and frequency of contact change these are defining factors of a networks structure and function second i examine how disadvantaged backgrounds and shifts in contextual factors correlate with network features by comparing the network features of disadvantaged groups and the reference group one can see how preexisting disadvantage can impact network size and structure by including the contextual factors one can see how contexts can alter network size and structure i explore how networks are constrained by preexisting social disadvantage but can be altered by the social contexts in the meantime one can also see how personal networks compensate for preexisting disadvantages to achieve the analysis goals i apply betweenwithin models the betweenindividual effect compares network structure and size differences across social groups the withinindividual change shows how contextual factors and personal networks evolve for an individual across time the results have significant implications on how social networks are associated with social inequality social disadvantage context and network dynamics in later life there is still debate about how personal networks evolve during the aging process on the one hand social disengagement theory claims that as individuals grow older they become less engaged with their network members this theory indicates that both network size and frequency of contact decrease as adults get older along this line of research socioemotional selectivity theory proposes that as older adults age they tend to downsize their networks in a way which benefits emotional wellbeing they prioritize the social connections which satisfy their emotional needs instead of social ties that give them useful information or financial benefits on the other hand some scholars advocate that personal networks remain relatively stable as individuals age these scholars acknowledge the potential network turnover that older adults experience due to changes in social contexts for instance retirement health decline relocation and adult children moving away can all fracture existing ties of older adults however these scholars suggest that older adults actively adjust for the loss of ties and make efforts to build new connections as a result older adults achieve homeostasis in network size the structure of older adults networks is as vital as the network size different types of networks such as diverse networks familycentered networks friendcentered networks and restricted networks usually indicate different accessibility to social resources moreover the type and structure of social networks are associated with health outcomes such as life expectancy health habits and quality of life more diverse networks are associated with better mental and physical health while restrained networks are linked to inferior mental health in older adulthood familybased networks are prevalent and of great importance for older adults older adults with familybased networks are less likely to experience depressive thoughts and are more satisfied with their quality of life this paper examines the size and structure of the confidant network because its members are essential for supporting older adults as age increases i expand on work that has studied how age contextual factors and sociodemographic background are intertwined and impact the close ties of older adults the answer to this question contributes to our understanding of the role of personal networks in aging and the corresponding consequences for social inequality preexisting social disadvantage is associated with less favorable network characteristics previous studies have used limited education and racial minority status as the key indicators of social disadvantage older adults with higher education are more likely to have their adult children as confidants despite geographical distance race and ethnicity affect the size and composition of an individuals network some scholars suggest that black americans are more likely to have a smaller network with higher frequency of contact their networks tend to be more familybased than other racial groups older black american adults and those who did not attend college are more likely to experience instability in their relationships with their adult children this might cause them to lose access to important resources and support since parentchild ties are essential for older adults contextual factors are the elements of the social environment in which one is embedded andor which describe essential changes in the life course which affect ones social interactions contextual factors including neighborhood environment job entry retirement functional health decline change in mental health status and relocation can also lead to personal network changes neighborhood environments have significant implications on social inequality in the us the community in which an individual lives is closely linked to their income level educational outcome high risk behavior delinquent activity criminal involvement and mental and physical health based on a randomized social experiment ludwig et al found that moving from a disadvantaged neighborhood to a less disadvantaged neighborhood benefits both mental and physical health which in turn contributes to a higher level of life satisfaction disadvantaged neighborhoods are more likely to experience higher rates of crime and homicide social cohesion within a neighborhood is relevant to the networks of the residents disadvantaged neighborhoods are associated with smaller network size for older adults older male adults who live in disadvantaged neighborhoods tend to have less frequent contact with family and friends the influence of residential contexts on individuals personal networks persists across different life stages working status also impacts network composition and structure retiring adults are less likely to maintain coworker relationships which results in a decline in network size and a more closely knit network the closeness of social ties from work and the timing of retirement both impact how the network changes peripheral ties have a higher a probability to dissolve during the transition to retirement regardless of occupational type some scholars suggest that networks become more stable after the transition to retirement other lifecourse changes such as mental health decline functional health decline and the transition into caregiving roles also affect how networks change in the long term for older adults transitioning into caregiving roles might put a lot of strain on their psychological wellbeing and lead to conflicts with family members apart from impacting personal networks directly social context can also be a moderating factor between networks and other life outcomes the studies above provide us with broad knowledge of the essential factors shaping personal networks as mentioned above i take a dynamic perspective and track the changes in the contextual factors as well as the changes in personal networks across time social networks are dynamic in nature and the stability of networks differ for different social groups likewise contextual factors can be unstable especially for disadvantaged groups moreover research in this area often focuses either solely on social disadvantage or contextual factors preexisting social disadvantages and contextual factors may be closely intertwined individuals from disadvantaged social backgrounds have higher likelihood to be trapped in less favorable social environments and encounter more instability and insecurity throughout the life course as a result preexisting disadvantage and the evolving contextual factors together shape the personal network of an older adult including both preexisting social disadvantages and social contexts in the analysis allows one to distinguish between the impacts due to each separate factor examining the coevolution of social environments and personal networks can help solve the problem of reverse causality furthermore instability in personal networks can affect individuals health and socioeconomic outcomes some research has shown how various life events impact network size and structure over an extended time period despite the innovation and advancement in these studies most are only based on a small number of observations which are not necessarily representative for an entire nationwide social group my study contributes to this line of inquiry by analyzing changes in personal networks and their association with evolving contextual factors as well as preexisting social disadvantage based on longitudinal and populationbased data i claim that network change is intertwined with preexisting social disadvantage and contextual factors on the one hand people from disadvantaged backgrounds are more likely to rely on resources provided by their close social circles thus they have the motivation to sustain existing network ties and seek potential new connections on the other hand individuals from underprivileged backgrounds might have limited resources to maintain or construct social ties previous theories such as social convoy theory suggest that close ties are less likely to dissolve than peripheral ties socioemotional selection theory also emphasizes the value of close ties and how older adults make great efforts to preserve these ties although close ties are more enduring than peripheral ties they can still be highly dynamic in later life by using longitudinal and nationally representative data on older adults confidant networks this paper captures the change in close ties over a 10year period in later life furthermore i examine how social disadvantage contextual factors and changes in these elements are associated with the change of network size and structure over a long time period in later life based on previous research i propose the following hypotheses hypothesis 1 on average network size frequency of contact and proportion of kin tend to decrease over the long term as age increases hypothesis 2 for older adults from disadvantaged backgrounds personal networks tend to be smaller in size with a lower level of diversity hypothesis 3 changes in the contextual factors can alter network size and structure even after controlling for preexisting social disadvantage data and methods nshap data this study uses three rounds of data on 1168 older adults from the national social life health and aging project nshap is the first nationally representative dataset on communitydwelling older adults egocentric network change in the united states this study collected detailed information from older adults including sociodemographic backgrounds egocentric networks marital and sexual relationship history health and neighborhood environment this paper mainly utilizes the network section and sociodemographic background section the first round of data was collected in 20052006 with a sample size of 3005 the second round and third round of data were collected in 5year increments at round 1 the older adults were aged between 57 and 85 years old the sample of this study consists of older adults who were surveyed in all three rounds the weighted and conditional response rates for round 1 round 2 and round 3 are 755 89 and 892 respectively measures the outcome variables are network size frequency of contact and proportion of kin the confidant network is an egocentric network with the respondent as the center of the network these egocentric networks were elicited by a widely used name generator specifically each respondent was asked to give a list of names of people with whom they discussed important matters in the past 12 months1 three aspects of the egocentric confidant network are of most interest in this paper namely network size average contact frequency and network kin composition network size is the number of close contacts that older adults have in the egocentric network the frequency of contact captures how often the ego talks to the alters on average the proportion of kin is the percentage of kin members in respondents confidant network the explanatory variables can be divided into two groups sociodemographic characteristics and contextual factors for sociodemographic characteristics i focus on respondents race and ethnicity and educational attainment these two variables are often used to identify social disadvantage for race and ethnicity i generated three dummy variables with white respondents as the reference group racial groups and educational attainment are treated as timeinvariant variables for contextual factors i primarily examine respondents functional and mental health status working status and neighborhood ties ideally all the contextual variables should be timevarying variables however some variables are only available in a certain round of the survey for instance neighborhood ties are only collected at round 2 it is still meaningful to include these screenshots of context to present a whole picture of how contextual factors impact network dynamics other contextual variables are all treated as timevarying variables in the models functional health mental health and working status were collected at all three rounds the range for selfrated mental health is from 1 to 5 2 with larger scores indicating better mental health functional health is evaluated by respondents difficulty in adl and iadl activities the range of the functional health score is from 27 to 0 3 0 represents that there is no difficulty in adl and iadl activities while more negative values represent more difficulty in the adl and iadl activities working status is a binary variable documenting whether the older adult worked for pay in the last week control variables include gender age marital status and household size previous research has suggested networks and their change could differ among people of different gender age marital status and household size based on the design of the nshap survey gender is treated as a timeinvariant variable age marital status and household size are treated as timevarying variables age is scaled by 10 to demonstrate the coefficient of age more clearly and to show the differences between 10year age groups more straightforwardly household size measures how many people live in the household being interviewed including the respondent methods and models the main model that i utilized is the betweenwithin model i use some key social disadvantage indicators and contextual indicators to predict the change in network size frequency of contact and network composition three models were estimated using the explanatory variables and controls to predict the change in network size the frequency of contact and network kin composition in later life respectively i estimated the following betweenwithin model where y it is the network characteristic x itm is individual i s explanatory variable m at time t x im is individual i s average value of variable m over ten years wm are the withinindividual estimators bm are the betweenindividual estimators and c ik is a set of control variables the coef ficient wm means each unit of withinindividual change in explanatory variable m is linked to wm change in the y it a i m ∑ m1 wm x itm x im m ∑ m1 bm x im k ∑ k1 k c ik e it outcome variable y it one strength of betweenwithin mod els over ols models is that they separate withinindividual effects and betweenindividual effects this advantage is especially valuable for the timevarying explanatory variables that i study the withinindividual estimator captures how changes in a feature of an individual over ten years are associated with changes in network structure results table 1 shows the descriptive statistics of the variables in the models the upper panel of the table shows the concentration tendency of the sociodemographic variables 76 of the respondents are white black nonblack hispanic 4 and other race and ethnicity constitute 12 9 and 2 of the sample respectively 37 of the older adults only graduated from high school or less on average the mean of the selfrated mental health score is 39 per the range of 15 at round 1 the average score of functional health is 14 this suggests that the respondents have moderate difficulty in adl and iadl activities on average over ten years mental health scores remain relatively stable while functional health declines monotonically at round 1 40 of the respondents worked for pay recently the average household size at round 1 is 2 meaning that on average older adults live with at least one other person the average size of older adults confidant network at round 1 is 365 this number increases slightly to 392 five years later and remains steady in the following five years on average older adults talk to network members more than once a week the frequency of contact decreased slightly in the following 10 years at round 1 67 of the network members are kin the composition of kin in confidant network decreases in the next 10 years on average as older adults get older their confidant networks tend to shrink more at the same time the frequency of contact and proportion of kin tend to decrease my first research question asks how networks change as age increases the betweenand withinindividual coefficients of age in table 2 show that as an individual ages the size of the social network increases while the frequency of contact and proportion of kin decrease but if the results from the lower panel of table 1 are combined one can see that for the entire sample the absolute change in network size frequency of contact and proportion of kin is relatively small based on table 1 network size has a small increase while the frequency of contact and proportion of 2 i assigned the scores to different mental health categories as below 1 poor 2 fair 3 good 4 very good 5 excellent higher scores indicate better mental health 3 similar to previous research i assigned scores to each of nine functional health categories as follows 0 no difficulty 1 some difficulty 2 much difficulty 3 unable to do scores closer to 0 indicate better functional health 4 the raceethnicity category in this paper is the same as the category in the original data from nshap nshap divides race and ethnicity into four categories 1 white 2 black 3 hispanic nonblack 4 other kin decrease monotonically for the entire sample on average hypothesis 1 is partially supported in addition none of the betweenindividual coefficients are statistically significant this indicates that no cohort difference in network size and structure is observed however this might be due to the small sample size of each cohort in the overall sample when performing more detailed analyses by social groups i find statistically significant differences between people from different social groups the upper panel of table 2 shows the association between preexisting social disadvantage and network size and structure as suggested beforehand racial minority status and lack of college education are indicators of social disadvantage in the upper panel of table 2 the coefficients suggest that older black and hispanic adults tend to have a smaller network size than older white adults at the same time older black and hispanic adults tend to have higher frequency of contact older hispanic adults tend to have higher proportion of kin in the confidant network these findings align with previous studies lower educational level is associated with a smaller network size more frequent contact and higher proportion of kin in the confidant network these results suggest that people from disadvantaged groups tend to have smaller networks a higher frequency of contact and are more likely to have kincentered networks hypothesis 2 is partially supported previous literature has suggested that a larger network size and a more diverse network are more beneficial my findings suggest that older adults from disadvantaged socioeconomic backgrounds are less likely to have these beneficial networks however preexisting disadvantages do not dictate the size and structure of individuals networks over a longtime period during older adulthood as contextual factors shift network features also shift contextual factors play an important role in shaping older adults networks net of preexisting social disadvantage mental health is an important indicator of network change better mental health is associated with more frequent contact with confidants and higher proportion of kin as mental health improves the average frequency of contact increases no significant difference in network change has been found between those older adults who worked for pay recently and those who did not however transitioning into working for pay is linked to more frequent contact with network members the cohesiveness of the neighborhood in which older adults live also has implications for network change older adults who live in a more cohesive community tend to have a larger network size higher frequency of contact and lower proportion of kin these results suggest that despite preexisting social disadvantage positive contextual factors can lead to increase in network size more contact with friends and lower proportion of kin hypothesis 3 is partially supported as for control variables older adults who were married or had a partner present at round 1 tend to have a higher proportion of kin than those who were not married or did not have a partner present those who transitioned into being married or having a partner present increased their proportion of kin in the confidant network older adults with a larger household size are likely to contact network members more often moreover a greater proportion of these contacts are kin members conclusions and discussion the changes in the size and structure of close social ties impact essential life outcomes of older adults however what leads to these changes is not yet fully understood socioemotional selectivity theory and social convoy theory claim close social ties are more enduring than peripheral or weak ties in the aging process the core question these theories address is which type of social ties are more enduring throughout the life course however even the strongest ties dissolve or change over a longtime period moreover the pattern of network change differs for different social groups for instance suanet and huxholds study on two dutch cohorts suggests that the 193847 birth cohort is more likely to have an increase in network size around retirement age than the 192837 cohort which is related to increased educational level and more diverse social roles for another the size and structure of the convoys of an adult are contingent on their own position in the network what previous scholarship leaves unanswered is how the change in the strongest ties across time differs by socioeconomic status to what extent do preexisting social disadvantage and contextual factors shape ones closest social network ties based on the longitudinal study of older adults egocentric networks i find that the pattern of network change in later life is contingent on the social background and the contextual factors in which individuals are situated additionally i did not observe a monotonic decrease in network size over the ten years as previous studies suggested my findings suggest that preexisting social disadvantage is associated with less favorable network features for older adults older adults who did not attend college have fewer close friends with whom to discuss important matters and have a higher proportion of kin in their close social circles likewise black older adults and hispanic older adults have fewer confidants and are more likely to have kin as their close friends some scholars argue that the rule of homophily based on race and ethnicity might contribute to a smaller network size for older black adults however studies have shown that homophily based on racial and ethnic background in the friendship network does not benefit racial minorities a larger and more diverse network often indicates more social resources and benefits are available from the network members however whether an individual can build and maintain such advantageous networks largely depends on their socioeconomic status and preexisting resources these findings align with previous scholarship in the meantime i find that less educated and racial minority older adults have a higher frequency of contact with confidants compared to their counterparts this could be because these older adults are more reliant on their network members for support and resources on a daily basis i propose that contacting network members frequently is a necessity and functions as a strategy to activate the potential resources in the network close social ties in this case act as a complementary resource to make up for the lack of financial cultural and political resources available for these older adults i claim that social contexts and the shifts in these contexts can alter personal networks in significant ways even though preexisting social disadvantage restrains the size and diversity of personal networks for instance neighborhood cohesion is positively associated with the network size and negatively associated with proportion of kin the social capital at the community level can be transferred to an individual level older adults living in a cohesive community have more chances to meet people outside of their family and build connections a welcoming community also encourages people to initiate contacts and stay connected on the other hand instability in a variety of key social and personal variables might cause shifts in the network and the pattern of network change also i find that mental health is linked to the size and structure of the close social circle older adults with better mental health tend to contact their close friends more often transitioning into better mental health or transitioning into working status is associated with more frequent contact with confidants better mental health empowers older adults to reach out and activate their social capital if retired older adults return to work this can still ignite social contact and connections based on these findings i propose that older adults make efforts to adjust to changes in their networks during the aging process while holding the social background constant withinindividual changes in personal networks can be seen as the consequence of individuals efforts to cope with changes in the social context since a diverse and wellconnected network is associated with more positive life outcomes older adults from disadvantaged backgrounds have more motivation to initiate contacts and stay connected for instance the death of a spouse is related to an increase in participation in group activities frequency of contacting friends and family and familial support for disadvantaged older adults the close social circle can be the only resource to cope with negative life events however for privileged older adults there can be multiple alternative resources at their disposal thus these adults have less frequent need to contact their close ties the cultivation and maintenance of social ties in later life depends not only on socioeconomic background but also on propulsive action that not everyone can take however to what extent personal effort counts in making and sustaining social connections needs to be further examined it takes a considerable amount of time material resources and emotional labor to maintain and convert social capital to materialistic or emotional resources individuals from disadvantaged social backgrounds have a higher likelihood of experiencing instability in the social environment and are more vulnerable to negative changes when preexisting disadvantage and less favorable social context compound the stress they place on the social networks of the disadvantaged is also aggregated in the end it can lead to the concentration of social disadvantage this paper has a few limitations first this paper did not investigate the socioeconomic status of the network members of the older adults previous research suggests that older adults adjust networks in a way that favors their emotional needs over their materialistic needs however i propose that the way older adults utilize their network is highly likely to depend on their life situation and socioeconomic background i mainly focus on the features of the ego and the contexts in which the ego is situated i did not include any dyadiclevel factors due to this limitation i did not examine the network members social resources to understand how much the confidant network could help older adults in daily life one needs to know what resources these network members provide for the older adults frequent contact could offer the emotional support that older adults need financial assistance is also a critical aspect of networks as resources however the nshap dataset does not have information on the degree to which the confidants provide financial aid for older adults i also do not have data on the general material support that older adults obtained from their confidants but previous studies based on empirical data have repeatedly shown that networks can provide various resources therefore i assume this as a given for future research it would be helpful to collect data on what type of resources the ego obtains from each social tie second this paper uses only three rounds of data across ten years to model change in network size and structure that is to say the survey may fail to capture changes in contextual factors and network features over short time scales however considering the size of the final sample i still found significant association between the change in the social context and network features ideally future research will benefit from more frequently collected longitudinal network data third this paper only investigates the dynamics of older adults close ties it does not show how the weaker ties change as adults age the pattern of change in social ties could be very different for the stronger ties and the weaker ties finally due to the limitations of the data the aspects of key explanatory variables and their change that i can include in the models are limited further research along these lines will help to improve our understanding of the relationship between various contextual factors and network dynamics page 10 of 11 were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 author contributions nf wrote and revised this manuscript competing interests the authors declare no competing interests open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

to what degree do social disadvantage and contextual factors matter for network dynamics in later life this paper answers these two questions based on egocentric network data of older adults over a tenyear period specifically i use longitudinal and nationally representative data on 1168 older adults from the national social life health and aging project i use betweenwithin models to separate the withinand betweenindividual effects of sociodemographic characteristics and contextual factors on three aspects of social connectedness in later life network size frequency of contact and proportion of kin patterns of network change vary among people of different races and ethnicities as well as educational levels black and hispanic respondents have a significantly smaller network size and a higher average frequency of contact with confidants moreover hispanic respondents have a higher proportion of kin in the network compared to white respondents similarly older adults with less education have a smaller network size higher frequency of contact and higher proportion of kin in their confidant networks compared to those who attended college older adults who have better mental health are more likely to have a higher frequency of contact and higher proportion of kin when an older adult starts to work for pay their frequency of contact with confidants tends to increase older adults living in neighborhoods with stronger social ties are more likely to have a larger network size higher frequency of contact and lower proportion of kin in their confidant network the above results show that disadvantaged backgrounds and contextual factors are associated with certain less favorable network characteristics which helps to explain the concentration of social disadvantage on certain populations

has the racialethnic digital divide among older community dwellers deepened or improved in the 2010s xiayu chen 1 j zak peet 2 danan gu 3 and kun wang 4 1 university of illinois at champaignillinoisunited states2 binghamton universitybinghamtonnew yorkunited states3 the united nationsnew york citynew yorkunited states4 binghamton universitystate university of new yorkbinghamtonnew yorkunited states after the rapid societal and technological changes that occurred during the 2010s it is unclear whether the racial ethnic digital divide has deepened or improved guided by critical race theory this study aims to examine trends of the racialethnic effect on the firstand secondlevel digital divide and how raceethnicity interacts with gender and education data from three rounds of the national health and ageing trend study were used in this study older community dwellers with normal cognition were included the firstlevel digital divide was measured by internet access the secondlevel digital divide was measured by the usage of six online activities using weighted multiple logistic regressions we found that raceethnicity became not significantly associated with the firstlevel digital divide in 2019 but was consistently associated with the secondlevel divide neither gender nor education moderated the firstlevel digital divide association across the three years for the secondlevel digital divide education moderated the racial ethnic digital divide on online grocery shopping and banking in 2011 and 2015 but not in 2019 by contrast educations moderation effects on buying prescriptions contacting health providers and getting health information online were significant in 2015 and 2019 no general trends were found for the moderation effect of gender on the secondlevel digital divide racialethnic gaps in the firstlevel but not the secondlevel digital divide were alleviated more interventions should be provided for racialethnic minorities especially those with low education jeffrey stout university of central florida orlando florida united states integrating assistive technologies into fall prevention interventions could improve health outcomes but older adults in lowincome settings face greater challenges with technology use due to factors such as cost access and location we examined the acceptance of technology in lowincome older adults and the factors associated with their acceptance in this crosssectional study 126 adults aged 60 years and older agreed to participate in the study three technologies including a btrack balance system bioimpedance measurement device and activity monitoring device were used to assess fall risk the senior technology acceptance was used to assess the acceptance of technology sta consists of four domains with 14 items the pearson correlation test was used to determine the correlation between sta scores fall risk and demographic factors we found a significant correlation between sta and the cdcs steadi fall risk score between sta and education and between sta and age participants had the highest mean sta scores to the lowest mean scores as follows health conditions control beliefs attitudinal beliefs and gerontological anxiety the use of technology is acceptable to lowincome older adults but fall risk education and age were associated with acceptance they may benefit from technologically based fall prevention intervention since they have the potential to use technology with low fear expressed toward it abstract citation id igad1042207 lack of pharmacological agents to improve cognition has prompted research on behavioral interventions such as cognitive training ct benefit is inconsistent across nonpatient populations however our recent work reveals multimodal commercialized ct shows promise for improving cognition and sleep in older adults with insomnia evaluation of noncommercialized ct allows for easy implementation of test scenariosvariables monitoring and iterative optimization this study 1 created a novel noncommercialized ct for older adults with insomnia and 2 conducted usability testingfeature evaluation cogmuse is a computerized multimodal ct ten older adults with insomnia complaints completed 20 minutes of cogmuse and the game user experience satisfaction scale openended feedback was solicited compiled transcripts were analyzed independently through deductive content analysis frequent topicsthemes were identified guess18 average scores ranged from 3570 to 5970 for star snatcher and from 3170 to 557 for worse for wire feedback themes were largely positive negative themes included quick movement and lackluster graphicsgameplay story and lack of error consequences and practice trials older adults with insomnia evaluated cogmuse as easy and enjoyable to use with acceptable aesthetics improvement themes largely focused on instructions and navigation next steps include updating cogmuse and evaluating its preliminary efficacy on cognition and sleep overthecounter medications with anticholinergic effects are widely used by older adults despite their association with an increased risk of alzheimers disease and related dementias authoritative bodies such as the american geriatrics society and national academy of medicine recommend discouraging the use of both prescription and otc anticholinergics however most interventions previously developed and tested have targeted only prescription anticholinergics despite the use rate of otc anticholinergics being higher in older adult populations consumerfacing technology may be ideal for addressing otc anticholinergic use as it is cost effective scalable and can address the constraints of relying on busy pharmacists to intervene during older adult otc medication purchases this has become especially relevant as pharmacies face staffing shortages increasing pharmacist workload and requiring pharmacies adjust their hours of operation our interdisciplinary team of pharmacists engineers and designers engaged both older adults and pharmacy staff in the codesign of otc senior station a usercentered consumerfacing kiosk to be placed in community pharmacies to promote reduced anticholinergic use by older adults kiosk users are prompted to input brief information which is used to present safer alternatives to otc anticholinergics this poster will present otc senior stationwhat we believe to be the first consumerfacing technology to target otc anticholinergic usethe participatory design methods used to create it and the results of studies to assess its usability with older adults mixedmethods evaluation of a novel multimodal cognitive training cogmuse in older adults with insomnia

subtle changes in instrumental activities of daily living iadl also termed everyday functional abilities may be early markers of dementia however there are no widely available tools for tracking iadl function and it is unclear whether such a tool would be used by older adults the present study investigates older adults adherence to a novel mobile app designed to conveniently and costeffectively monitor iadl function we also examine participants acceptability of the app including their overall satisfaction perceived ease of use benefits and limitations and suggestions for improvement communitydwelling older adults n24 mage7163 years were randomly assigned three different simulated iadl tasks to complete at specified times each day for two weeks adherence was assessed using app usage data app perceptions were assessed via survey and individual interview at the end of the twoweek study period results indicate high adherence with an average total task completion of 942 results from followup interviews revealed the app was generally perceived as easy to use and the assigned tasks could be completed quickly participants expressed frustration over app glitches that prevented them from successfully completing tasks and noted the assigned tasks and associated steps to complete were too simplified to be realistic high adherence rates and general acceptance indicate the apps potential usefulness further research should assess longterm effectiveness and user experience especially among a more diverse sample if reliable and valid such apps could enable early dementia detection but only if their use is feasible and accepted

are kept out of all important decision making processes while the responsibilities ultimately impinge on them they have no or very little power to take decisions due to many reasons like lack of education lack of mobility lack of control over resources low level of awareness of their civic human rights lack of credit facilities from the government the importance womens participation in family decisionmaking among third world countries is limited to some extent the discriminatory social norms across societies imbalanced gendered power within households and communities unequal access to resources and opportunities impact on womens participation at all levels of decision making the participation of women in decision making of major household purchases has a strong significant association with sociobackground characteristics in outcome there is a lack of confidence to contribute to public decision making of women prevents many women from trying to take on leadership roles in myanmar women in myanmar have a high burden of work which includes both productive and reproductive work thus the participation of myanmar women in the development implementation monitoring and evaluation of policies and programs can develop their qualities and leadership roles nowadays it is often argued that womens contributions are undermined and their involvement in decision making is minimal information about womens extent of participation and decisionmaking power in livestock and household management is still lacking in myanmar there is no study and research about womens participation and activities in livestock management related to their decisionmaking behavior thus the study was conducted to assess the factors affecting on rural womens participation level and decisionmaking behavior of rural women in livestock management and household activities specifically the study aimed to 11 objectives analyze the livelihood status social norms and beliefs related to livestock production of rural women in study area assess rural womens participation level and decisionmaking behavior of rural women in livestock management and household activities explore the factors affecting on rural womens participation level and decisionmaking behavior of rural women in livestock management and household activities materials and methods livestock development is the driving force for rural development in myanmar according to census in 2019 there are 112891 populations of cattle 70 populations of dairy cattle 15849 populations of sheep and 29455 populations of goats livestock is playing a crucial role in the fulfillment of basic subsistence requirements of the countrys poor the livestock farmers embark on various activities of livestock management like watering and feeding of animals cleaning activities and milking women are the household managers but their work is considered as nonproductive unorganized undocumented and their contribution in agricultural labor force in developed countries is 367 while it is about 436 in developing countries as compared to men contribution of women in livestock care and management is higher and they contribute 60 to 80 of labor in the animal husbandry women carry out their livestock production to their household commitments or duties which include food preparation childcare water collection gathering firewood milling grains cleaning sewing and embroidery the success of livestock enterprise relies heavily on effective involvement of women because they are closely involved in animal husbandry sort of activities on the other side male dominance in the decisionmaking of the household has continued in the gender biases of some areas even if women are the key providers of the labor perform the most of all male dominance and traditional belief system are the main factors which had affected the involvement of rural women in decision making process men are taking the lead role in the decisionmaking of their households the reasons women are kept out of all important decisionmaking processes are due to lack of education lack of mobility lack of control over resources low level of awareness of their human rights and lack of credit facilities from the government results data collection and analysis the number of households about 60 were selected from three villages in natmauk township central dry zone area myanmar a survey was collected quantitative numbered data using questionnaires or interviews and statistically analyze the data to describe trends about responses to questions and to test research questions or hypotheses interview using a structured questionnaire key informant interviews focus group discussions and desk review of relevant secondary documents were used in the study descriptive analysis and inferential statistics were used through the aid of the spss software for chisquare test with the use of goodman and kruskals lambda coefficient correlation and stepwise regression methods to determine the relationship between the dependent and independent variables results and discussion demographic factors data of livelihood status social norms and beliefs related to livestock production of the respondents were included in these factors age the mean age of the respondents was 51 years within the range of 1773 years besides the age of the respondents was categorized into three groups such as young middle and old most of the respondents are middle age group and they are between 3864 years old this was followed by the young group under 38 years the old group64 years and above in the same percent respectively this finding is similar with the finding of australian center for international agricultural research which described that the average age of the farmers in cdz of myanmar is 488 years educational attainment nearly about half of the respondents had no formal schooling however about 26 of them had primary level education and 20 had middle level education more than 6 of the respondents had the monastic education this finding agrees with the statement of food and agricultural organizations and yezin agricultural university that most myanmar people had in the primary education on this regard myanmar education consortium reported that monastic education was the first education system of both men and women in myanmar despite its chequered and politically sensitive history it is still in demand today and currently provides education for 3 of schoolaged children occupation all respondents are involved in livestock farming however respondents are cooperateworking in other jobs such as agricultural works construction sites standing as the hired labor and selling in grocery respondents spent all their working time in the livestock activities of their houses including fodder cutting watering and feeding of animals animal shed cleaning and milking as their main occupation a few respondents said that they are grazing in pasture because they have enough food for their livestock the national consultative committee also pointed that about 86 of the myanmar people live in rural areas and are engaged in livestock farming land holding of the respondents there are three kinds of crop growing seasons in the study area premonsoon monsoon and postmonsoon thus the respondents have different farm sizes in the three seasons according to the data gathered more than 56 of the respondents have 15 acres while nearly 12 have 610 acres and 17 have 1620 acres in premonsoon respectively when it comes to monsoon season 60 of the respondents have 15 acres followed by 34 of the respondents and 17 of the respondents have 610 acres and 1630 acres respectively as to postmonsoon season the respondents have 15 acres and 610 acres for 166 and 34 when compared with the countrys average rainfall level cdz receives limited rains and the farmers in this region are mostly grown in premonsoon and monsoon crops in contrast their farm sizes of premonsoon and monsoon are also higher than postmonsoon farm size and postmonsoon crops are lack of rainfall according to the results of fgd the respondents mostly cultivated their crops during premonsoon and monsoon because they got low profits for postmonsoon crops during lack of rainfall in the study area hein et al pointed out that the main two farmland categories lowland and upland for premonsoon monsoon and monsoon crops in the central dry zone and he also described that the landholding of the intermediate farm households is within 15 acres majority of the respondents cultivated sesame and groundnut while some cultivated sorghum and cotton in the premonsoon season as per in table 3 a few respondents has pigeon peas during this season asian development bank approved that sesame and groundnuts are the two principal oilseeds produced commercially in the cdz myanmar when it comes to monsoon season more than 55 of the respondents cultivated sorghum and nearly 42 of them cultivated cotton besides the rest of them are cultivated groundnut rice sesame chilli pigeon pea and greengram naing approved that rice sesame and groundnut are the most widely cultivated crops in central dry zone area during monsoon season results also show that most of the respondents cultivated cotton and chickpea at the same percent while others cultivated for sorghum and sunflower in postmonsoon areas in this regard oxfarm also reported that the farmers in the dry zone are mostly grown cotton pulses including chickpea and other oilseed crops including sunflower according to jica report of the central dry zone in 2010 the farmers in the dry zone area cultivated sorghum for the marginal cost effectiveness demographic factors the ownership of livestock depends on a herd or flock size in the study area according to the categorization of livestock guide in aciar research project in 2019 the livestock were categorized based on the lifespan and tercile analysis in fact the livestock were classified into two groups of young and adult for male and female in this study two years of male cattle were counted in adult and less than 2 years are in young male cattle likewise one and half years of female cattle were counted in adult and less than one and half years are in young female cattle based on the terciles analysis the 33rd 66th and 100th percentiles were used to describe the herdflock sizes according to the data the herdsflocks were classified into three sizes corresponding to these terciles for each livestock species cattle herdssmall medium and large small ruminants flockssmall medium and large the respondents mostly had the small size of adult cattle male and female while the small size of young male group and female group is likewise the medium size of adult cattle male and female is the same percent followed by the medium size of young male group and female group is when it comes to the large size the adult cattle male group and female group however the respondents have only young male group this categorization results of cattle herd are agreed with the finding of win et al that the number of animals kept per herd or flock was examined by terciles analysis and the adult and young groups were categorized based on the life span in the central dry zone area the small ruminants were also categorized based on their lifespan and ten months of male are added in adult group and less than ten months are in young male group likewise eight months of the female small ruminants are added in adult group and less than eight months are in young female group in the flock size of goat the respondents have only the small young size of male and female in terms of adult groups the small size of male and female while the medium size of male and female groups has the same percent there has only adult large size of female in the study when it comes to the flock young sizes of sheep the respondents have only the small size of male and female in case of sheep flock adult sizes they have the small size of male and female the medium size of male and female and the large size of male and female in this study this is similar with the categorization of win et al in the small ruminants flocks size and lifespan analysis key informant interviews revealed that the respondents used lifespan and tercile analysis to categorize their herd or flock sizes of livestock womens participation in decisionmaking behavior of livestock management and household activities as per table 7 it was found that the breakdown of the gendered division of labor in terms of livestock chores the respondents participation in the livestock rearing activities was found in this table results show that women are responsible for performing livestock chores especially around the house a greater percentage of women feed livestock provide water care for young animals clean shelters care for sick animals and purchase forage than men this finding is agreed with the reports of awan et al the participation of women in livestock management activities is higher than mens contribution in various livestock activities including clean livestock shelters care for sick livestock care for young animals etc cutting and carrying forage is a chore that is shared equally between men and women and for those households that own sheep this finding agrees with fischer et al finding that the forage chopping is the highest done with both husbands and wives in domestic groupings and male households are mostly found in chopping machine while female households are chopping with manual men are more influenced in decision making of sale of livestock agricultural work for forage crops and take manure to fields for fertilizer than women this finding is agreed with the results of arshad et al that about 74 of the male dominance has in decision making of livestock activities including sale of animals fodder cultivation sale of animals produce to get useful if shearing is performed by someone in the households it is more likely to be a chore for women the result was assumed that respondents are seldom to shear their sheep in this region in the reports of worksafe new zealand and national centre for farmer health which pointed that shearing and crutching are highrisk jobs that need a lot of manual effort workers who shear or crutch thousands of sheep each year can be at high risk of being injured data shows that both men and women seldom to collect the milk from their livestock and seldom to sell their livestock milk in this study because they used milk for their home consumption van der lee et al approved that dairy milk is the source of livestock milk production and only 6 of dairy cattle milk production has in the central dry zone this finding agrees with van der lees finding that the livestock farmers in the dry zone area seldom to collect their livestock milk and seldom to sell out them in the market the domestic chores who actively performed in the household see in table 8 apart from agricultural work where duties are predominantly performed by men or shared by men and women women disproportionately bear the responsibility for performing all other domestic chores women are mostly involved in the four of five household chores such as clean house wash clothes cook for family and prepare donations for monks this is agreed with the report of alliance for gender inclusion in the peace process which described that men are seen as responsible for hard productiveand outside work while women are seen as responsible for work taking place inside and domestic works although agricultural work is done jointly by men and women men are also involved in this domestic chore result is similar to the findings of fao and singh and srivastava they stated that most agricultural activities are done jointly by men and women in which men are more involved in agricultural activities besides they all spend their leisure time together with their friends and family this finding is approved by the report of the united nations office for project services in myanmar in which myanmar farmers can spend their free time with their families todays because they get more free time due to changing mechanized farming the gendered patterns of access to the resources required to care and manage livestock are seen in table 9 results indicate that women appear to have more access to the financial resources that required to manage livestock than men based on access to household income to spend on expenses and access to credit either from formal institutions or friends and family razzaq et al also approved that male and female respondents can manage their households finances but the animals and equipment are more likely to be owned by men or coowned by both parties the report of united nations women watch information and resources on gender equality and empowerment of women explained that in fact womens lack of ownership over assets that can be used as collateral to leverage loans also constrains them more than men men have more access to traders and information about markets while women have access to traders and they got information about market when they want to buy or sell their livestock in contrast women have no opportunity to get traders and information to know about market in this study this agrees with the findings of garcía that rural women in developing countries face difficulties to get information and difficulties in the process of negotiating prices with buyers and lack of mobility due to access to markets the assessment results of fao and wfp report also pointed that farmers did not access traders their crops will get low price with lower demand than usual men predominantly own cropping land but women have 167 of land as their own this finding is agreed with the report of sasakawa global that women have less access to land than men for a variety of legal and cultural reasons legislation has affirmed womens basic right to land but other customary practices and laws limit womens land rights in some cases some legislations restrict rural women in developing countries both men and women have access to communal grazing land this means everyone has the right to graze livestock on a common pasture the result is agreed with the report of gilles and jamtgaard that most of the worlds grazing lands is the publicly owned factors affecting on rural womens participation on decisionmaking behavior in livestock management and household activities as per table 10 the participation in decision making is a commonly used indicator of womens agency in the gender literature it was found that womens decisionmaking behavior affected their domestic chores and livestock management activities in this table results from our study concur with evidence from other asian countries in which women are often in control of the family finances half said that they make decisions on when to borrow money and many are either unilaterally or jointly involved in decisions on how to spend the money earned from selling livestock while the tasks of feeding and caring for sick animals are the responsibility of women men are more dominant in decision making on these matters including when to get medical treatment when to sellbuy livestock and what to feed the livestock however a third of women stated that they unilaterally make decision on providing treatment to animals arshad et al approved that caring for diseased and sick animals was one of the main activities performed by rural women table 11 shows the important values and meanings for understanding womens motivations and purpose of their activities to encompass a range of different factors such as social and cultural beliefs and norms that guide behavior and to gauge religious and social values and norms for womens mobility that guide livestock rearing while there is little evidence suggesting that women follow buddhist norms of abstaining from killing animals and eating meat livestock are commonly used to pay for donations to the monastery for rituals mowe explained about buddhist teachings on killing animals and abstaining from meat in buddhist review of tricycle and mon recommended that myanmar farmers hold their donation festivals after harvesting their crops and selling livestock based on their rituals in terms of mobility many women can go to the market but there is a spread in terms of limitations in mobility in and outside the village it is also recommended that women frequently have poorer access to markets than men and play a limited role in the commercialization of livestock to sell out in market by themselves and livestock products in the management of livestock assets nearly half said they enjoy the social benefit of meeting friends to chat while taking animals grazing this is agreed with the finding of undeland that women graze animals jointly with the relatives and have no problems with access to good pastureland and water sources analysis of local values and meanings allows extension services to provide benefits to participants beyond income relationship of variables to determine the relationship between the independent variables and the dependent variables of the womenheaded households on the livestock rearing in the study area specifically the nonparametric chisquare test with the goodman and kruskals lambda correlation coefficient was used to analyze the variations table 12 shows the significant and highly significant correlations between access to resources and decisionmaking descriptions of the womenheaded households on the livestock rearing in this study the ownership of land information about markets access to traders and the information about livestock are highly significant correlated with time to buying or selling livestock what to feed for livestock and when medical treatment according to the results the ownership of land is highly correlated with the decision making description of when to buysell livestock what to feed and when medical treatment it is approved in the report of hernándezjover et al that ownership of livestock can take health records of animals and engage with the surveillance system for animals the united nations development programme recommended that if the farmers have their own land they can be considerable capability in managing small scale livestock enterprises covering the whole livestock program and they also pointed that even some landless households have demonstrated considerable capability in managing small scale livestock enterprises when it comes to access to information about market it is highly correlated with when to buy sell and livestock and what to feed this finding is similar with the finding of garcía that access to market information can provide the information of suitable food and process of negotiating prices with buyers to know the exact time of selling and buying due to lack of mobility access to traders is highly correlated with when to buy and sell livestock what to feed and how to spend money earned from livestock in fact the report of aciar fao and wfp and win et al explained that access to traders can support to access feed to get veterinary services and inputs including when to buy and sell livestock and manage of their livestock income access to information about livestock rearing practices is also highly correlated with when to buy sell and livestock and what to feed undp pointed that access to information on livestock can be the extent of official livestock rearing processing and practicing and exports livestock and livestock products access to information from friends and family is highly correlated with when to buysell livestock and how to spend money earned from livestock this finding is agreed with the report of animal welfare institute the livestock information sources and services such as the activities performed to facilitate any stage of the livestock life cycle information that were available to farmers from their friends family neighbors and coworkers and social media garcía also approved that rural women in developing countries face the most challenges in financial resources due to a lack of information multiple regression analysis multiple regression analysis the statistical findings of spearmans rho correlation not only established the relationship between women households livestock activities access to resources and decisionmaking discretion in the study area but also identified the possible predictors for the multiple regression analysis multiple regression analysis was used to further streamline the predictors of decisionmaking discretion to guide the researcher in formulating the recommended appropriate livestock management practices to access the better resources the prediction formula of multiple regression analysis is y β0 β1x1 β2x2 βkxk x independent variables y dependent variables a yaxis intercept β regression coefficient k number of predictor variables stepwise regression method was used to ensure the significant predictors remain after iterative model building using the set of predictors as variables the predictors are the women households livestock activities and their accessing resources that have strong significance with their decisionmaking discretions those predictors that have pvalues less than the significance level of 005 and less than highly significant level 001 have statistically significant impacts the multiple regression analysis results in table 13 reflect that care for young animals livestock feeding livestock buying livestock selling caring for sick livestock sheep shearing cutting and carrying forage for livestock of women households livestock farming practices and access to income access to credit either from institutionsfriendsfamily livestock ownership livestock shelters or equipment ownership access to a local trader access information from friends and family access information about market of the resources will have the highest impact on decision making discretion of livestock farming table 13 regression analysis of women households decisionmaking discretion their activities and access to resources not taking these predictors altogether will not have the expected high impact on improving the womens participation and their decisionmaking behavior in the study area in essence it points out that the participation of women in livestock farming practices and their access to resources in livestock management will have the highest impact on their decisionmaking discretions in this area model the results imply that womens participation in livestock farming and their decisionmaking discretion could clearly improve the activities in caring young and sick animals livestock feeding livestock buying and selling sheep shearing cutting and carrying forage for livestock ahmad arshad et al and fischer et al approved that women are actively involved in animal husbandry sort of activities including livestock feeding and caring watering fodder cutting milking and animal shed cleaning etc result also shows that some products of livestock are commercialized when the benefits can be switched to women furthermore fao also mentioned that womenheaded households are responsible to large and small animals marketing including byproducts in practical but they need the decisionmaking power over sale of livestock the result shows women can be more actively participate and they can make the good decisions to access income if they access resources of credit trader market information and information from friends and families fao agreed that access to good market access to credit the high status and education the high levels of customary practices can support women in the decisionmaking power over rural assets additionally win et al andfao andwfp highlighted that access to traders can be benefit in getting animal feed veterinary services time to sale of livestock and manage of their livestock income on the other side shearing is performed by one of the household members and it is more likely to be a chore for women result shows that the respondents seldom to shear their sheep in this region worksafe new zealand and national centre for farmer health pointed out that shearing and crutching are highrisk jobs that need a lot of manual effort contractors who shear or crutch thousands of sheep each year can be at high risk of being injured according to the results the respondents need to be the owners in their livestock farming to manage their livestock and livestock equipment undp pointed out that the farmers with their own lands can manage small scale livestock enterprises covering the whole livestock program conclusions the role of womens participation becomes important not only in livestock management but also households activities even the respondents are in the middleaged but they did not get the lead role in decision making due to lack of access to resources and poor education of no formal schooling almost 60 of the respondents are smallsized farmers with the average household size is 46 and they mostly grow sesame groundnut and other tropical crops the respondents mostly rear small sizes of adult cattle male and they categorized their livestock based on the tercile analysis and lifespan of livestock besides the respondents serve as the good housewives with domestic chores in case men households are chief of the decision makers in the households because they access to resources more than womens households however access to financial resources and household income to spend on expenses are stronger on the women access to resources contributed substantially to the decisionmaking descriptions of the households the respondents also need to be the owners in their livestock farming to manage their livestock and livestock equipment the information got especially from friends family and traders are helpful in buyingselling livestock spending money earned from livestock taking medical treatment of the livestock and feeding the food for the livestock in fact women can be more actively participate and they can make the good decisions to access income if they access resources of credit trader market information and information from friends and families this implies that the higher access to resources the decision making will be more prominent thus women can improve their decisionmaking in livestock activities for the household by empowering women in livestock farming since the correlation and multiple regression analyses were able to identify and streamline women activities that need to be focused on so that to make good decisions in livestock farming this should be taken as a concrete guide for the involved villages their officials the government of myanmar and all project implementers to follow for longerterm outlook participation of women and access to resources are important to achieving decision making behavior in livestock farming in addition providing the necessary resources to women in livestock farming they can easily facilitate their livestock activities and their performance will be improved policy makers have to consider these constraints identified in this study to provide the necessary resources to women in livestock farming to train women as the female leaders in their households and to develop guidelines for sustainable livestock production not only in the central dry zone but also the whole country the genderbased equal opportunity can be initiative through a policy to enhance the participation of women and achieve development of women decisionmaking behaviors at the national scale credit author data availability statement not applicable funding this research was funded by the australian centre for international agricultural research under project developing market oriented small ruminant production systems in myanmar farming experiences 1 crop production yrs 2 livestock production yrs access information about markets when they want to buy or sell livestock owns the land that crops are grown on access to communal grazing land when they need constraints decision making activities decision made by family member men women both when to buysell livestock how to spend the money earned from livestock what to feedgraze the livestock when to get medical treatment for livestock when to seek medical treatment for family how to educate children how to manage household finances when to borrow money how to organize the marriage of children

the study aimed to assess the factors affecting on womens participation level and decisionmaking behavior of rural women in livestock management and household activities in particularly 60 randomized respondents from three villages of natmauk township central dry zone area myanmar descriptive analysis chisquare test and stepwise regression methods were applied to analyze the relationship of womens participation and decisionmaking behavior of respondents results of the kii and fgd were used to further explains in survey respondents are middleaged group smallsized farmers busy with domestic chores and had no formal schooling they mostly grow sesame groundnut and other tropical crops and rear small sizes of adult cattle males in the study men are chief decision makers in their households because they have access to more resources ownership of land and access to information is highly affected on decision making of when to buysell livestock what to feed and when medical treatment of livestock information got especially from friends family and traders are helpful in the decision making of buyingselling livestock spending money earned from livestock and feeding the food for the livestock spearmans rho correlation was used to identify and streamline womens activities that need to be focused on so that to make good decisions in livestock farming

introduction generation z refers to people born between the mid1990s and 2009 who grew up with the digital society and view digital technologies as the foundation of their lives genz belongs to a larger social media user population that has been conceptualized as the digital natives digital natives were born and raised in the digital age and they spend most of their lives surrounded by and using computers video games cell phones and all the other toys and tools of the digital age while the rationality of the conceptualization of digital natives is still in debate a growing number of research has indicated that the younger generations significantly differ from their predecessors in terms of technologyrelated perceptions motivations and behaviors china has ∼300 million genz and 30 million genalpha internet users constituting 13 of chinas internet user population most of chinas internet users are also social media users and about 14 of them spend more than 4 hday on wechat one of chinas most popular social media previous studies have discussed from multiple perspectives the predictors characteristics mechanisms and consequences of the social mediauser interactions in china however what has been relatively understudied is the extent to which chinese genzs social media habitus are associated with their characteristics as being digital natives as well as how their social media engagements are associated with digital social inequalities in this study therefore the main objective is to fill these gaps by examining the characteristics of and differences in social media habitus among chinese genz users as well as exploring how their social media uses and gratifications are associated with economic capital using the bourdieusian approach literature review one influential theoretical framework to approach the social mediauser interactions is the uses and gratifications theory which highlights the importance of individuals social and psychological needs in shaping their motivations and consequently their communicative behaviors on one hand previous studies indicated that genzs differ from their predecessors in many aspects of online motivations such as being more desired for selfexpressing and selfdisclosing online shopping online enjoyment memetic engagements contentgenerating and sustainable online behaviors on the other hand the extent to which social media uses can satisfy genzs online motivations depends on their affordances social media affordances keep evolving with the development of the technologies and the industry shifting from a focus on networked communication to the scope of online sociality there have been discussions on how socialization as a pivotal social media affordance plays an important role in satisfying some of genzs online motivations in this study we will contribute to the discussions by exploring how genzs social media uses including both socialization and beyond connect with their online motivations in the chinese context therefore we propose our first research question rq 1 what are the relationships between chinese genzs online motivations and social media uses previous studies indicated that individuals technological engagements are associated with inequalities in their social economic and cultural status and life opportunities in light of the limitations of a functionalist perspective to studying digital social inequalities scholars introduced the bourdieusian approach that views technological engagements as occurring in social spaces made up of interrelated fields constraining and shaping each other with distinctive user habitus and capital according to bourdieu habitus is a set of dispositions that structures individuals practices and capital refers to socially valued assets that can influence individuals status in the system through accumulating and exchanging the conceptualizations of habitus and capital contribute to deepened understandings of genzs social media uses and gratifications social media habitus serves as an embodiment of the interactions between genzs and their situated socioeconomic context and it shapes and repeatedly magnifies user disparities in social media practices through machine learning and algorithms capital is another key to understanding the predictors and consequences of genzs social media practices previous research showed significant correlations between economic capital and technologyrelated habitus which further connect with digital social inequalities as for genz there is still insufficient knowledge to unpack how the youth from lowand uppermidincome families would differ in terms of their preference of social media practices and how economic capital can moderate their social media uses and gratifications hence we propose the second and third research questions rq 2 what are the differences in social media practices between genzs from lowand uppermidincome families rq 3 how does economic capital moderate genzs social media uses and gratifications methods procedures and participants this study employed an online survey for data collection the questionnaire was adapted from literature and revised based on several pilot studies participants were students from a large public university in southwestern china participants consisted of 221 chinese genz social media users and aged between 20 and 24 annual family income was coded as low and uppermid using 50001100000 as the threshold measurements online motivations ten items were adapted from literature and were measured on a 5point likert scale a principal component factor analysis identified two dimensions of the motivations daily routine alternatives were motivations regarding gaining information entertainment online shopping and doing schooland workrelated things socialization included seeking help sharing with others developingmaintaining relationships and selfpromotion social media use nineteen items measured how frequent participants engaged in social media activities a principal component factor analysis constructed four dimensions networked communication included checking updates likingcommenting communicating with others and checking groupdiscussion records social capital accumulating and exchanging included asking for help supporting others selfpromotion and obtaining selfbeneficial information selfexpression included posting updates sharing selfies and selfexpressing news watching included watching news via social media demographics participants age gender education background urbanness and annual family income were collected results for rq 1 we used sem to explore the relationships between genzs online motivations and social media uses with demographics as covariates a bootstrapping technique with 5000 replicates was performed to achieve generalizability beyond the sample results indicated that the daily routine alternatives motivation significantly predicted nc and nw and the socialization motivation was associated with scae and se on social media for rq 2 significant differences in social media practices were observed between lowand uppermidincome families when controlling for age gender and education background genzs from uppermidincome families used social media for more nc f 1778 p 0001 and nw f 501 p 005 than those from lowincome families whereas two groups did not significantly differ in scae and se on social media regarding rq 3 several hierarchical regressions were conducted for genzs with the daily routine alternatives motivation income significantly moderated nc b 023 β 112 t 267 p 001 for those driven by the socialization motivation income significantly moderated scae and se we used dawson and richters approach to probe the interaction effects as daily routine alternatives motivation became stronger the lowincome participants had a greater increase of their nc on social media than those with uppermidincome when socialization motivation was low genzs with more economic capital showed less scae and se than those from lowincome families whereas when the richer were strongly motivated to socialize online they would surpass the poorer in both social media practices discussion results indicated that chinese genzs have different social media uses depending on two categories of online motivations social media as communicative tools and news portals when they are doing their daily routines online and as platforms for social capital accumulating and exchanging and selfexpression during online socialization the findings are consistent with and extending literature on characteristics of digital natives and indicate different social media uses based on different scenarios furthermore compared to other u g studies on social media usage our results highlighted an emphasis on social capital throughout social media uses and gratifications and the integration of social media into daily routines by chinese genzs another contribution of this study is that we employed bourdieusian approach to explore how economic capital influences genzs social media uses and gratifications we observed distinct social media habitus between genzs from lowand uppermidincome families the latter embrace a more instrumentalrational habitus to use social media more frequently as a communicative tool whereas the former value the importance of online socialization to increase their social capital but have no more practices in related social media activities finally genzs from uppermidincome families take a more conservative stance in scae and se when their socialization motivation is low this finding is consistent with the literature that a higher income is not necessarily associated with more frequent social media practices conclusion in this study we examined chinese genzs social media uses and gratifications and found daily routine alternatives motivation predicts nc and nw and socialization motivation is associated with scae and se genzs from uppermidincome families employ a more instrumentalrational habitus to use social media as a communicative tool than those from lowincome families genzs with higher economic capital tend to be more conservative in scae and se when socialization motivation is low applying the bourdieusian approach to u g studies this study highlighted the importance of economic capital in genzs social media practices it helps formulate distinct social media habitus that may be repeatedly consolidated by machine learning and algorithms as well as influences social capital accumulating and exchanging both may lead to more digital social inequalities among genzs despite the limitations our findings shed light on future studies on connections between economic capital social media u g and digital social inequalities among and across digital generations data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation 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 publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

this study aims at contributing to literature by investigating characteristics of generation zs social media uses and gratifications and the moderation effect of economic capital specifically we employed online survey as the main research method to examine the connections between the young generation cohorts online motivations social media practices and economic capital a total of 221 chinese generation z social media users were recruited in the survey results indicated that 1 generation zs have different social media engagements depending on whether they were connected for daily routine alternatives or socialization 2 the young cohorts from uppermidincome families demonstrated a more instrumentalrational habitus to use social media more frequently as a communicative tool than those from lowincome families and 3 motivations and family income interacted to influence generation zs social media practices eg social capital accumulating and exchanging and selfexpression findings here provide empirical reference to deepened understandings of the interactions between social media and digital generations and their connections with digital social inequalities

introduction muhammadiyah as a religious social organization has a social responsibility to manage changes in society productively and progressively the work of muhammadiyah branch kadirojo and aisyiyah branch west palbapang has been very deep and deeprooted however there has begun to be a stagnation of community participation in following the pace of change managed by muhammadiyah lately there was something quite disturbing lately about the existence of muhammadiyah and aisyiyah in the village of kadirojo palbapang bantul first a number of members or sympathizers of muhammadiyah and aisyiyah began to feel reluctant to attend a number of routine activities such as recitation which is carried out both weekly and monthly when conducted a personal search a number of members stated that they were uncomfortable attending the activity because they were unable to provide infaq in all muhammadiyah activities this is closely related to the social contraction after the covid19 pandemic which caused a number of shocks to the pillars of public welfare moreover muhammadiyah and aisyiyah studies discussed more about the morals of life in the end times compared to studies with material about managing the world productively competitively and islamically studies that provide softskills and hardskills seem to have not received an adequate portion second the presence of joyful activities at the muhammadiyah congress in november 2022 had a considerable bitterness this is related to the failure of prm kadirojo and pra palabapang barat to depart by bus together the number of prm and pra members in kadirojo and west palbapang is actually quite large to be able to rent 23 buses with a passenger capacity of 50 however in the program to become cheerleaders for the muhammadiyah congress the group could not leave because the number of muhammadiyah members and sympathizers who wanted to leave by bus did not meet the quota of just one bus finally a number of prm and pra administrators used their own modes of transportation after being traced it is undeniable that there was a relatively large financing factor to be a happy congress where each participant was charged around rp 100000rp 150000 this condition was considered quite burdensome in the midst of agricultural problems in the palbapang bantul area in the last 5 months because no suitable planting activities have been carried out so that practically a number of members and sympathizers of muhammadiyah and aisyiyah did not have adequate income this condition provoked prm kadirojo and pra palbapang barat to address the issue of islamic teachings based on ghairu madhlah or muamallah duniawiyyah to get a larger portion a study conducted by menchik showed that muhammadiyah must be able to answer the dynamics of social economic and political problems in society a number of studies from roasyadi also showed that a number of muhammadiyah universities have developed programs on the formation of young entrepreneurs as a form of muhammadiyahs responsibility to contribute to the institutionalization of community welfare the activity base of prm kadirojo and pra palbapang barat in 3 mosques namely alfajar istijabah and sayyidah qawwiyah will be the central point in the economic development of the ummah studies from rambe have shown that mosques can play an important role in building the economy of muhammadiyah in the assessment conducted together with pra palbapang barat there was a problem of discomfort to follow activities in aisyiyah which were routinely carried out both weekly and monthly periods because they tended to be mobilized to provide the best infaq when present in a number of recitations aisyiyahs activity platform based on ansich religious studies has made the situation uncomfortable so that a number of variations of aisyiyahs activities are needed in the form of increasing productive economic capacity by utilizing a number of social capital owned by the community such as large agricultural land around the house and the potential availability of planting media made of both humus and livestock manure second problems were related to the bad experience of caring for aglonema ornamental plants and aroids that are easily dead rotten or stunted so it is not attractive to look at and has no economic value this includes the lack of knowledge of aisyiyah members on aglonema and aroids plant species that have high economic value so far only a million aglonema plants such as donacarmen and big roy are known which have ordinary economic value variants such as moonlight emerad sultan of brunei tiara cunkwok and golden hope which worth tens of millions are relatively unknown in addition the aroids variant which has a variegate pattern is also not widely known this knowledge would be shared with the audience third the problem was the marketing the products produced it is undeniable that selling ornamental plant products is perceived as a type of sale that requires certain expertise this is related to the need for ornamental plants which is still at the level of tertiary need so the knowledge of the marketing map is new this includes marketing using digital platforms such as marketplaces on todays social media such as instagram tiktok and facebook methodology the method of implementing this service activity took 3 major steps first conducting fgd to build new awareness that being active in the muhammadiyah organization will get benefits in the world such as social economic cultural and benefits in the end such as getting the paradise that allah has promised muhammadiyah is not an organization that will reduce the social capital of its members and sympathizers but rather facilitates the social benefits of capital to be more useful second training in the management of household industries based on aglonema and aroids ornamental plant agriculture which have a high investment value training in the context of handson practice from how to chop and separate the mother of houseplants to the preparation of ornamental plantfriendly planting media by utilizing the resources available in the community such as humus from bamboo leaves cocopeat from coconut husk rice husks and manure from cow goat rabbit and chicken dung third training in marketing ornamental plants on social media platforms both for marketing at the domestic level and export opportunities for consumers abroad this is because the domestic and international market segments regarding the need and availability of unique ornamental plants are still broad evaluation of this method would be measured from pretest and posttest instruments whether there is an increase in knowledge attitudes and behavior of the audience after the community service intervention process is there an increase in awareness of muhammadiyah participation or does it just stop at the level of knowledge of ornamental plant management results and discussion in the view of the community there is a stigma that being a muhammadiyah activist means giving up time property and soul to fight in the path of allah to be muhammadiyah will be very noble if the person is finished with the problems of social economic and cultural life so that he can fully devote himself to the struggle of muhammadiyah in upholding the religion of islam this view seems to emphasize that people who are not finished with themselves in the context of world affairs when participating in muhammadiyah will be a burden to muhammadiyah and instead of becoming a burden it is better to stay away from muhammadiyah this condition was also confirmed in a number of studies in forums organized by a number of mosques affiliated to muhammadiyah around the palbapang community actually in muhammadiyah there are a number of islamic forums that have very diverse tasks principals and functions from majlis tarjih tabligh council education health and economy however at the village level the majlis that has the most routine activities is the tabligh council which is then the main base of activities to hold recitations other councils are more widely known by muhammadiyah activists or who are administrators at the branch regional regional and central levels for muhammadiyah sympathizers muhammadiyahs activities are in the form of recitation education and health services this devotion shows the sympathizers of muhammadiyah and aisyiyah that muhammadiyah and aisyiyah have an economic council which pays strong attention to how to empower all muslims and humanity to become an independent society and not become a weak society the context of aroids and aglaonema empowerment has a strong momentum in palbapang village so that after discussion at the branch level there is enthusiasm to join and get to know muhammadiyah more closely this program received more response than the economic council program which offers training in making decorative objects batik and ecoprint or making batik using natural materials why are muhammadiyah and aisyiyah sympathizers interested from the fgd it was found that the covid19 pandemic has made gardening activities a favorite fun refreshing activity and has the potential to increase income in popular terms gardening is part of an effort to multiply the oxygen space located gardening means giving alms of oxygen while earning additional income very different from popular activities during the covid19 pandemic such as cycling a fun activity but it actually consumes oxygen is expensive and does not have an impact on increasing income second gardening activities for villagers are actually an observed daily activity so far the residents have undergone farming from generation to generation meaning that basic knowledge about gardening from planting caring fertilizing propagating and harvesting is something that has been lived every day however some people do not have much knowledge about how to get good seeds competitively and how to market productively third aglaonema and aroid are unique plants a variety of types that continue to grow rapidly along with many breeders who produce beautiful and exotic plant variants aglaonema as ornamental plants also has a relatively high price compared to traditional ornamental plants where both have become global plants and are also marketed globally this plant in its form is relatively small so it can be placed in the corner of the house exotically and pleasant to the eye figure 1 community service activity from the implementation of pretest and posttest regarding gardening procedures there was relatively little change in knowledge where the increase in knowledge was more about how to make the right planting media this is closely related to planting material for farmers as the basic knowledge farmers carry out daily the knowledge that increased significantly was the knowledge about online marketing where the participants previously did not know much about buying and selling plants through facebook instagram tik tok or youtube for most participants social media was a space of expression to vent or watch a number of entertainments from music films to religious lectures after the service activities were carried out there was a change in the mindset of the residents of kadirojo palbapang that being active in muhammadiyah and aisyiyah are not only saving rewards in the last day by reducing their social capital but also getting progress information needed by the community it can share information access capital to strengthen each other this view is reflected in the testimony of the participants that inclusivebased empowerment allows the participants to get equal treatment and distribution of social capital and provides direct benefits conclusions service for the community is a part of social organization advocacy to the needs of the community social organizations that cannot provide proper advocacy space to the community will be increasingly alienated and will eventually be abandoned by the community itself critical awareness began to be realized by muhammadiyah and aisyiyah regarding the need to accelerate the majlis within muhammadiyah to move and serve the community proactively an inclusive and objective program will be able to mobilize public awareness that being part of muhammadiyah and aisyiyah are a matter of mercy and grace the empowerment of aisyiyah activists through the selection of programs that are in accordance with the needs of the community has a positive impact on making the participants to be active in the organization where the aisyiyah organization is perceived by the community as an organization that continues to pay attention to social and economic problems faced by the community diversification of community empowerment has a positive impact on community participation in muhammadiyah engagement empowerment that touches the substance of the problems faced by the community will increase the positive image of muhammadiyah which always develops social capital for esmpathy and sympathy empowerment programs that have a domain at the family level but have an impact on equality in the family environment and are able to give socioeconomic impacts on families are programs that are in great demand for women

this article explains about the assistance given for the aisyiyah branch in stimulating women in doing shaleh charity in the muhammadiyah company through the aisyiyah organization through empowering the economic sector it is related to the emergence of saturation in some womens communities towards aisyiyahs routine activities which contain recitation activities and motivation to perform shadaqah and infaq this pattern builds character that to become a member of muhammadiyah and aisyiyah one must be a welloff person to change this trend this community service has developed the local wisdom of the women community in kadirojo with a productive social and economic approach in the field of ornamental plants as a new trend of gardening in modern society the methods carried out are cultural training of aglaonema and monstera ornamental plants as types of ornamental plants that have high economic value and product marketing training in the marketplace the results showed that muhammadiyahs program run towards increasing the social and economic capacity of the community will increase the community engagement to actively participate in muhammadiyah

introduction globally many people have faced challenges during the covid19 pandemic including loss of income and employment worsened mental health and decreased access to medical care 12 the pandemic has also amplified the intersectional vulnerabilities faced by many people living with human immunodeficiency virus for example among people living with hiv in the united states africanamericans and those with low incomes were more likely to suffer complications following severe covid19 infection 3 people living with hiv may also have difficulty placing trust in the health care system in one cohort of africanamerican people living with hiv in the united states 97 of individuals endorsed at least one covid19 mistrust belief and half had covid19 vaccinespecific mistrust 4 by contrast people living with hiv may be more engaged in covid19 preventative behaviours or vaccine uptake than the general population 56 people living with hiv have known history of activism and high level of community involvement in research considering this more study of covid19 preventative behaviours is needed within the population of people living with hiv that can guide new policies and enhance vaccination success since the first global covid19 immunization campaign was launched attitudes and uptake of the covid19 vaccine in people living with hiv have been much more extensively researched than behavioural practices in this study we sought to understand the relationships between preventative behaviours and covid19 infection in a multicentre crosssectional study of people living with hiv in canada we addressed this topic through four questions does previous known covid19 infection influence preventative behaviours among plwh is participant multimorbidity associated with preventative behaviour practices among plwh are preventative behaviour practices living in a crowded space and working in close proximity to others associated with covid19 transmission among plwh are preventative behaviour practices andor uptake of covid19 vaccination associated with developing symptomatic covid19 infection during the highly contagious omicron wave among plwh methods our study population comprised people living with hiv living in montréal ottawa from the total study population responses from appropriate subsets of participants were analyzed to address each of the four aforementioned questions as described in table 1 statistical analysis was performed to assess for significant differences between demographics and citf questionnaire responses with ttest chisquare test and fisher exact test used as appropriate multivariable logistic regression was performed to assess for associations between outcomes and predictors of interest while accounting for other factors that might confound the association based on prior knowledge no imputation was performed to impute the missing data as this is mainly a descriptive study conduct of this study was approved by the canadian institutes of health research canadian hiv trials network scientific review committee and community advisory committee as well as by each sites research ethics board as previously outlined 7 and laboratory testing of note the vaccine immunogenicity study is still ongoing so the total number of covid19 infections during the total study period is currently unknown overall preventative behaviours were frequently practiced in the cohort with 87 masking in public 79 distancing 70 avoiding large gatherings and 65 limiting contact with vulnerable persons does previous known covid19 infection influence preventative behaviours to address this question we excluded individuals with positive serum covid19 antibody testing but no knowledge of prior infection a detailed explanation of the participant subsets used in each of the four questions is found in fig 1 participants reporting prior known covid19 infection were more likely to identify as nonwhite less likely to have stable hiv infection have more household members fewer household bedrooms and bathrooms per person and were more likely to be employed in health care than those not reporting prior infection there were no significant differences in the other demographic factors between the prior known infection and noninfected groups in response to the preventative behaviours survey participants with prior known covid19 were more likely to selfquarantine when thought to have been exposed to covid19 but were not symptomatic and selfisolate when thought to been infected with covid19 these differences remained statistically significant after adjusting for age sex and the aforementioned patient characteristics that were different between groups these were the only significant differences in preventative behaviours between groups is participant multimorbidity associated with preventative behaviour practices participants in the multimorbidity group were more likely to be older live in a household with fewer members have more bedrooms and bathrooms in the household per person usually get an influenza immunization and less likely to be performing paid or unpaid work in close physical proximity to others they were more likely to be vaccinated with four doses against covid19 by september 2022 in response to the preventative behaviours survey participants in the multimorbidity group were more likely to be practicing physical distancing this difference however was no longer statistically significant after adjusting for participant characteristics and no other significant differences in preventative behaviours between groups were noted are preventative behaviour practices living in a crowded space and working in close proximity to others associated with covid19 infection the participants in the covid19 infection group were more likely to have fewer bedrooms per person there were no identified differences in the proportion of participants performing paid or unpaid work in close physical proximity to others between those with and without covid19 infection there were no identified differences in preventative behavior practices between those with and without baseline covid19 infection are preventative behaviour practices andor uptake of covid19 vaccination associated with developing symptomatic covid19 infection during the highly contagious omicron wave in canada the omicron wave began in late november 2021 9 participants in the omicron infection group were more likely to have been tested for covid19 at some point before study enrolment p 0015 discussion using data from our cohort of people living with hiv we examined four questions regarding covid19 preventative behaviours another study done in the canada in general population assessed determinants of adherence to major coronavirus preventive behaviours including demographics attitudes and concerns and showed that adherence to covid19 prevention behaviours was worse among men younger adults and workers and deteriorated over time 10 we did not observe these differences among those having prior known infection with covid19 the only difference noted in preventative behaviours was an increased likelihood of selfquarantining after a suspected exposure participants engaged in work with close physical proximity to others did not report different preventative behaviours or covid19 infection proportions multimorbidity was associated with more physical distancing although there were also multiple demographic factors noted to be different in this group in the highly contagious omicron wave we did not observe any differences in vaccine uptake or preventative behaviours between those who did and did not sustain infection overall preventative behaviours were practiced in a high proportion of the cohort with 87 masking in public 79 distancing 70 avoiding large gatherings and 65 limiting contact with vulnerable persons in a 2020 canadian survey cohort of the general population over 70 always reported masking in public and staying home when sick while over 50 avoided large gatherings only 40 engaged in physical distancing 11 preventative behaviours including masking physical distancing and limiting gatherings have had high uptake globally in people living with hiv in a south african cohort of people living with hiv 80 changed one or more activities based on public health recommendations 12 one united states cohort of 149 people living with hiv reported engaging in an average of 28 physical distancing behaviours 13 in a cohort of 545 primarily male indonesian people living with hiv 70 reported practicing preventative behaviours 2 among 376 rwandan people living with hiv factors associated with the increased practice of preventative behaviours included duration of antiretroviral therapy and female gender 14 increasing age had a consistent association with preventative behaviours in one rapid review of the general population in developed countries while health status and education did not show consistent effects 15 limited data exist on the effects of prior covid19 infection on preventative behaviours or on the influence of working in close physical proximity to others on covid19 behaviours in people living with hiv greater vaccine uptake among those with multimorbidity andor older age has been reported in a south african cohort of people living with hiv 12 in contrast a chinese cohort of people living with hiv was less likely to receive covid19 vaccination 16 fear of disclosure of hiv status at vaccination appointments was reported in this later assessment which may explain the heterogeneity of findings across reports we observed no difference in vaccination status between participants sustaining omicron infection and those not infected we note that studies in the general population have shown a less protective effect of original vaccine formulations against the omicron variants although behavioural differences during the omicron wave may have also played a role in our cohort 17 our study has several limitations the entire cohort was participating in covid19 vaccination programs to some degree and had easy access to provincial and federal public health programs for testing and education this may limit the generalization of our results to settings where public health infrastructure is not available to disseminate information and vaccines it also encapsulates behaviours for only a portion of people living with hiv who consented to vaccination data was collected only at the beginning of omicron wave resulting in small number of participants being infected by covid19 omicron variant and therefore may not be fully generalizable to omicron and subsequent waves in summary our canadian cohort of people living with hiv reported high rates of preventative behaviour practices we found differences in preventative behaviours among those with prior covid19 infection and in those with multimorbidity suggesting these are key motivating factors in facilitating preventative behaviours • fast convenient online 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few studies have examined preventative behaviour practices with respect to covid19 among people living with hiv human immunodeficiency virus using a crosssectional survey from a canadian institutes of health research canadian hiv trials network study ctn 328 of people living with hiv on vaccine immunogenicity we examined the relationships between participant characteristics and behavioural practices intended to prevent covid19 infection participants living in four canadian urban centers were enrolled between april 2021january 2022 at which time they responded to a questionnaire on preventative behaviour practices questionnaire and clinical data were combined to explore relationships between preventive behaviours and 1 known covid19 infection preenrolment 2 multimorbidity 3 developing symptomatic covid19 infection and 4 developing symptomatic covid19 infection during the omicron wave among 375 participants 49 had covid19 infection preenrolment and 88 postenrolment the proportion of participants reporting always engaging in preventative behaviours included 87 masking 79 physical distancing 70 limiting social gatherings 65 limiting contact with atrisk individuals 33 selfisolating due to symptoms and 26 selfquarantining after possible exposure participants with known covid19 infection preenrolment were more likely to selfquarantine after possible exposure although asymptomatic 650 vs 234 p 0001 chisquare test participants with multiple comorbidities more likely endorsed physical distancing 857 vs 755 p 0044 chisquare test although this was not significant in logistic regression analysis adjusted for age sex race number of household members number of bedroomsbathrooms in the household per person influenza immunization and working in close physical proximity to others overall participants reported frequent practice of preventative behaviours

from 10 to 21 percent changes in childbearing rates within subgroups and recent immigration trends have further contributed toward dramatic populations shifts at the same time leading educators and policymakers note the challenge of working with diverse populations and the importance of closing the achievement gaps often associated with them for several decades schools of education and national accreditation agencies have recognized the need to train candidates in the knowledge skills and professional dispositions necessary to help all students learn these groups also agree that all educators even those who are themselves from diverse backgrounds must acquire new perspectives to effectively instruct students across broad socioeconomic and ethnicracial groups teacher education context many candidates particularly those from a relatively homogeneous white middleclass background may have limited exposure to the diverse populations they will be called upon to teach at our institution for example the student body is 92 white while less than 1 is native american even though the state population is approximately 10 native american this demographic pattern of predominately caucasian teachers generally holds true across the country according to the national center for education statistics schools and staffing survey 2010 data 83 of elementary and secondary teachers are white 7 are black and 7 are hispanic one concern expressed in the literature is that white teachers with limited experiences with diverse student populations might have lower expectations for lowincome and minority learners in we cant teach what we dont know white teachers multiracial schools howard explored how lack of exposure to other cultures may result in fear our reaction to fear he theorized determines whether or not we grow in multicultural understanding or remain socially isolated howard emphasized that teacher preparation programs must look for ways to bring candidates out of isolation by developing in them the competencies necessary to become partners in the dance of diversity author note mary r moellereddassistant professorteachinglearningand leadership departmentbox 0507south dakota state universitybrookingsmamfainstructorenglish departmentsouth dakota state university moeller bielfeldt shaping perceptions 83 teacher perspectives that limit classroom effectiveness one of these critical competencies is a professional expectation that all students can succeed villegas and lucas have emphasized the importance of believing that all students can learn and deserve equal access to educational opportunities to ensure that all students have such equal access reform is needed ullucci argued however that because educational beliefs and teacher perspectives form the bedrock on which we build educational policies and practice schoolwide reform is significantly hampered when educators hold negative perceptions if candidates enter the profession with foregone conclusions about student abilities they expect less see less and get less from this mindset emerges a cultural deficit model characterized by descriptions of people and their cultural values as pathological and deficient in the cognitive emotional linguistic and spiritual resources the cultural deficit perspective attaches labels and identifies weaknesses in students backgrounds suggesting that children of color are victims of pathological lifestyles that hinder their ability to benefit from schooling furthermore when educational systems place the blame for low achievement in their students homes and cultures systemwide practices and policies contributing to the problem are often overlooked shaping teacher beliefs at the preservice level remains a significant challenge in combating such oppressive perspectives and systems at the same time working toward this reform is a significant goal for teacher preparation programs to embrace particularly because once teachers are placed within a school their perspectives may become influenced by the system making it more difficult for them to change their perceptions critical race theory in teacher education context critical approaches in research look beyond examining and understanding to include a larger goal of reforming and improving bell crenshaw and delgado popularized the critical race theory framework in the 1970s to identify systemic racism subsequently it has been utilized as a critique in many disciplines including teacher education as a teacher educator who promotes multicultural education vavrus has suggested that adding knowledge of crt to the teacher education curriculum could foster increased crosscultural competencies yosso also affirmed crt as a basis for examining the ways that race impacts schools two central tenets of crt are particularly relevant for teacher education 1 crt challenges the traditional claims of the educational system and its institutions to objectivity and meritocracy 1 and 2 crt places a value on the experiences and applied knowledge of minority cultures examining the lives of real people to understand how actual events have shaped their understandings and status crt asks educators to consider what important experiences minority students bring to school and how those experiences might be viewed as resources increasing the students likelihood of success both crt and applied learning place experiences at the center of the learning process although developmental theorists such as piaget have focused on the formal learning process as occurring in stages prior to adulthood crt has emphasized that lived experiences throughout ones entire life can bring insight and knowledge to learning schwartzman and henry likewise note the true test of knowledge lies in its connection to lived experience yosso has applied crts approach of valuing student experiences to chicanoa students and identified specific categories of what she terms community cultural wealth these ccw categories identify an array of cultural knowledge skills abilities and contacts possessed by socially marginalized groups that often go unrecognized and unacknowledged ccw thus offers concrete alternatives to the cultural deficit perspective and serves as a means to challenge the social injustice that yosso believes is endemic in schools ccw guides teachers to acknowledge the strength of culturallyrelated attributes such as bilingual homes and large extended families instead of seeing those qualities as barriers to success community cultural wealth model the ccw model defines six forms of cultural capital which often overlap and intertwine 1 aspirational capital the resilient nature of people who hold on to their hopes and dreams for the future even in the face of real and perceived barriers 2 linguistic capital the skills attained through communication experiences in more than one language andor style including communication through musical and visual arts 3 familial capital the ways that familia …carry a sense of community history memory 4 social capital the networks of people and community resources…both instrumental and emotional support to navigate through societys institutions extending the concept of familial capital into a broader and more extensive system of relationships to provide information and reinforce confidence 5 navigational capital skills maneuvering through social institutions or the ability to work and even thrive in hostile and unresponsive environments 6 resistant capital those knowledges and skills fostered through oppositional behavior that challenges inequality or asserting oneself in the face of repression integration of community cultural wealth into teacher education curriculum the basic principle of identifying strengths in other cultures as a foundation for building positive expectations is wellgrounded in crosscultural theory both learning and development are deeply embedded in cultural contexts teachers must understand and appreciate the variety of ways childrens experiences can differ and be able to see and build upon cultural strengths if they are to help all students succeed however little research has been conducted that investigates the integration of ccw in teacher candidates experiences working with native american populations method this study describes the initial steps taken to integrate ccw theory into a required teacher education diversity course as it partnered in a servicelearning project with a federally operated native american boarding high school the flandreau indian school this partnership operates within the flandreau indian success academy a crosscultural program that encourages the university at large to adopt the ccw perspective of respect for the families communities and tribes from which our students come 2 within the fisa teacher education instructors created a workshop specifically for the college of education and human sciences teacher education faculty recognized that candidates are not immune from believing the stereotypes prevalent in todays society about native americans as either desperately poor or newly rich from casino profits to achieve the two project goals of breaking these stereotypes and of replacing them with an assetbased perspective instructors added lessons on ccw and then assessed the candidates application of the content during a servicelearning experiencehosting an fisa workshop during the fisa workshop series freshmen from a native american high school came to sdsu seven times to experience higher education opportunities each college in the university prepared its own threehour workshop with students rotating through in small groups the workshop experience described in this study was hosted by the college of education and human sciences with candidates leading the following activities a tenminute icebreaker in small groups an introduction to multiple intelligences theory an online assessment of multiple intelligences followed by a onetoone discussion of the implications for candidates and students and a creative project where students decorated quilt squares to reflect their personalities each fisa workshop concluded with a dinner which gave additional time for interaction two research questions guided this study 1 do candidates apply their knowledge of ccw in reflecting on their facetoface interactions as hosts for the fisa students in the fisa workshop 2 which types of community cultural wealth capital do candidates identify most frequently as they reflect on their fisa experiences with native american students prior to hosting the fisa workshop candidates in the education course on human relations received the following uniform curricular materials and experiences 1 a reading and discussion of turning the notion of community on its head sdsuflandreau indian school success academy as background for serving as hosts in the fisa workshop this article also briefly explained the ccw concept and challenged the deficit model of using labels to depict diverse students 2 a presentation on fisa by the sdsu coordinator a class activity following the lecture served as a formative assessment indicating to the instructor that the candidates could identify and explain the six categories of capital for a summative course assessment instructors used the following three reflection prompts related to the course content goals of applying their knowledge to the servicelearning setting as suggested by ash and clayton 1 describe what the fisa experience was like for you think of the roles you played in all components of the workshop which role felt the most successful from your perspective why 2 what did you discover about yourself as an intentionally inviting teacher 3 what did you discover about working with the fisa students thirtyeight candidates constructed their responses during the last week of class to reflect their fisa experiences and as such the reflections were identified as data indicative of the phenomena of interest candidates in this course signed informed consent statements that indicated their understanding that their written submissions could be used for research and that assured them of confidentiality related to their participation the responses were collected by a graduate student to ensure anonymity and to encourage the construction of honest responses content analysis was selected as the most appropriate method to use because the responses provided insight into candidates perceptions of native american students thus enabling researchers to draw inferences results and analysis initially six categories of ccw were used as the basis for coding however the two researchers decided to collapse the social capital and familial capital categories because of the difficulty of defining these as mutually exclusive within this population research on educational questions are often complex and require interpretation and discovery as methods of inquiry each constructed response was coded independently by the researchers by identifying themes that matched the ccw capital categories as defined earlier and as revised above the researchers initially coded 27 out of 38 responses in agreement with agreement defined as identifying the same ccw categories in each response responses with codings outside the range of agreement were reread discussed by the two researchers and based on their discussion a consensus was reached for all responses the coded responses were tabulated by category and the category totals were converted to percentages of the total responses the first research question asked if candidates applied knowledge of ccw in reflecting on their facetoface interactions with the students twentyseven candidates responses exemplified an ability to apply knowledge of ccw during the servicelearning activity eleven candidates responses did not show this ability only one candidate specifically mentioned the ccw theory in the response however the constructed response prompts intentionally elicited a broad range of ideas to evaluate the transfer of classroom knowledge to experience overall the results indicate that a more intensive focus is needed on ccw theory if it is to be applied successfully in the field the second research question asked which types of capital candidates tended to identify in their reflections table 1 illustrates the percent of candidates who identified a certain ccw category in their constructed responses categories of content candidates most frequently identified socialfamilial capital and aspirational capital in their responses as they reflected on their fisa experiences conversations about family and friends were apparently frequent topics during the workshop which would account for the high percentage of codes in the socialfamilial category evidence of close friendships among the fisa students was noted in this response the two girls we had were good friends so that also helped with the awkwardness in considering combining the categories of social capital and familial capital the instructors noted that native americans often have broad definitions of who is considered family and extended family relationships in vertical and horizontal directions can blur the lines between family circles and social circles the english instructor who had also previously worked with the fisa students noted this in the language they used to describe family members for example one student told her my mother is my grandmother and in another instance a student referred to his friend as brother in an essay when the instructor suggested changing the term so as to not confuse his readers both students protested a lakota saying that illustrates this global perspective of claiming relationship with all people and in fact all living things is mitakuye oyasin or all my relatives the decision to collapse the social and familial capital categories aligned with what the instructors perceived as native american cultural values and perspectives responses were coded as aspirational capital in reference to conversations about future plans such as she was very interested in a science field…and hoped to come back again in the context of the fisa workshop it is likely that school and careers were logical topics of conversation between fisa students and candidates which could explain the higher frequencies of this category navigational capital was identified when candidates commented that fisa students were able to overcome their initial shyness and became engaged in the workshop activities for example by the time we started working on the crafts…they felt free and were able to speak their minds linguistic capital includes abilities in music and visual arts several candidates were surprised by displays of fisa artistry during the creative activity as exemplified by this response what she fisa student drew in thirty minutes blew me away however few responses indicated an awareness of this resource although the instructors did not identify any response as having made thematic connections to resistant capital the instructors noted that responses included references to noncompliant behavior from the fisa students however the candidates did not appear to perceive the negative behavior through the lens of resistant capital overall the results indicate that a more intensive focus is needed on ccw theory if it is to be applied successfully in the field in addition other themes that emerged through the researchers discussions indicated additional preworkshop interventions might be beneficial emergent themes in the constructed responses during the researchers discussions about the content of the constructed responses several other themes of interest to teacher educators emerged the following themes were perceived to be most evident and significant for future study candidates most frequently identified socialfamilial capital and aspirational capital in their responses as they reflected on their fisa experiences conversations about family and friends were apparently frequent topics of conversation during the workshop which would account for the high percentage of codes in the socialfamilial category evidence of close friendships among the fisa students was noted in this response the two girls we had were good friends so that also helped with the awkwardness in considering combining the categories of social capital and familial capital the instructors noted that native americans often have broad definitions of who is considered family and extended family relationships in vertical and horizontal directions can blur the lines between family circles and social circles the english instructor who had also previously worked with the fisa students noted this in the language they used to describe emotional responses more than half of the candidates reported experiencing various levels of anxiety about the fisa workshop as they anticipated their role as hosts and as they engaged with fisa students their comments ranged from feeling out of my element a little bit to nervous to the point of jitters howard points out the significance of these reactions whether we deepen our awareness and continue to grow through such experience or merely shrink back into the safety of isolation is determined by our reaction to the inevitable fear of stepping outside the boundary of ignorance guiding candidates through this emotional transition will most likely require more intensive intervention perceptions of success several candidates reflected upon their perceived success most notably equating success with interpersonal connections they made with the fisa students for example we feel as though we succeeded when we see a smile or even when we see someone opening up another wrote i felt the classroom went very well when the girls were making their postcard things by that time everyone had opened up to one another and there was a lot of visiting happening as opposed to awkward silence a third candidate reported that the most successful part was when he was able to invest and get to know a student the candidates also reported success when the fisa students were fully engaged with the workshop activities and reported a corresponding lack of success when the fisa students didnt seem to want to be involved one candidate for example reported a lack of success when she didnt feel her student was doing what she should have been doing pratt argued however that such selfreports of success within what she calls a contact zone should be questioned she defined contact zone as social spaces where cultures meet clash and grapple with each other often in contexts of highly asymmetrical relations of power which arguably was the case with the fisa where mostly white candidates met with native american high school students perceptions of lack of success several responders noted other instances in which the fisa students did not respond as expected or desired for example they reported instances of fisa students joking around going on facebook during computer time and having a bit of an attitude pratt however noted that when social situations are described in terms of orderliness games moves or scripts usually only legitimate moves are named as part of the system where legitimacy is defined from the point of view of the party in authority in other words when the fisa students did not do what was expected when they did not follow the game or script the candidates did not count it towards success in discussing the responses however the instructors wondered if some of the illegitimate moves on the part of fisa students might in fact be unrecognized resistant capital for example one candidate reported that a fisa student called a drawing activity stupid then proceeded to write the word death on his paper another fisa student drew an elaborate dragon which was swearing several candidates reported other behavior on the part of fisa students behavior which the candidates considered rude and troubling might these behaviors in fact have been evidence of resistant capital pratt asked what is the place of unsolicited oppositional discourse are teachers supposed to feel that their teaching has been most successful when they have eliminated such things and unified the social world probably in their own image another example of possible misinterpretation is the number of candidates who expressed frustration at perceived lack of attention for example several responses noted that fisa students put their heads on their desks the researchers wondered however if such action which again does not fall within the imagined ideal classroom behavior might indicate close and attentive listeningthe opposite of how candidates perceived it might not cultures with strong oral traditions also foster strong listening skills and might that listening be perceived differently by those from a culturally distinct background changing perceptions and attitudes finally several responses indicated disconfirmed expectations about the fisa students and the experience in general demonstrating a changed perception in the candidate one respondent wrote i misjudged them all my thoughts were that these students are mean students who do drugs and that they never listen that was me being ignorance sic because what i came to find out is that they are just students who need a little help or push to get along another particularly selfaware candidate wrote i learnedthat i am not as openly inviting as i wish i could be limitations the use of content analysis as a research methodology limits the findings from this study in several ways the researchers made inferences based on their interpretations of candidate responses to determine perceptions and attitudes towards fisa students however inferences never yield absolute certainties the researchers used an established theory yossos community cultural wealth theory as the basis for coding categories and established theories relating data to their context are the most unequivocal sources of certainty for content analysis however ccw was developed in the context of hispanic experiences although there may be similarities between the hispanic and native american cultures the validity of ccw has not yet been tested in a native american content although the constructed responses that served as the data for this study were collected in an anonymous way one of the researchers was also a course instructor her knowledge and personal observations of the candidates may have introduced some evaluator bias into the findings the second researcher had no knowledge of the candidates although candidates were assured that their responses would not be graded for content some responses may have been written with the instructor as an audience in mind this may have influenced the perspectives the candidates presented the scope of the threehour fisa workshop limited the ability of candidates to more completely know the fisa students and thus limited the candidates amount of information on which they based their responses finally the assessment of the integration of ccw into the teacher education program relied heavily on candidate selfreporting which also invites systematic bias because candidates likely know what answers the instructors want and because the candidates positive reports will also affirm their personal growth as future teachers exaggerated responses were possible implications and suggestions for future research yosso concludes her book critical race counterstories along the chicanochicana educational pipeline with this haunting question can educationrooted in a sense of community responsibility and with a goal of racial and social justicetransform society this study explored the use of an intervention to shape candidates perceptions and attitudes by including critical race theory and community cultural wealth theory in a required diversity course yossos categories appeared appropriate for use with native american students with the possible exception of two forms of capital the researchers found that distinguishing between social capital and familial capital in candidates responses was difficult because some 93 native american cultures such as lakota embrace a global perspective of relationship formative assessments indicated that candidates were able to identify different cultural capitals however in the summative assessment of this knowledge as applied in the fisa 59 of the candidates included elements of ccw capital in their reflective responses describing the students while 41 of the candidates did not the results indicate that a more intensive classroom and field focus on ccw theory is required some candidates responses also suggested that more preworkshop activities to acquaint the two populations with each other might be beneficial several candidates noted that both they and the fisa students felt uneasy or awkward and needed time to warmup to each other in addition to yossos categories of ccw the instructors are interested in the way she distinguishes between majoritarian and counterstories both recount the experiences and perspectives of individuals majoritarian stories are told by those with racial and social privilege but counterstories are told by socially marginalized people pratt also defined autoethnographic texts as those which people undertake to describe themselves in ways that engage with representations others have made of them perhaps one preworkshop activity might be for all members of the two populations to create and share narratives about their own lives so that the warmup period of the workshop might be more quickly navigated digital storytelling 3 might be one form of narrative that the students could use to become more familiar with each other before meeting wiconi waste education an existing social networking site could provide the platform for sharing the stories this private social networking site was developed as a communication link between the two servicelearning partners fisa and sdsu teacher education students another useful addition to the applied learning experience might be to develop pratts suggestion for ground rules for communication across lines of difference and hierarchy that go beyond politeness but maintain mutual respect as a way to enhance crosscultural communication skills conclusion teacher educators know that candidates need significant experiences to learn about and to interact with diverse students especially in light of current demographic trends with the schoolage population however experiences have the potential to move people in different directions this means that each classroom experience must be evaluated on the ground of what it moves toward and into instructors should look for evidence that their course curriculum provides valuable learning opportunities that enhance and broaden candidates perspectives and that such learning connects classroom theory with field experiences if candidates can be taught to view their future students through the lens of an assetbased perspective such as ccw candidates might reject the stereotypical views about diverse students this study showed that over half of the candidates were able to access their knowledge of ccw capital as they reflected on their interactions with native american students but some forms of capital were apparently more identifiable than others within the context of this study further investigation is needed to determine what potential exists for shaping future teachers attitudes and perceptions of native american students through the integration of ccw theory into the teacher education curriculum utilizing a curriculum that enables candidates to identify the strengths of diverse cultures might also enable future teachers to create more culturally relevant lessons identifying and valuing cultural capital might allow candidates to gain insight into their own students which also allows preservice teachers to make more meaningful connections by learning important community strengths or identifying a communitys funds of knowledge candidates develop an especially vital cultural competency the ability to view their future students in a positive light as described in this response i saw that many of them wanted to achieve more than just the simplicity of life they wanted to become something more the passion for education indeed for any service in which the recipient is lower in the power hierarchy than the provider a clearer understanding of the strengths of the recipients community network will serve to balance the relationship and enhance the significance of the learning experience

teacher candidates need to be prepared to work effectively with rising numbers of diverse student populations and yet classroom interventions do not always impact perceptions and attitudes in the field this study explored the initial steps of integrating critical race theory and community cultural wealth ccw theory yosso 2005 yosso 2006 into the teacher education curriculum the study asked if the candidates applied their knowledge of ccw in reflecting on their facetoface interactions as hosts for native american students in a diversity workshop it further asked which types of ccw capital the candidates identified most frequently as they reflected on their experiences with native american students results indicated that candidates can identify ccw in the field with some types of capital more frequently identified than others because the potential exists for knowledge to shape perceptions kolb 1984 the study concludes that ccw could be a valuable addition in teacher education curriculum a more intensive focus on ccw and the addition of precontact activities such as the sharing of counterstories yosso 2006 may also promote knowledge translating into perception and attitudes the 2010 us census affirmed projected demographic shifts american classrooms will increasingly include children and youth from diverse populations resulting in a decrease in the proportion of nonhispanic white students us census bureau 2010 specifically from 1986 to 2008 the percentages of white students decreased from 70 to 55 percent while the overall percentage of hispanic students rose

introduction as the problems that society is facing today are too complex to be tackled by only one institution the literature states that organizations from civil society and the public and private sectors must collaborate to solve social environmental and economic challenges 1 2 3 4 to address these issues more than 10000 local governments around the world have implemented sustainable community plans in their cities since 1992 any of which are collaborative in nature 5 when organizations from different sectors bring their diverse skills together they can create new capabilities that help with solving unsustainable challenges 167 this form of collaboration when formed into an entity is called a crosssector social partnership 8 the number of cssps has been increasing at both global and local levels due to the benefits that they bring not only to sustainability in general but also to their partners including resources and skills 17 research showed that structural features within the partnership such as the means of communication partner engagement strategies decisionmaking structures monitoring and reporting help partner organizations achieve their own goals 9 since they have the capacity to transform strategic goals into positive outcomes 9 the structural arrangements of partnerships vary 10 thus impacting outcomes 11 in this study the outcomes of partner organizations are understood through an extended version of the resourcebased view the rbv includes human physical organizational and financial capitals 12 human capital refers to the knowledge developed by the people working in an organization physical capital is related to the technology and location of a firm organizational capital refers to the procedures and culture of a firm such as the means of reporting and financial capital is the earning debts and equity of an organization 13 the extended rbv includes the naturalresourcebased view approach proposed by hart 14 and socioecosystem resources 1 this is called community capital in this study despite past contributions there is still a gap in the research of the relationship between the structural features of a large cssp and the outcomes that partner organizations can obtain by participating in cssps in addition little attention has been given to the structuring of partnerships 10 large cssps have been selected for this study not only because they are understudied but also because the literature suggests that they are more powerful than small partnerships due to their diversity and size which helps partnerships to address the variety of challenges identified as key in the cities sustainability plans 9 to fill in this gap this study explored the relationship between the structural features of three large cssps that all aim to contribute to the achievement of sustainability goals for their cities barcelona sustainable in barcelona spain gwangju council for sustainable development in gwangju south korea and sustainable montreal in montreal canada and the outcomes their partner organizations have achieved during the implementation of community sustainability plans this research aimed to analyze the partnerships structures and determine which structural features are present for each cssp analyze the value that partner organizations from different sectors and partnerships give to their achieved outcomes and analyze the relationship between the structural features of the cssps and the partner outcomes the relevance of this topic is that the design of partnerships affects their ability to achieve their desired sustainability outcomes 11 therefore knowing more about structuring partnerships will enable better design of governance structures thus ensuring desired partner outcomes can be achieved crosssector social partnerships crosssector social partnerships are typically a voluntary form of collaboration although some are mandatory 15 where organizations from the civil society the public sector andor private sector partner with the purpose of solving social problems of mutual concern 8 many of the complex issues that different societies are facing such as the creation of sustainable communities need strong cssps to solve them 1 small cssps have two or three partners from two or three sectors and large cssps or multistakeholder partnerships have multiple partners from the three sectors 9 large cssps tend to be more inclusive since the participation of many partners is required while the partners of small cssps are selected for a specific fit 9 partnership structures the interest in partnership design has grown due to a variety of challenges related to resilience and environmental sensitivity among others 1016 the design stage is important since the foundation and key elements for the success of a partnership such as the relationship and roles between partners how the partnership is structured in terms of formality continuity governance and coordination as well as the allocation of resources are sorted out in the design process 17 as organizations are part of the external environment with which they interact and engage for resources and in which they have interests they must structure themselves according to the contexts they face 1819 and this is not different for partnerships 20 within the cssp literature structures are a key driver of the way agendas are shaped and implemented they affect the things organizations do by determining key factors around influencing power and resources 21 p 1166 research showed that an effective method of encouraging successful crosssector collaboration is through the implementation of structures 9 that allow for the achievement of collaborative goals 22 structures have the capacity to transform strategic goals into outcomes due to the interactions between different organizations through decision making through being involved in the process and actions and by exchanging resources that are necessary in order to achieve desired outcomes 9 as argued by contingency theorists they must be designed according to the environments they face ie formally when facing certainty and informally whenever dealing with complex issues such as those presented by sustainability challenges 18 due to the lack of attention being given in the literature to structures for implementation in large cssps 910 this research considered the structural features adopted by different authors and then developed a framework to analyze the structural features of the partnerships structural features of large crosssector social partnerships this study considers seven categories to organize the cssps structural features communication systems monitoring and reporting systems partner engagement coordination entity renewal systems decisionmaking systems and the composition of the partnership something that is not considered in this paper but is also an important structural feature of partnerships is resource allocation 23 several authors considered communication systems as an important component of crosssector partnerships in particular koschmann et al 24 stated that communication systems are a key factor within organizations and collaborations for clarke 22 as well as for kuenkel and aitken 25 new communication systems are established for the implementation phase of a partnership a partnership for the improvement of health finance policies in ghana and kenya demonstrates the importance of structured ongoing communication systems to develop a strong relationship and mutual understanding between the public and private sectors 26 some scholars also indicated that communication with multiple stakeholders is critical for strengthening relationships at multiple scales 27 some of the factors that allow for successful partnerships are monitoring and reporting systems 26 it was shown that when there is a lack of these structural features within a partnership it lowers the ability to achieve longterm goals 28 rein and stott 28 studied six crosssector partnerships in southern africa that had a lack of monitoring and evaluation processes which made it difficult to evaluate the benefit of the partnership for the partners monitoring and reporting can focus on the sustainability impact 2329 andor on the process and actions 3031 partners engagement is helpful within collaboration systems to engage key partners and attract new organizations 3233 adding new partners is also an important component of partners engagement 34 in terms of resources new partners enable the achievement of the partnerships common goals allowing for the continuity of the collaboration systems 17 coordination helps to organize the activities where partners participate in order to achieve the partnerships goals it can also organize the resources provided by each partner 35 according to kamiya 17 coordination can be done through hosted secretariats separate secretariats or without secretariats when a partnership has a hosted secretariat one lead partner oversees the secretariat which reflects a medium level of institutionalization a separate secretariat means that the partnership creates its own coordination means 17 therefore the secretariat is separated from the partner organizations which have their own staff and space although the cost of the partnership might be higher than having a hosted secretariat 17 this modality can be considered a high level of institutionalization 17 a low level of institutionalization is reflected through partnerships that do not have a secretariat that coordinates the partnerships activities the way that this modality functions is that one or more partners play the role of a coordinator when it is needed 17 it is quick and it does not need many resources which might work better for a small startup partnership with a restricted budget 17 renewal systems are relevant for crosssector partnerships due to their iterative and nonlinear path toward achieving goals 22 they create opportunities for collaborative advantage 35 learning and building relationships 36 and allowing partners to adapt to new challenges 22 renewal systems also help to assess how resources are being managed in order to reach transformational goals over time adjustments are likely needed to the partnership goals and design 3738 decision making is a collaborative arrangement set in place to govern strategy formulation and implementation 22 the involvement of partners in decision making is often related to an improved capacity for the partnership as it is able to adapt to changing circumstances 39 in terms of the allocation of authority the question lies in who makes the decisions and at which organizational level mintzberg 40 states that when power for decision making resides in one entity then the structure is centralized contrarily when power is shared among entities then the structure is decentralized 40 kamiya 17 states that it is important in large partnerships to define which partners are going to be part of the decisionmaking process because not all the partners are involved in that way this is different from the case of small partnerships where most of the partners participate in the decision making of the partnership 17 for complex arrangements such as large cssps decentralized decision making with a proper coordination and monitoring mechanism is an appropriate design 22 the composition of the partnership is considered in this study as part of the structural features that is the longevity of the partnership size and sector makeup of the partnership the length of time of the partnerships is considered as the time that the partnerships have been operating which is likely to have an effect either positively or negatively on their outcomes 1 partners can develop relationships and processes that are needed for the implementation phase however longstanding partnerships might face partner fatigue as one of their outcomes 9 in terms of size several authors stated that the structures that partnerships implement might be different depending on the size 172241 lastly studying the predominance of the sector in crosssector partnerships is relevant as the literature suggests that organizational partners have different levels of capacity and capabilities based on their sector although not necessarily different types of outcomes 19 therefore the structures within the cssps examined in this research may vary regarding their composition partners outcomes extended resourcebased view for cssps the framework that was used to understand partners outcomes in this research was an extended rbv approach the rbv considers that resources that firms consider valuable are scarce 12 therefore partnerships become a strategic approach that allows organizations to have access to other organizations resources 42 the rbv is based on a hierarchical classification of the partners resources which means that partners value some resources more than others 14 the value assigned by the partners to some resources over others depends on the returns that these resources bring to organizations 9 one of the values of joining a partnership is the idea that partners can accomplish outcomes that they could not achieve alone 1 although some authors claim that partnerships do not prioritize strategies for the needs of the partners 43 recent research showed that partners positively value their results when joining a cssp 9 several studies compiled long lists of partner outcomes from cssps 144 which were also used for this study there are some specific outcomes by sector both positive and negative that partner organizations could gain when they join a partnership 1 however previous empirical studies on large crosssector social partnerships did not show differences between the resources achieved by the partners when considering the sector they came from eg 9 this study considered the question of sectorspecific partner outcomes in each of the three partnerships the study only considered positive outcomes as that is what the respondents to the survey used in this research reported partnership structure to partner outcome relationship literature related to crosssector social partnerships argues that this type of arrangement creates the necessary conditions for partners to have access to resources that are valuable for them 45 and contribute to sustainability challenges 46 at the same time partners contribute to the sustainability plan of the community by implementing the sustainability strategies that were outlined in the plan tracking the progress of the goals and identifying opportunities for improvement which allows for progress 1 the implementation of a sustainability plan relies not only on the structural features adopted but also on a deep understanding of the benefits that partners can have by joining the partnership which helps keep them involved empirical research showed that partners can gain physicalfinancial human and organizational capital when they join a partnership 15 despite the importance of the role of the partners in cssps there has not been much research undertaken that relates to the relationship between the structural features of a large partnership and partners outcomes the aim of this research was to contribute to that field by researching three large cssps for the sustainability of barcelona gwangju and montreal material and methods the selection criteria for this multicase study are listed below 47 these criteria enabled the study of large cssps that have existed for at least 20 years and are intended to continue to exist into the future impacting similar populations so that the size of the city did not influence the comparison • the cssps had at least one hundred partner organizations confirmed who were from civil society public and private sectors • the cssps had a community sustainability plan with a long time horizon and a history of implementing sustainable community plans for more than 10 years • the size of the community impacted by the partnership was from 1 to 2 million people • partners were highly engaged in the partnership 8 contributing to at least some of the sustainability goals of the sustainability plan • the partnerships were from three different countries and continental contexts selected cases the community sustainability plans of each partnership are introduced here the partnership structures are presented in the results barcelona sustainable the sustainable agenda in barcelona has been a priority since 1995 when the city of barcelona committed to the creation of local agenda 21 48 their latest public commitment and the plan considered in this research was their 20122022 sustainability plan with goals and objectives that focused on public spaces and mobility environmental quality and health efficiency productivity and zero emissions the rational use of resources good governance and social responsibility wellbeing progress and development education and citizen action and resilience and planetary responsibility 49 gwangju council for sustainable development local initiatives for sustainable development in south korea were introduced in 1995 and gwangju has been one of the cities working for sustainability since then 50 the main goals of the gwangju council for sustainable development are encouraging local participation as well as focusing not only on environmental issues but also integrating the scope of the initiative on economic social and cultural matters 51 the main topics of the 20172021 plan were clean water air and energy city forests a city safe from chemicals recycling of materials green and social economy urban farming a welfaresharing diverse healthy and beautiful community a peopleoriented traffic system residential environments and education for sustainability 52 sustainable montreal at the montreal summit held in june 2002 the city of montreal committed to sustainable development montreals third community sustainable development plan 20162020 focused on four priorities ghg emissions and dependence on fossil fuels adding vegetation increasing biodiversity and ensuring the continuity of resources ensuring access to sustainable humanscale and healthy neighborhoods and making the transition toward a green circular and responsible economy 53 the studys methods and results are presented in three parts the first part presents the structural features of each partnership the second part presents the partners outcomes and the third part considers the relationship between the structures and outcomes qualitative study data collection the information about the partnerships structures was collected during the iclei world congress held in montreal in june 2018 the directorscoordinators of the partnerships were asked about the structure of their partnerships through semistructured interviews that were recorded by video the interviews were mainly focused on the structural design of the partnerships further questions were answered by the directorscoordinators either by email andor phone call to complete the structural features framework of this study data analysis the content was coded through qualitative content analysis 47 based on the deductive framework from the literature review ie the partnership structural features next an inductive round of coding was completed on the interview transcripts to see what additional codes or subcodes were needed to further categorize the data in a comparable way quantitative study data about the partners outcomes were gathered through a crosssectional online survey conducted between june 2015 and june 2017 that was offered in three languagesfrench spanish and korean partner organizations were asked to value the outcomes according to a 5point likert scale from 1very valuable to 5not valuable outcomes were organized into five groups organizational human physical financial and community capitals following the extended version of the rbv data collection data collection happened in two stages first an online invitation was sent out by the secretariats of the partnerships to all their active partner organizations asking them to respond to the online survey the active partners are organizations that are currently participating and are committed to contributing to the sustainability goals of the cssp if the number of responses needed was not reached to make the results generalizable a second recruitment effort was conducted by sending an email to active partners inviting them to complete the same survey through a personal meeting table 2 shows the number of partners that completed the survey in each partnership data analysis the response bias was calculated using wave analysis and no response biases were found among the partnerships ie variances could be assumed to be equal with respect to the assessed variables the data analysis included the creation of indices based on rbv capitals including community capital the survey questions used to create the indices were as follows as a result of remaining a partner of the partnership your organization has achieved partners had the option to rate the achieved outcomes on a 1 to 5 scale where 1 was very valuable and 5 was no value table 3 shows each of the capitals with their corresponding items the indices were created by combining the items that measured each capital to test the internal consistency of each index cronbachs alpha test was used and it was found that all coefficients were greater than 070 confirming the internal consistency 54 once the indexes were created given that the data were not normally distributed kruskalwallis tests were used to compare the means of the indexes by cssp and then by the sectors of each cssp this study employed version 25 of spss statistics software to conduct the statistical analysis explanation building study data analysis part 3 used an abductive analysis for explanation building explanation building is a technique used for explanatory case studies that allows for explaining a phenomenon through a set of casual sequences enabling the exploration of the hows andor the whys of that phenomenon 47 abductive analysis focuses on making a preliminary guess based on both the current theory being used and the data 55 the explanation process of the relationship between the structural features and the partners outcomes started by inferring from the results of the relevant characteristic structural features of each cssp and the significant results on the partners outcomes side by doing so it was possible to provide an explanation of why and how both levels were related and how the structural features had an impact on the outcomes that the partners gained by joining a cssp results and discussion qualitative study 411 barcelona sustainable barcelona is in catalonia spain with a population of approximately 16 million people the cssp of barcelona namely b s has been working for the citys sustainability for about 17 years with 1305 partners in 2019 this large cssp consists of partners from all three sectors the majority are civil society organizations and private sector businesses with minimal participation from public sector entities it is important to mention that a large number of public schools are members of b s with a specific role in sustainability education and thus they were not included in this study in such a large partnership the communication system in place is a reflection of its complexity it has both electronic and hardcopy newsletter formats that are delivered to the partners two times per month it also has an ongoing website and a digital map the digital map is a tool where not only partners but also the residents of barcelona can find sustainability initiatives pictures of places in the city activities related to sustainability etc b s also has regular meetings and social events with its partners communicates through email daily if needed and has an annual gala where the partnership reports progress on its goals workshops are led by b s and each sector runs its own workshops regarding monitoring and reporting b s reports about activities on an annual basis including its projects the evaluation of the progress on the partnerships goals is done every 10 years which is the timeframe of every plan and plan renewal they do not report or evaluate the partners goals and outcomes due to the number of organizations participating in this cssp in terms of partners engagement there are two categories partners commitment and how new partners are being added to b s b ss partners commit to the cssp through endeavors that they decide to follow during their participation which are very flexible the b s coordinator mentioned that the commitments could range from reporting their actions to making their own action plan that aligns with the goals of b s as the cssp has many partners already there is no need for b s to recruit new members however the mechanism to attract new partners is by providing information through activities resources and working on the partnerships goals so that other organizations can see what the cssp is doing most of the people in the city know about b s and thus the cssp does not need to advertise for partners engagement new partners can join at any time regarding plan renewal b ss latest sustainability plan went from 2012 to 2022 following a previous one from 2002 to 2012 however the renewal of the plan began in 2020 since barcelona declared a climate emergency on 1 january 2020 and the climate emergency committee stated the necessity of implementing a 20202025 and a 20262030 climate action plan in order to meet carbon neutrality by 2050 this climate action plan falls under the larger b s and replaces the 20122022 plan the coordination of b s is based on a technical secretariat that has 16 people it is hosted in the municipality of barcelona and is funded by the municipal government each sector ie civil society organizations public and private sectors has its own dedicated coordinator hours in terms of the decisionmaking mechanism there is a committee composed of 50 members that are elected by the signatories of the commitment each sector elects its own representatives the city council is also part of the committee gwangju council for sustainable development gwangju is located in south korea with a population of about 15 million people the gwangju council for sustainable development has been working for gwangjus sustainability for 24 years with 115 partners in 2019 from the three case studies this cssp had the least number of partners from their active partners surveyed in 2017 the majority represented civil society organizations the communication system developed by gcsd is similar to b s some differences can be found in the frequency of newsletters its enewsletter is delivered once a month and the hardcopy newsletter twice per year it also has ongoing meetings and a website emails are sent and social events occur every two months gcsd runs workshops once per year and if needed they can run more there is an annual gala where they report the outcomes of the cssp their monitoring and reporting mechanisms are based on the cssps goals which are reported every five years along with annual projects that are reported and monitored every year gcsd creates sustainability agendas every five years which are based on an evaluation of the past agenda and the local situation of gwangju therefore they can promote actual social change the partners engagements in place are closely connected with the plan renewal process two years before the implementation of a new plan gcsd recruits new partners through the recommendation of existing council members once the partners decide to participate they have to plan their actions linked with the gcsds agendawhich is supported by the local governmentso that they can contribute to the cssps sustainability goals in terms of coordination gcsd has a secretariat that is hosted in the gwangju city hall and it is funded by the local government thirteen people work in the secretariat and make the coordination of the cssp possible regarding the decisionmaking processes gcsd has a steering committee with nine people who represent the gwangju region under the steering committee there are six committees that oversee policy education business ecological environment economic society and community lastly partner organizations are involved in decision making through their involvement in the 5year agenda which means that each year partner organizations develop a project plan and participate in the decisions of that plan sustainable montreal montreal is located in quebec canada with a population of about 16 million people montreals sustainability initiatives have been led by sm for 25 years with 230 partners in 2017 from the active partners that were surveyed it is possible to see that there was a more even percentage for each sector in comparison with the other cssps 40 of the partners were from civil society 27 belonged to the private sector and 33 of the partners were from the public sector in sustainable montreal the communication system in place is different from those of the other two cssps in terms of formats and frequency partners communicate through emails when needed and on the ville de montreal website there is a partner portal that partners can access sm has an annual gala where it reports the cssps goals and the partners accomplishments compared with the other cssps sm is the only one that reports about its partners commitments and accomplishments both outcomes ie the cssps and the partners are reported every two years sm is on its third sustainability community plan and in 2020 it was in the process of developing a new plan every time the city adopts a new sustainability community plan there is a renewed commitment with the partner organizations sms partners are in charge of carrying out and endeavoring to align with the cssps sustainability plan the partner engagement mechanism to add new partners is based on the adoption of a new plan they reach out to the organizations they have targeted regarding the similarity of the organizations actions to the cssps goals the recruitment is also conducted through networking events and by disseminating information regarding the coordination of sm six people work in the bureau du développement durable for the cssp itself there are four mobilization teams that are aligned with montreals four sustainable development challenges which are lowcarbon montreal green city neighborhoods that are great places to live in and a prosperous and responsible city the mobilization teams have one elected person one administrator and one citizen plus the partners moreover the secretariat is the coordinator for the mobilization teams in terms of decision making there is a coordination committee that includes people from the partner organizations the central services and the mobilization teams the participation of the partner organizations in the plan formulation decisionmaking processes is based on ideas they share regarding actions they want to happen for the plan quantitative study through a kruskalwallis test it was possible to show statistically whether the differences in how partners valued their achieved outcomes were significant among the three cssps the results show that with a 95 confidence interval there were significant differences in the value that partner organizations gave to community capital and physical capital sm valued community capital more than b s and gcsd and gcsd valued physical capital less than b s and sm pairwise testing using dunns test indicated that the value assigned by sm to community capital significantly differed from that assigned by gcsd and it marginally differed between sm and b s for physical capital the results indicate that the difference between the values assigned between gcsd and b s and gcsd and sm were statistically significant when comparing the values that partner organizations representing different sectors of society give to their achieved outcomes by cssp it was possible to see differences in the results the kruskalwallis test for b s showed that the most valuable outcome by its partners was human capital followed by community organizational physical and financial capitals when comparing the values of each capital by the sectors that were part of b s the differences in the means were not statistically significant in other words there were no differences between the value that each sector gave to each capital nevertheless there were marginal differences in the value that partners gave to financial capital in b s with a 90 confidence interval the public sector valued the outcomes of financial capital less than the private sector and the civil society organizations in b s similar to b s the kruskalwallis test for the partners of gcsd showed that they valued human capital the most followed by organizational community financial and physical capitals the kruskalwallis test showed that in sm the most valuable outcome was community capital followed by human organizational financial and physical capitals however in both partnerships there were no significant differences in the values that their partner organizations by sector gave to the outcomes they had achieved therefore in these two cssps partner organizations regardless of the sector they represent did not differently value the five types of outcomes being studied explanation building study barcelona sustainable and partners outcomes the statistical results for the partners of b s indicate that public sector organizations gave less value to financial capital than private sector and civil society partners these results were not the same for gcsd and sm significant differences in the value that public sector organizations gave to financial capital were not found in these cssps therefore what was different in b s with respect to the other cssps that made its public sector partners value financial capital less than organizations from other sectors when delving into the structural features of all the cssps it was possible to notice that the composition of b s was different from the other cssps out of the total number of b s partners only 7 belonged to the public sector while in gcsd and sm the percentages from the public sector were 19 and 33 respectively showing a clear difference in the number of public sector partners in b s in comparison with the other cssps details in the database of partners outcomes show that the public sector partners in b s were universities the board of libraries in barcelona and a park most of these organizations receive public funding among other types of resources moreover the index of financial capital was measured through seven items improving financial performance reducing costs funding opportunities developing new productsservices making new business attracting new investors and increasing financial resources this suggests that these organizations did not see financial capital as a valuable outcome since their own financial system was strong enough to not necessarily value that outcome meanwhile the private sector and civil society organizations did value this outcome more when participating in b s this could be explained by the place and institutional context of how these public institutions were funded compared with other country contexts table 5 details the partnership structure for b s along with the significantly different partner outcomes 6 details the partnership structure for gcsd along with the significantly different partner outcomes the kruskalwallis test for partners outcomes on physical capital showed that the partners of gcsd valued that type of outcome less than the partners of the other cssps similar processes as used in b s were followed to understand what was different in gcsd that made its partners value physical capital less comparing gcsds structural features with the structural features of the other cssps it was possible to notice that the partners engagement in particular the commitment of the partners was different from those used in b s and sm in b s partners had the leeway to choose any type of action that they wanted to adopt from reporting actions to implementing a sustainability action plan in sm partners had to adopt at least 10 actions from the sustainability plan but in gcsd partners were not asked to implement actions in their organizations in contrast they collectively implemented actions to contribute to the sustainability of gwangju therefore the rest of the structural features seemed not to allow their partners to improve their resources and processes perhaps local culture influenced the design in gwangju which was only implemented through community actions and not internal organizational actions 7 details the partnership structure for sm along with the significantly different partner outcomes the descriptive results for the partners outcomes and in particular for community capital show that this type of outcome was the most valued by the partners of the three cssps however the kruskalwallis test for community capital indicated that the partners of sm valued community capital more than the partner organizations participating in the other cssps community capital was measured using five items that focused on contributing to the sustainability goals of the vision environmental challenges social challenges and the sustainability of the community these results suggest that if all the partners value community capital the most what was different in sustainable montreal that made it possible to find significant differences in them while comparing the structural features of the cssps it was possible to notice that the partners engagement in sm was stronger than in the other two cssps the commitment of the partners was based on adopting 10 actions from montreals sustainability plan which ensured the partners were aligned with the local plan completely as the partnerships goals and the partners actions were aligned monitoring and reporting the outcomes of the partners became easier and therefore partners could have accountability not only from their organizations but also from the cssp about their own goals when it came to decisionmaking mechanisms as the partners were implementing the actions of the sustainability plan they had a say in the decision making regarding the types of actions they wanted to see happen in the sustainability plan this configuration did not happen in the other cssps which suggests why despite the fact that all the partners from every cssp did value community capital the partners of sm valued it more the main differences occurred in terms of three key structural features that were stronger in comparison with the other cssps conclusions the aim of this research was to understand the structural features of large cssps and the partner outcomes during the implementation of sustainability community plans the main contributions were related to the structural features of large sustainability partnerships and the relative similarity of partner outcomes from large cssps regardless of sector this research offers a framework of seven structural features that were considered to be key within the cssps communication systems monitoring and reporting partners engagement renewal systems coordination decisionmaking processes and the composition of the partnership some of these structural features were offered before within the collaborative strategic management literature however they were not sufficiently studied and developed in the context of large cssps the results suggest that the most distinguishing structural features that differed between the three cases were monitoring and reporting in particular whether these were focused on the partners activities partners engagement in particular whether partners are actively implementing the collaborative strategy and the composition of the partnership in particular the predominance of the sector the other features of communication systems decisionmaking systems renewal systems and coordination were also important structural features for achieving the partnerships goals and for having a better understanding of the partners outcomes and they had considerable similarities between the three cases however the analysis presented here focused on differences between partnerships and as these structural features were relatively similar they did not appear to be linked to the differences in partner outcomes the empirical results on the partners outcomes show that there were almost no differences found in the value given by partner organizations to outcomes that could be relevant for them regarding the sector they represented the extended rbv literature offers five types of outcomes community organizational physical financial and organizational capitals 11214 the literature states that the types of outcomes that partners can obtain from joining a partnership are related to the sector to which they belong 11556 however except for the results found for barcelona sustainable where the public sector rated financial capital the lowest valued partner organizations did not give more value to the types of outcomes based on the sector to which they belonged through understanding these large cssps and their partners outcomes we aimed to contribute to the success of partnerships and in particular to how partnerships can help their partners achieve their organizational goals the studied partnerships have been operating for many years with a high number of partners from across sectors and thus their experience and the relationships they have developed are a good learning experience for other partnerships to consider however understanding that success and impact are dimensions that are understudied in the partnerships research 57 this research also opens room for further research on the contributions that large partnerships make toward their collaborative goals and to their partners sustainability outcomes and what difference the structural features make in achieving that progress data availability statement data available on request due to restrictions informed consent statement informed consent was obtained from all subjects involved in the study

the aim of this research was to understand the structural features of large crosssector social partnerships cssps and their resulting partner outcomes this study analyzed and compared the partnership structures of three large cssps each from a different continent barcelona sustainable in barcelona spain gwangju council for sustainable development in gwangju south korea and sustainable montreal in montreal canada based on a survey of the partners in each of the three partnerships the partner outcomes were also determined and compared building on these findings and using abductive analysis the relationships between the partnerships structural features and partner outcomes are considered an updated set of seven structural features for studying large crosssector partnerships is offered the empirical findings show some differences between the partnership designs and between the partner outcomes of the three partnerships the experiences of the civil society private sector and public sector partners in each of the cases were relatively similar showing that in large partnerships the sector was less relevant than in small partnerships

introduction kgatla holds a firm belief that the churchs efforts to convert black individuals in africa to christianity through missionary work have had unintended negative consequences on social interactions and justice in the region he proceeds to assert that certain regions have experienced a distortion of holy scripture pertaining to fundamental human relations and social justice as a result of the christian crusades civilization and colonisation of african people the colonial perspective of the entitlement to conquer and appropriate land from individuals of african descent resulted in a deviation from the fundamental principles of christianity which emphasise the importance of adhering to christs teachings of love and fostering positive relationships with ones neighbours kgatlas argument is founded upon the work of johnson who posited that the perception of africa as the pinnacle of human development in south africa was due to the prevalence of white racial supremacy and control over black individuals consequently the pursuit of social justice in this context resulted in more negative outcomes than positive ones the prevailing understanding and maintenance of christianity among the white population in south africa during the apartheid period did not align with the principles of social justice and coexistence the individuals religious beliefs involved abstaining from involvement in political matters and deferring to the governing party with a focus on spiritual pursuits that would lead to salvation a variant of christian theology centred on escapism was formulated with the backing of white piety and global pentecostalism which pledged redemption devoid of concerns for social equity however in our attempt to assist the church in her missional task of holistic diaconia we have found that the colonial irony is still predominant in various congregations the colonial mentality was we do to you and we do for you because we know what is best for you however we believe that a colonial indoctrination happened within the mindset of many ministers hence the irony although we are today very critical of colonialism many of our colleagues in the church ministry and in their understanding of diaconia within the uniting reformed church in southern africa are still doing diaconia in a charity mode and with the colonial irony of we do to the poor and we do for the poor because we know what is good for the poor this colonial irony limits us to move beyond a charity mode of diaconia as we are stuck in shortterm projects and handouts such as soup kitchens food parcels and clothes banks although these charity mode services remain important to address the immediate need in order to move to a more sophisticated mode of development we propose in this article that perhaps we should redefine our understanding of diaconia through the lens of a social justice approach hence it is our perspective that the historical impact of the apartheid regime is a crucial element to consider when examining contemporary social inequities in south africa the south african government has identified unemployment poverty and social injustice as the primary challenges that must be addressed to foster a robust nation however thus far government efforts to tackle social injustices in postapartheid south africa have primarily centred on political and civil rights while the socioeconomic needs of a significant portion of the countrys impoverished and marginalised population have remained unfulfilled this article highlights the correlation between social injustice and poverty emphasising the profound impact that poverty and unemployment have on human dignity simultaneously it is imperative to acknowledge that the act of excluding individuals from poverty and unemployment alleviation practises is a transgression of dignity thus the goal of sustained poverty reduction and sustainable development cannot be achieved unless social justice is emphasised of course we can hold the government accountable for this situation but we should also renew our understanding because the authority is often fragmented and involves nongovernmental role players such as faith leaders which is an important lesson to learn from development praxis according to gaventa and oswald the church being closer to the reality of people and communities is called within this context to be true to her missional calling of doing diaconia but how do we move beyond mere handouts project mode to transformational differences as a church how can we consciously strive towards strengthening the agency role of people from poor communities as a church with a diaconal task we propose that the social justice theories should be used as a lens to assist us in making this shift within our understanding of diaconia in south africa the purpose of this article is to explore specific justice theories feeding and leading to a social justice approach in development the objective of this article is to analyse various aspects including a concise overview of the socioeconomic and sociopolitical context of south africa a call for action in the form of diaconia and social justice a justification for adopting a social justice approach an evaluation of selected social justice theories a proposed approach for implementing social justice in practise finally the article concludes with deductions drawn from the proposed praxis for social justice the present argument posits that by adopting the aforementioned identification the social justice approach will strive to ensure equitable treatment of individuals and collectives alongside equal access to services their availability and opportunities for growth and progress a socioeconomic and sociopolitical south african context in presentday south africa analysts are directing focus towards the resurgence of outrage among impoverished black communities reminiscent of the apartheid era as they engage in increasingly aggressive demonstrations against their substandard living conditions and apparent lack of municipal service provision in a manner comparable to the era of apartheid there is a resurgence of nationwide unrest that prompts significant inquiries regarding the condition of democratic governance in presentday south africa protests are being carried out by impoverished communities due to their discontentment instead of positing a singular cause a nexus of interconnected causes can be discerned to account for this collective fury specifically elucidating why a significant number of the nations most impoverished communities are agitated and thus engaging in protests that have escalated to violence while the notion remains disputed in the discourse surrounding service delivery it has been claimed that the communitys discontent may have stemmed from a feeling of relative deprivation among its constituents this unequal service delivery and unequal access to other services in poor communities created anger as there existed a disparity in the provision of infrastructure and services between the impoverished areas and other regions of the city with the former receiving subpar amenities moreover in contemporary south africa a total of 26 million of the nations 55 million inhabitants are presently residing below the poverty threshold of usd 2 per day harold asserts that the majority of black south africans and africans in general experience significant disadvantages in comparison to their white south african counterparts the proportion of african adults holding a tertiary qualification is 4 while the corresponding figure for white south africans is 25 in the south african economy the proportion of white individuals occupying top managerial positions is 70 while 59 of senior managers are also white the unemployment rate for individuals of african descent stands at 288 while for those of white ethnicity it is 59 the data indicate that a significantly higher proportion of white south africans approximately 61 reside in households that have a monthly expenditure exceeding zar 10000 whereas only a mere 8 of africans have the financial capacity to spend the same amount according to statistical data a significant proportion of the african population approximately 16 experience extreme poverty and frequent hunger in contrast a vast majority of white south africans approximately 999 enjoy a higher standard of living the aspiration for peaceful coexistence among south africans is being challenged by the lingering effects of apartheid resulting in animosity and an escalation of demonstrations in recent years and months these protests might not be ideal but it obliges us to broaden our understanding of agency and how it contributes to empowerment and accountability which is an important lesson to learn from development praxis the churchs response must be situated within this particular context rather than leading an ascetic lifestyle and disengaging from the world the church should actively involve itself in the struggles of the majority in postapartheid south africa this can be achieved by aligning its words and actions with those of the marginalised and voiceless thereby serving as a prophetic conscience to both the government and the community at large in the context of postapartheid south africa the church can serve as an alternative community that fosters the growth and development of individuals to achieve this it is imperative for the church to acknowledge and reinforce the shared humanity that binds people together this necessitates proactive attention to justice and the welfare of society arising from a sense of solidarity with the rights and needs of fellow individuals thus solidarity is considered a virtue that motivates the church to take action rather than a fixed state of being or objective a call for action diaconia and social justice in the past two decades a significant change in paradigms has occurred resulting from both political and social advancements the united nations convention on the rights of persons with disabilities has resulted in the adoption of an inclusion paradigm in both theoretical and practical contexts the concept of inclusion pertains to a societal structure that does not involve the marginalisation of individuals it envisions a scenario where individuals with varying abilities are visibly and tangibly integrated into the wider society actively participating and connected to the overarching goals and objectives the trend towards inclusivity entails a dual emphasis namely a focus on the individual as well as on the community to enhance the involvement and selfgovernance of individuals it is imperative to take the dynamics of a community into account this entails exploring ways in which individuals can mutually empower and enhance each other as well as how various entities and actors can provide distinct forms of support to enable individuals to lead selfsufficient and selfdirected lives swart argues that the practical and applied discipline of diaconia is currently facing a significant challenge to its identity this challenge is being shaped by the concept of a new paradigm of diaconia which represents a distinct shift in the way that theorists of diaconia approach their work specifically there is a growing awareness of the need to move away from traditional conceptualisations of diaconia as a form of humble service or paternalistic charity instead there is a renewed emphasis on relating to those in need of assistance in a way that fully respects their humanity and agency as independent subjects thus with regard to the objective of formulating the concept of diaconal practice this implies that those who are providing help or offering diaconal service should do so in a way of respecting the autonomy and integrity of the other and avoid creating relationships shaped by uneven dependencies this principle is relevant both at an interpersonal level for instance when providing financial support to individuals and at a more structural level as in international aid where longstanding relationships of dependency should be avoided thus diaconal service should focus on reducing dependencies supporting independence and activating the other persons own resources to cope on their own in the long run autonomy and interdependence are not opposites but are related to each other dialectically and complementarily this encouragement for a paradigm shift by both swart and dietrich reassures us that social justice values should be taken seriously in this endeavour of understanding diaconia in a holistic sense rather than mere charity and humble service poverty is widely recognised as a tangible illustration of the potential infringement of dignity within social contexts the concept of human dignity pertains to the right of an individual to be recognised as an autonomous being who possesses the freedom to pursue their own beliefs and values thereby leading a life characterised by selfesteem the reliance of impoverished individuals on external sources for sustenance and support undermines their capacity to assert themselves and engage with others as autonomous agents thereby impeding their ability to pursue selfdetermined lives this dynamic transgresses their inherent sense of selfworth and by extension their dignity the resolution of such instances of transgression can solely be achieved through the provision of alternatives to individuals residing in impoverished conditions and when their subsistence is not entirely subject to the discretion of external agents this would imply that individuals not only possess the material resources required but also possess the necessary abilities or capabilities to facilitate the actualization of various options fundamentally diaconal labour involves addressing the concept of otherness which pertains to individuals who are distinguished as distinct within societies due to factors such as gender ethnicity social and economic standing physical and mental capabilities age and other similar characteristics the concept of new diaconal professionalism pertains to the management of otherness in the realm of professional social work and theology in response to emerging challenges particularly those related to inclusivity hence we will turn our focus on the social justice approach as a manner to reshape diaconia in our south african context a rationale for a social justice approach this article acknowledges that there is a close correlation between social justice diaconia and human rights the purpose of this article is not to duplicate the extensive scholarly discussions pertaining to the concept of social justice the emphasis lies on the application and practical implementation of the concept as a framework for diaconia and community development social justice is multifaceted and therefore there is a need to identify key concepts underpinning social justice which is required for critical engagement in the implementation of diaconia as well as community development the theme of social justice is present throughout the entirety of the bible spanning from the book of genesis to the book of revelation according to crossway there are 69 scriptural portions in the 69 books of the bible that contain a direct appeal to social justice this concept underscores the shared ancestry and ultimate fate of the human race the bibles primary message is underpinned by gods summons for social justice grounded in the shared origin of humanity and the divine intention for their existence it has been ordained that certain responsibilities are attributed to the human race the original divine plan was for humanity to coexist in concordance with the laws and purposes of god humans were appointed as representatives of god on earth to carry out his justice moreover from a biblical or theological standpoint comprehending justice within the framework of the covenant wherein each covenant member is bound to demonstrate love towards god and their fellow human beings proves to be a valuable perspective moreover justice is an ethical concept that pertains to individuals who exhibit generosity within their community with the aim of fostering maintaining and augmenting the communitys welfare the term who refers to an individual who is recognised for actively engaging in community investment and displaying exceptional care and attention towards individuals who are impoverished vulnerable or in need the prophets have provided a comprehensive outline of a communitarian ethic regrettably the israelites who were selected as a model by god misconstrued their election through abraham and their departure from egypt along with the accompanying benefits and entitlements as their individual prerogative that ought to be exclusively exercised by the jewish people according to leviticus 1918 the term neighbour was interpreted by the people of that time to refer to their associate as a result the jewish community defined a neighbour as an individual who belonged to their collective group it was incumbent upon the israelites to treat individuals of this nature with equity and benevolence refraining from engaging in any form of deceit or theft however the jewish communitys treatment of individuals who were not of jewish descent was such that they did not regard them as being of the same status as jewish individuals jesus arrived with the intention of altering this viewpoint among the four authors of the gospel namely matthew mark luke and john lukes account is particularly lucid in its portrayal of jesus aim to rectify erroneous jewish notions regarding the concept of neighbour in contrast to the jewish belief that social justice should only be extended to their own community jesus challenged this notion and advocated for the inclusion of both kin and nonkin as deserving recipients of social justice he emphasised the importance of treating strangers with the same level of care and consideration as ones own family members in general human beings are inherently social creatures and their lives are significantly shaped and influenced by their social interactions and relationships on an individual basis people have the ability to either positively or negatively impact the development and dismantling of their respective organisations the coexistence of human beings is a collective experience wherein interdependence on fellow individuals is a crucial aspect of survival therefore social relationships and institutions serve as the fundamental basis upon which human existence is established and maintained within any given society or organization there exists a power dynamic that serves to either limit or facilitate the actions of individuals the presence of checks and balances within an organisation can facilitate the equitable distribution of opportunities for all members to contribute to its overall welfare provided that corrective measures are implemented in a just and impartial manner the institution of the church is founded upon the fundamental principles of social relations the promotion of human rights for all members of society is a fundamental principle of community work which is underpinned by the concept of social justice the attainment of social justice entails the recognition and endeavour to mitigate systemic hindrances prejudicial treatment and disparity according to frasers analysis there exist two primary methods of addressing social justice the initial perspective centres on the equitable allocation of resources and commodities whereas the latter perspective centres on the politics of acknowledgement according to frasers argument instead of separating the two aspects of justice it is imperative to consider and tackle both of them lister argues for the integration of redistribution and recognition contending that this approach enables policy demands that lead to equitable representation and adequate social security to support a dignified standard of living the pursuit of recognition is an everyday occurrence in various strata of society and can be demonstrated across multiple tiers unequal access to resources such as income job opportunities schooling and medical services can result in a dearth of political and policy recognition the recognition of voice and identity is imperative encompassing the acknowledgement of diverse identities and the reevaluation of undervalued marginalised or overlooked identities the act of recognition should not be superficial or symbolic but rather should actively facilitate opportunities for expression participation and authentic incorporation the absence of acknowledgement is frequently linked and intensified in instances of economic disadvantage according to taylors proposal the formation of identity and expectations of individuals and groups is influenced by recognition and the lack of it can result in significant adverse consequences authentic christian justice based on biblical principles is firmly rooted in the compassionate nature of god the individual maintains that the deity possesses a distinct concern for the wellbeing of individuals situated at the lowest rungs of the societal hierarchy such as orphans widows and other legal immigrants residents of impoverished neighbourhoods and other marginalised or alienated groups if the church acknowledges this matter it ought to take the lead globally in pursuing social justice by establishing a clear definition of social justice identifying fundamental biblical principles of social justice and formulating a robust stance on any measures taken to address current social issues social justice in the south african context can only be fully comprehended when approached from a holistic perspective taking into account the countrys complex historical and colonial legacy the correlation between unemployment and the quality of school education for historically marginalised individuals substandard and restrictive infrastructure and subsequent occurrences of corruption favouritism familial biases and a sense of entitlement should be comprehended chipkin posits that social justice is achieved through the establishment of justifiable relationships between social classes and groups which are based on a fair distribution of public and private goods and benefits associated with national and economic growth altmann provides a definition of social justice in his speech to the tenth assembly of the world council of churches characterising it as a shared journey towards a collective fate the wcc has articulated its definition of social justice in a public statement which involves the pursuit of the common good through the identification and confrontation of privilege economic injustices political and ecological exploitations and oppressive forces that exploit marginalised individuals and communities social justice refers to the ability to collaborate with others and achieve goals that are advantageous to the entire community the concept of social justice pertains to the equitable preservation of access to rights and opportunities as well as the provision of care for the most vulnerable members of a given society rawls posits that the determination of justice or injustice is contingent upon its ability to facilitate or impede equal access to civil liberties human rights opportunities for health and fulfilling lives as well as the equitable distribution of benefits to the most disadvantaged members of society the notion of social justice employed in this context of diaconal and community development endeavours to tackle and emphasise the comprehensive and inclusive rights of communities and their members while simultaneously acknowledging that the rights each person has should not be invalidated or disregarded by the collective frasers conceptualisation of social justice posits that in order to achieve justice it is necessary for collectives to attain both recognitionbased justice and economic distributionbased justice the practical question that arises from this twofold understanding of social justice is how to effectively engage groups in this pursuit theories of social justice in relation to the aforementioned section the pursuit of social justice is rooted in the fundamental premise that all individuals are created in the image of god and as such possess inherent worth with regard to the biblical foundation of social justice it can be argued that individuals possess a moral obligation to assist those who are marginalised within their community the principle of love as prescribed by christian doctrine mandates the provision of care to individuals in need irrespective of their nationality or relational proximity the aim of social justice is to rectify instances of inequity and promote parity in the distribution of resources and assets on 26 november 2007 the united nations acknowledged the necessity of advancing endeavours to address concerns such as destitution marginalisation and unemployment consequently the un resolved to commemorate february 20th every year commencing in 2009 as the world day of social justice 1 the italian catholic cleric and scholar luigi taparelli coined the phrase social justice in the 1840s he used it to define the fundamental principles of a just society as well as how advantages and responsibilities are shared in a community numerous theories and methodologies have evolved over the course of the 20th century each of which has its own meanings principles and consequences for the idea of social justice each of these uses a distinct data basis of reasoning to make decisions about the suitability and fairness of various social circumstances by including and excluding pertinent information therefore it is crucial to weigh the benefits and drawbacks of the informational foundations of some of the key theories of social justice including the utilitarian perspective john rawls theory of justice sens capability approach and nancy frasers theory of social justice in order to comprehend the complexity of social justice and incorporate its principles in development the utilitarian perspective the utilitarian viewpoint which held sway as the preeminent doctrine of justice for more than a century prioritised the aggregate utility of an individual the concept of utility pertains to the quantification or evaluation of an individuals happiness or pleasure this viewpoint posits that the sole desirable entity is happiness the state of happiness is considered a selfsufficient objective whereas all other things are regarded as instruments or pathways towards achieving that objective this perspective emphasises the need to judge the consequences of all choices choices are right if they promote happiness and wrong if they do not promote happiness therefore it is imperative to evaluate every institution law or action based on the level of happiness it produces ultimately happiness is good as in the final analysis the state of being happy is considered to be beneficial thus this viewpoint advocates for the advancement of the common good that benefits a larger population however this is not only for a greater number of people but ideally inclusive of all people as indicated by benthams view on utilitarianism john rawlss theory of justice the theory of justice by john rawls is widely regarded as an influential concept of justice in the 20th century rawlss theory of justice is primarily grounded in the notion of fairness the concept of justice as fairness posits that the principles of justice that are most rational are those that would be mutually agreed upon by individuals under equitable circumstances with the aim of achieving fairness fairness can be defined as the antithesis of unfairness pertaining to connections that facilitate transform and empower simultaneously therefore the implementation of social justice necessitates sound decisionmaking skills from individuals in positions of power and authority the very first principle posits that there should be an equitable distribution of all social primary goods among all individuals the second principle pertains to the equitable allocation of social primary goods wherein any departure from parity ought to be advantageous to those who are least privileged while the utilitarian school of thought prioritised utilities rawls argued for the significance of social primary goods the author posited that primary goods are the necessary means that an individual is presumed to desire in order to advance their objectives these primary goods encompass elements such as income and wealth basic liberties freedom of movement and selfrespect moreover it is suggested that rather than concentrating on a single principle such as utility the prioritisation of social goods should be arranged in a lexical sequence of equivalent importance namely liberty necessity and utility sens capability approach sens scholarly work introduces the concept of the capability approach which centres on the correlation between individuals resources and their capacity to utilise said resources the objective of the capability approach to social justice is not limited to the identification of individuals functioning instead it aims to consider the degree of freedom that individuals possess to achieve this functioning and to establish circumstances that enable all individuals to enhance their freedoms and experience comparable capabilities for instance this approach would consider the capabilities of a fasting man and a destitute person sen expresses hesitancy towards endorsing a universal set of capabilities that would serve as a baseline standard for all societies however he does outline five political freedoms that he deems instrumental in contributing to peoples overall freedom to live their lives as they desire these freedoms include civil and political rights economic facilities that provide opportunities for the production or exchange of economic resources social opportunities that encompass both public services and private facilities transparency guarantees to prevent corruption and financial irresponsibility and protective security measures that ensure social security sen has made significant contributions to the field of social justice by establishing connections between the public and private spheres of society in the past scholars in the field of social justice overlooked the significance of private inequalities specifically those related to gender in the attainment of social justice nancy frasers social justice theory the application of social justice in the realm of community development endeavours to tackle and prioritise the comprehensive entitlements of groups and communities while concurrently acknowledging that the interests of individual members should not be disregarded by the collective nancy fraser is a renowned contemporary american political philosopher whose fundamental principle of justice is centred on the concept of participation equality fraser argues that collectives must strive to achieve both recognition justice and economic distribution justice thus the concept of justice necessitates the establishment of societal structures that facilitate equitable peer interaction among all constituents and an even allocation of tangible assets frasers framework for justice comprises three dimensions namely redistribution recognition and representation the concept of redistribution entails the notion of equitable allocation of resources a principle that bears resemblance to the ideas espoused by scholars such as john rawls the objective of recognition is to emancipate individuals or collectives from the inferior position in social culture and to guarantee equivalent cultural status and identity for every member of society regarding the political aspect of justice the concepts of redistribution and recognition extend beyond nationstates within the framework of globalisation hence the political facet of representation can solely furnish mechanisms for resolving issues by determining the eligibility of individuals to partake in communal existence as a constituent political representation encompasses both symbolic framing and political voice achieving equality of participation necessitates the equitable allocation of material resources irrespective of the varying characteristics of participants such as gender race and other attributes fraser contributes to the theory of justice by speaking to the struggle for equitable distribution but this view has been challenged robeyns contends that fraser fails to acknowledge the distinctions among various theories of distributive justice the individual posits that the assessment of rawls theory appears to be overly simplistic and is not applicable to sens capability approach therefore redistribution must be redefined to include the main ideas of theorists like rawls and sen the principle underlying justice ought to be that of equal participation with the inclusion of the dimensions of redistribution recognition and representation fraser formulates a theory of global justice by incorporating the element of representation this dimension prioritises the inclusion of the general populace over political elites thereby offering fresh insights and avenues for research aimed at addressing the challenges inherent in contemporary global justice systems fraser posits that her theory of justice should be grounded on the principle of participation equality whereas forst suggests that addressing issues of domination and unjustifiable arbitrary decisions can be achieved through redistribution recognition and justification because the distribution of certain goods is not mandated by the fundamental principles of justice in addition gaventa warns that although there are increasing prospects for civic participation in policymaking procedures it is evident that the mere establishment of novel institutional frameworks may not inevitably lead to amplified incorporation or policy modifications that are favourable to the impoverished rather the efficacy of these new conceivably more democratic domains is heavily contingent upon the character of the power dynamics that envelop them however fraser continues to make equal participation more applicable through practical methods to recognize the uniqueness of participants diversity common humanity and complexity of the forms of wrong recognition having mentioned that we agree with frasers normative foundation of equal participation and concur with parfitt that depending on how participation is implemented it may be perceived as a method of pursuing conventional development objectives in a hierarchical manner while creating a deceptive impression of executing more comprehensive initiatives that aim to empower marginalised communities and individuals but despite these risks most definitions of participation share the view that involving and informing individuals in projects that impact them can lead to an improvement in development outcomes a proposed praxis for social justice the utilisation of social justice by ginwright and cammarota has the potential to cultivate critical consciousness of the social context our argument is that the aforementioned approach should be combined with social action which freire refers to as praxis social justice as a facet of community development entails promoting group introspection analysing available alternatives and subsequently implementing actions based on these reflections social justice pertains to addressing social and economic disparities while upholding human rights and enabling individuals to take action towards rectifying these inequalities thus it necessitates a heightened awareness and capacity for action how do we as a church utilise embody or praxis our rich sources such as the accra 2 kairos 3 and belhar 4 confessions to enable transformation in our communities the warc has made efforts to implement practical applications of the confessions within its framework a robust theoretical framework has been established on the basis of accra and belhar what is currently required is a form of practical application or implementation in essence the task at hand involves establishing a structured system that can enable groups and associations to comprehend discern and contemplate the significance of acknowledgement allocation and portrayal this system must also offer the necessary assistance to devise remedies and avenues for improved relationships with the ultimate goal of remedying perceived inequities concepts that will assist us in our understanding and application to move beyond a charity modeservicesonceoff projects to social justice are recognition redistribution representation including key concepts like fairness empowerment compassion equal participation building of relationships and holistic wellbeing we will continue this article by first unpacking these concepts to enhance a praxis for social justice redistribution the living conditions of many south africans reveal that poverty serves as the initial point of attack on the image of god in south africa it is a prevailing fact that the demographic group most affected by poverty is the black population the enduring economic impact of centuries of colonisation and oppression which included limitations on mobility and social interactions has had a significant and ongoing impact on the majority of black individuals in south africa therefore the church is tasked with a ministry that entails maintaining a delicate equilibrium between providing assistance and fostering growth development ministries aim to empower individuals who are unable to support themselves financially when the church recognises its authentic identity as gods children it rediscovers its genuine purpose by viewing itself as responsible and efficient caretakers of god working towards the betterment of all essentially development is about people and how to improve their quality of life the level of satisfaction with fundamental human needs is a crucial determinant of an individuals quality of life therefore maxneef proposes the human scale development as a needs theory for development he identifies a total of nine essential human needs which encompass subsistence affection protection understanding participation identity creation leisure and freedom there exists no hierarchy of needs and none of the aforementioned needs is more important than the other unsatisfied needs are viewed as poverties and therefore he extends the concept of poverty to more than a lack of income which means that development is the reduction of different poverties furthermore the means to satisfy these needs are by satisfiers including being having doing and interacting which in turn can result in different economic goods these satisfiers are merely suggestions which are not conclusive but can vary depending on diverse cultures and historical moments due to the diverse nature of needs transdisciplinary approaches should be adopted to operationalise development in support of the united nations sustainable development goals south africa has aligned its vision to the sdgs and allocated a budget accordingly 5 these goals are no poverty zero hunger good health and wellbeing quality education gender equality clean water and sanitation affordable and clean energy decent work and economic growth industry innovation and infrastructure reduced inequalities sustainable cities and communities responsible consumption and production climate action life below water life on land peace justice and strong institutions and partnership for the goals however based on various research works it seems that south africa is not successful in addressing the needs and reaching these goals of south africans within these mentioned research works it is evident that african people and specifically youths are viewed as a vulnerable and marginalised group within presentday society of a variety of contributing factors which cause marginalisation the three main contributing factors identified are poverty unemployment and exclusion this view is supported by various research findings and statistics related to young people being excluded from education employment andor training opportunities other social issues that marginalise south african youths are reported to include a high dropout rate in educational settings inadequate skills development inadequate youth work services poor health high hiv and aids prevalence high rates of substance abuse crime and violence a lack of access to sporting and cultural development opportunities a lack of social cohesion and volunteerism and disability and exclusion in addition based on our argument hitherto we would like to use the land reform initiative as another example nancy frasers concept of redistribution can potentially serve as a means to prompt the government to accelerate its land reform initiative additionally the 1913 land act in south africa has been identified as having unfairly advantaged specific racial groups and as a result restorative measures are necessary to address the injustices inflicted upon those who were negatively impacted by this oppressive system the act of redistribution or restitution is a crucial aspect of the process of reconciliation as it entails relinquishing something that leads to a deeper comprehension of the affliction inflicted upon the majority by apartheid it is arguable that this facet of the process is the most humane when the church as the collective body of individuals who belong to god takes charge of this procedure it does so from a standpoint of empathy this kind of praxis will lead to empowerment as indicated by chambers in empowerment means that people especially poorer people are enabled to take more control over their lives and secure a better livelihood with ownership and control of productive assets as one key element christens in gaventa clarifies community power even further arguing that empowerment refers to any positive development amongst group members or as the process by which groups attain increased authority over their situation linking themes of power and empowerment can be done by bringing together several prepositions which frequently accompany the word power such as power over with to within and for in this analogy power over denotes the ability of individuals or groups to exert influence and authority over others and power to refers to the ability to act and therefore suggests empowerment these are frequently perceived as being in conflict with one another or as competing definitions but could be seen and used as being interrelated and unified whereby social action is a dynamic process in which marginalised groups cultivate a sense of agency and collective empowerment to contest external forces that exert control over their lives thereby enabling them to attain greater autonomy and selfdetermination the prevalence of power changes and therefore it is of utmost importance for a development practitioner to reevaluate power relations continuously recognition the church is therefore tasked with the responsibility of manifesting the attributes of god as evidenced by its demonstrations of benevolence and affection hence it is imperative to delve into the definition of compassion and its application in the context of south africa the south african church has the potential to embody the ideals of a benevolent empathetic and affectionate community which serves as a model for other communities to emulate according to davies the virtue of compassion necessitates a profound shift away from selfcentredness and entails a willingness to jeopardise ones own comfort in order to empathetically experience the plight of those who are marginalised and in pain the concept of compassion is rooted in acknowledging the inherent divinity of others as they are created in the likeness of the divine the self undertakes the responsibility of the other due to this comprehension according to davies the recognition of gods image in others albeit veiled leads to a better understanding of our own identity according to nouwen et al the term compassion denotes the act of suffering with compassion therefore requires one to enter spaces where one identifies with the weak vulnerable and powerless compassion entails complete engagement with the state of humanity compassion is a complex emotion that transcends mere pity and is considered to be the most authentic manifestation of divinity in human form the compassion of god is transferred onto us the concept of selfdenying or kenotic love as described by davies has implications for various aspects of human existence and endeavours to facilitate the achievement of social cohesion this extreme expression advocates for the recognition of ones own identity reflected in another individual the church as an alternative community endeavours to recognise the divine image in all individuals within the society what does it mean to be made in gods likeness and how does that bring this deed of mercy into focus this image is provided by god and is essential to human dignity because the forgiving caring god is the fundamental religious problem in human dignity as an alternative community the church is compelled by this knowledge to voice out against the social political and fiscal obstacles that keep people apart the church takes on the role of the prophetic voice that condemns poverty as a condition that compels people to live in a state of inadequacy and servitude in relation to those who must continue to be their dependencies and masters the church allows us to engage with and inquire about the one who grounds the purpose and structure of our existence as being human but also calls the church to live and minister as the authentic possibility of our existence because the church comprehends the profound truth that human beings share in the character of god even in a limited and derivative sense the church is accountable to the underprivileged and downtrodden gods society is obligated to stand up for the rights of the underprivileged the helpless and those who lack social or fiscal influence the church provides for the material and social requirements of its members as a sign of a restored sacred and different society not as if these were the only needs or the only thing that needed to be done when the church is compassionate it reflects the character of god and displays its care for spreading his love through both words and actions it develops into a welcoming society where the other or all are acknowledged for their agency and power gaventa developed the power cube framework that helps us understand the complexity of power interactions including the different forms of power different spaces and levels these places forms and levels of authority and power interplay constantly consequently affecting possibilities and strategies for change these different dimensions of power can make it difficult to facilitate inclusive dialogue and decisionmaking the understanding of these multiple forms of power is equally important as an increase in citizen participation because due to power certain people are marginalised while amplifying the voice recognition and influence of other people one important task of leaders is to identify surfacing power dynamics and strategies to shift power in favour of marginalised groups representation personal relationships are rooted in social justice justice is impossible where there are unequal power ties and where there are no human connections god created his beings with a strong sense of intimacy and he actively cultivated this betweenness to the point where he willingly died on the cross for them he left his people with this example of fairness and compassion to live by being in partnership and united in affection with one another is what it means to be human by building a religious community where these disparities do not stand in the way of friendship and affection for one another the church as an alternative community must voice out against these problems that distort the picture of god in people when led by this vision the church will possess doctrinal tools sufficient to help it fight the urge to support race and socioeconomic division the church becomes a force for healing where human thriving occurs as a result of its compassionate deeds the church cannot look on as obvious persecution occurs and stay quiet being quiet entails accepting the status quo and taking responsibility for our inaction mass devotional gatherings should be held to address this wicked system that undermines humanitys ability to reflect god but social action should also be prioritised the alternative communitys true religion is manifested in its deeds and actions that show ones affection for god and other individuals those who are aware of god must rise and act participation should be implemented as both a means of reaching development goals and an end by empowering people to follow their own growth initiatives projects and development activities therefore instead of mobilising people behind the predetermined objectives of development agencies empower people to pursue their own development activities and projects development practitioners should adopt participatory behaviour which includes tolerance mutual respect openness to differing views adaptability and the ability to learn from mistakes to find the synergy between specialist knowledge and the peoples knowledge or social capital selfcritical awareness and reflection are paramount to the process of participation deductions for a proposed praxis for social justice as a proposed praxis for social justice we can deduct the following crucial elements of our argument as follows and say that in south africa diaconal project goals with a social justice approach should be equitable in attempting to rectify unfair disadvantages caused by our history of segregation discrimination apartheid and oppression establish concepts of holistic wellbeing and improvement of quality of life within the specific context determine who is happy within the current application of diaconia when having to choose between the needs of different groups the needs of the most vulnerable or vulnerable groups should be prioritised encourage equal participation by consciously addressing power forms spaces places and levels everybody should have the opportunity to influence decide and determine fundamental human needs in addressing these needs everybody including marginalised groups can partake and have access to resources as an element of empowerment due to the diversity of needs a transdisciplinary approach should be adopted to operationalise development build relationship by being honest real transparent fair and compassionate remain selfcritical and reflective and reevaluate goals and the process continuously prioritise redistribution distribute tasks information and resources equally keeping in mind that individuals have different capabilities therefore vulnerable groups should possibly be skilled educated developed and favoured to enhance the collective goal in other words establish equity prioritise recognition consider cultural and positional differences and adapt development goals accordingly recognise resources recognise power dynamics recognise talents recognise social capital recognise possible dependence recognise a need for advocacy recognise a need for voice and identity and recognise the rights of individuals prioritise representation be critical of whose voices are being heard implement participatory behaviour which includes mutual respect tolerance openness to differing views ability to learn from mistakes and adaptability and find the synergy between specialist knowledge and peoples knowledge conclusions throughout our article a comprehensive understanding can be gained of the characteristics and value orientation of a social justice approach for diaconia undoubtedly when using only one theory for social justice although it might make some valuable contributions on the one hand the limitations on the other hand will not do justice to a social justice approach we have also argued that many theorists made some functional contributions and therefore we are of the opinion that a social justice approach should also include concepts such as empowerment fundamental human needs social capital power relations and equal participation our discussion of social justice has shifted away from a focus on specific initiatives or services almsgiving charity and handouts towards human dignity equality and selfrealisation which not only reflects a shift in political philosophys ethical outlook but also the most recent development in critical social theory with this identity in mind the social justice strategy will work to ensure that all individuals and groups are treated with dignity and that all individuals and groups have equitable access to services provision of services and growth opportunities by no means do we put forward that these are the only social justice theories but we have made a cautious selection of theorists in order to assist us in the purpose of this article namely that this approach should assist first and foremost the church and also other role players in understanding the new paradigm shift of diaconia as more than just mere paternalistic charities and services towards the establishment of sustainable and empowered communities as a result of this article the authors were left with the realisation that additional research and possible publications are needed for further explorations patents this section is not mandatory but may be added if there are patents resulting from the work reported in this manuscript data availability statement not applicable 2 the accra confession presents a critique of prevailing economic doctrines by drawing upon the conventional reformed denunciation of idols such as mammon consumerism and financial and speculative markets these idols are deemed to obstruct gods lifegiving sovereignty and contravene gods covenant by marginalising the destitute the susceptible and the entirety of creation from experiencing a complete life the accra confession can be understood as a form of response and resistance to empire according to the confession the term empire encompasses the amalgamation of various imperial interests systems and networks including economic political cultural geographic and military aspects with the aim of accumulating political power and economic wealth

south africa although a young democracy has quickly become one of the most economically uneven nations due to its history of segregation and discrimination as contributing factors south africans have seen an increase in the number of protests over the past several years because of the frustration that has been caused by unbearable living circumstances a lack of service delivery and empty promises made by the government poverty unemployment and social injustice are seen by the south african government as the most important obstacles that need to be overcome to construct a prosperous nation despite the governments commitment to a better life for all since 1994 the postapartheid south african government has predominantly prioritised civil and political rights in its efforts to address social injustices while the socioeconomic needs of the countrys impoverished and marginalised populations have remained largely unfulfilled the degradation of human dignity that results from conditions such as poverty and unemployment is significant a violation of ones dignity can also occur when one is excluded from efforts to combat issues such as poverty and unemployment which should be considered amidst all of this the church is criticised for remaining silent and doing little to address the situation this article proposes social justice as an ideal approach to diaconia and development therefore it seeks to understand and include social justice principles as a means of empowering people to ensure effective development the objective of longterm poverty reduction cannot be accomplished unless there is an emphasis placed on social justice this article conducts an indepth analysis of a variety of social justice theories to rationalise a social justice approach to diaconia

introduction after three decades of housing reform housing assets now represent a significant share of the wealth held by chinese families accounting for 37 of the total amount of the familys private assets which are worth on average chy 930000 per household the gender distribution of that wealth however is very uneven as many families register the male household heads as homeowners according to the third national survey on the social status of chinese women in 2010 only 379 of the women own housing property compared to 671 of the men among married respondents 132 of the women hold the title in their own name and 280 jointly with their spouses while the shares for married men are 517 and 256 respectively in many families whose 1 3 biggest asset is the housing property this property is registered solely in the husbands name even though these properties have also been funded by the wife and her parents among the unmarried respondents only 69 of the women own their dwelling while 218 of the men do it is thus clear that women own much less housing assets than men little literature however has tackled the reasons behind this phenomenon one relevant explanation is that the female partners generally have a lower income than the males and therefore contribute less to the financing of the family home the average annual income of females is merely 673 of the income of males in urban areas and 560 in rural areas an often overlooked reason for women to own less housing property lies in the fact that females receive less intergenerational transfers than males considering the high price of housing in china one can hardly afford home ownership without pooling resources derived from family members this is especially true for young adults who do not have built up much savings while some parents make great sacrifices to help a son buy a home they tend to decline a daughters request even if they have the means to help out the improvement of gender equality in nutrition health conditions and educational opportunities in china is documented in the literature yet gender equality in wealth and asset owning is lagging behind in this domain the chinese market reform and the trend towards individualism of property ownership seem to work in the direction of a widening gender gap at the same time womens economic security and wellbeing have become a crucial issue in the rapidly aging chinese society where the policies hope to boost fertility thus this paper contributes in two ways first it reveals the gender inequality in opportunities to accumulate housing assets and the role of intergenerational transfers in this phenomenon second it systematically analyzes the connections between welfare state family reciprocity home ownership and gender in the context of china thereby providing a framework for future comparative research in another contribution we have elaborated on the negotiation processes that underlie intergenerational transfers for the purpose of home ownership in this paper we will investigate how the gender of an adultchild affects these negotiation processes utilizing 31 indepth interviews from chongqing this paper answers two research questions how and why does the gender of the recipient affect the negotiation of intergenerational transfer on home ownership and against this backdrop what are young womens possibilities for accumulating housing assets the answers to these questions will be framed within the broader system of social coordination outlined above the next section presents the conceptual framework of social coordination in more detail subsequently we describe the contextual background of china through the lens of this framework then a summary of the research methodology and data collection process is given the empirical analysis consists of two parts the first elucidates how intergenerational transfers on home ownership are differentially directed to male and female adult children the second describes how young women cope with this and elaborates on their possibilities to accumulate housing assets the final section summarizes the research findings and discusses their wider implications literature review and conceptual framework social coordination of welfare state home ownership family reciprocity and gender division the system of social coordination existing research has noticed the substitution effects between welfare state and home ownership and between welfare state and family reciprocity when social protection is not available to the public and the generosity of the welfare state is limited individual households are motivated to accumulate private assets to offset income uncertainty over the life course a common way for families to accumulate assets is home ownership homeowners can reduce the cost of living and ensure a safety net to offset financial risks there is also a tradeoff between state and family as welfare providers without or with limited public welfare individuals have to rely on the mutual support of the families particularly intergenerational reciprocity to provide care and offset risks in the long term in developing and underdeveloped countries where the welfare state is not effectively established extended families in which different generations can help each other are common and vice versa in developed countries where intergenerational reciprocity is encouraged in culture such as in east asian countries the development of the welfare state is confined family reciprocity also works within one generation in the form of the male breadwinning model the incomeless wives use their free labor at home to reciprocate their husbands responsibility in providing cash income for subsistence in a little developed welfare state with a high percentage of home ownership family reciprocity in intergenerational transfers of housing property is important in a homeowner society access to alternative tenures is limited and living in an owneroccupied home becomes a social norm a high demand for home ownership coupled with insufficient access to the rental sector may drive up the price of owneroccupancy properties as a consequence home ownership is often unaffordable for young households unless they receive support from parents andor other family members parents are usually inclined to help out as home ownership is a good investment for the family and their help could evoke reciprocity from their children which is the major source of support in old age when welfare state provisions are limited we call the interconnectedness between welfare state home ownership and intergenerational reciprocity discussed above social coordination as it illustrates how individuals families and the state are connected in a society home ownership family reciprocity and welfare state in china in another publication we document how reciprocity works in smoothing the exchange between parental help in accessing home ownership and the childrens support in old age care the expectation of reciprocity plays a key role in deciding whether an intergenerational transfer takes place basically the parents only make the transfer when they view the beneficiaries as trustworthy providers of old age care some adult children under the purpose of maintaining their autonomy in deciding an acceptable level of filial duty refuse or avoid asking for support of their parents the reciprocity expected by the parents can be financial instrumental or emotional depending on the needs of the parents and the availability of the children in due time this exchange is not to be explicitly discussed during the process of negotiation but it is well understood and perceived justified by the adult children we also observed an influence of the welfare state on the motivation of intergenerational transfers in the current chinese welfare system rural residents receive far less state welfare than urban residents this motivates them to invest more in intergenerational reciprocity while the urbanites can be more altruistic in the transfer households with a rural migration background are more willing and more likely to feel responsible for supporting their children in getting access to home ownership than their urban peers even though they have fewer resources to do so the role of gender in this paper our main concern is to add another dimension in the triad of social coordinationgender gender divisions are important in the understanding of how individuals families and the state are organized in a particular society in most of the preindustrial societies and to a lesser extent but far from extinction in the industrialized societies production and property ownership are organized along lines of gender the men work outside the family as the breadwinner and represent the household in public they are recognized by the community and the authorities as the head of the household and the owners of family properties women on the contrary provide services and care within the household without any monetary compensation they are viewed as dependents of their husbands and fathers which implies that they cannot hold properties the gender 1 3 differences did not disappear when welfare states started to develop and social protection became a civil right after all the organization of social protection is often gendered as well many modern welfare states are still based on the male breadwinner model in which the male workers receive a family wage to support their wives staying at home and doing unpaid house and care works after decades of feminist movement and progress in social policies gender gaps in education and income have in different extents diminished in many developed and developing countries yet the gender gaps in the distribution of property and assetholding remain persistently large direct or indirect discriminations affect women in the distribution of proprietary resources in both private and public spheres such as in inheritance of properties in registering the ownership of housing in taking mortgage loans in the distribution of land and in the allocation of social housing femaleheaded households in particular experience significant disadvantage in terms of accessing and sustaining appropriate housing in next section we will apply the perspective of social coordination and examine how welfare provision family relations and housing are linked in the context of traditional and contemporary china social coordination in china from past to present social coordination in traditional chinese society in traditional chinese society the provision of housing was always associated with elderly care and generally arranged patrilineally in a patrilineal society marriage is normally patrilocal residing matrilocally is deemed socially undesirable patrilocal means that the grooms parents prepare a space so the new couple can move in with them and become coresident after marriage the bride becomes a member of the grooms family and will care for her husbands parents rather than for her natal parents the children of this couple would also be named according to their fathers genealogy in this way a chinese family is reproduced patrilineally housing both as living space and property is an important link in this chain of reproduction a home is both a practical place and a symbolic space in this way providing housing either financially or inkind justifies the providers rights to care and enables them to receive it consequently in traditional chinese society there is a preference for sons only sons are considered permanent members of the family and the source of care as a result of this girls receive much less from the family in terms of resources and investment they receive less nutrition than boys and they carry out duties within the household from a very young age they are relatively deprived in terms of formal education and human capital accumulation social coordination in contemporary china the feminist movement in the twentieth century campaigned for gender equality and womens access to civil rights such as freedom of marriage and divorce right to education and formal occupation and right to acquire and maintain properties the communist regime particularly promoted womens participation in the labor force and gender equality in allocating job opportunities as means of mass mobilization and means to facilitate industrialization chinese welfare state from 1949 and onwards a nationwide welfare system was gradually developed it started in a very preliminary form covering only state employees and gradually expanded into a somewhat more comprehensive system the current chinese welfare system has eligibility criteria based on formal employment and benefits based on contribution which means that women can only gain access to social benefits if they are paid workers and contribute to the social security fund as a result of lower female participation in the labor force and lower pay scales only 541 of the elderly females in the cities have pension compared to 793 for their male counterparts in the countryside the gap is even wider 388 for females and 591 for males even though gender equality is still on the official political agenda state institutions in many domains are suppressing womens rights toward land and housing under the assumption that they will get it from their husbands women have been more vulnerable than men to forced acquisition and have had to protect their land rights though with far less success than men in 2010 210 of the rural women were landless 91 higher than the rate for rural men furthermore current chinese laws do not provide mechanisms to distinguish womens property rights within the household therefore if the marital status of a woman changes her rights to family property such as land and housing can be easily infringed onechild policy and family reciprocity from 1982 and onwards china launched the socalled one child policy stipulating that in principle each couple should only have one child this policy is applied strictly in urban areas but somewhat more loosely in rural areas as a result of the policy the fertility rate dropped from 27 in 1986 to 15 in 1997 and has since remained stable a line of research suggests that the onechild policy reduced the number of competitors for a familys resources and improved gender equality to some extent under this policy singlechild girls and girls with only female siblings receive more education than girls with male siblings many families even from rural background started to encourage their daughters to pursuit a career and provide help such as child care however the improved gender equality is not yet visible statistically in the allocation of family property and assets even though the inheritance rights of daughters are written in law inheritance allocation only to sons still dominates in rural areas why women own less housing assets in china the role of… 1 3 a survey from the 1990s showed that only 40 of urban residents and 14 of rural residents agree with shared inheritance among daughters and sons postreform policies pay more attention to the protection of individual property rights and interests different from family policies in the socialist era which emphasized protection of women current policies highlight the financial contribution and rights toward the family assets of the breadwinner and loosen the rights of the female homemakers as divorce rates and disputes over marital property rise a new judicial interpretation of the marriage law was issued in 2011 this new interpretation stipulates that the housing property paid by one spouse before the wedding belongs to the payer in recent years with children that are born under the onechild policy reaching marriage age new dynamics were introduced in family relations and power structures the existence of families with only daughters challenged the patrilineal family reproduction model as parents in these families also need care from the daughters and sonsinlaw the parents of the bride and groom have to compete for priority in their childrens future caregiving considering the direct linkage between the surname of the grandchild housing provision and rights to care some parents of the brides insist to finance the new couples home in order the gain the right of surnaming and future care if the parents contribute significant amounts to their childrens home ownership they are not only more likely to arrange a desirable location at which they would eventually receive care but are also holding the moral high ground either to claim their childrens reciprocal care or to use part of the equity stored in their childrens home to pay for institutional care and health treatment thus a gendered relation of housing intergenerational transfer and age support can no longer be automatically assumed instead casebycase negotiations become the norm in such negotiations the financial ability of the bride or grooms parents the affection between adult children and parents and the geography of their residence play a crucial role research design 1 chongqing has been the international trade and administrative center of southwest china since the 19th century and was the capital city from 1937 to 1944 the core area yuzhong district has been occupied by families established there for generations they were employed in the administrative trade and service sectors and lived in crowed privately owned homes during the 1960s chongqing experienced rapid stateled industrial development and has since established itself as one of the centers of heavy manufacturing in western china with more recent settlers working in stateowned factories during the economic reform of the 1980s and 90s many immigrant workers came from nearby rural areas and found informal employment in the rapidly growing private sector being one of the four cities controlled directly by the central state and the only one in inland china since 1997 chongqings vigorous development has attracted many migrants with high educational qualifications from both rural and urban areas in our study we approached all three groupsthe locals urban migrants and rural 1 3 migrantsas the public welfare systems they have entered were different the state workers enjoy the best public welfare and receive support for education career development and housing from the state the established residents working in the private sector receive less from the state but can fall back on the family resources accumulated over generations finally new migrants that have arrived after the economic reform tend to receive less state support and their earning capacity varies according to their educational qualifications the fieldwork was conducted in the metropolitan area consisting of nine districts with an approximate area of 500 km2 and a population of eight million the data was collected in november and december of 2015 and 31 participants were interviewed with the help of a semistructured interview guide the interviews were started with an information table collecting a range of basic information the demographic and socioeconomic status of each member of the extended family the housing history from birth including the time period location dwelling type dwelling size affordability tenure situation and living arrangement for each period of occupation the payment structure of the first and current dwelling ie who pays for what percentage of the total value the semistructured interviews also addressed the following two topics the process of home purchase particularly who initiated the purchase and how the payment structure was negotiated and settled the perception of and attitude towards intergenerational transfers both within the own family setting and in general terms the semistructured interviews lasted from 45 to 75 min depending on the complexity of the story the language used in the interviews was mandarin or the local dialect immediately after the completion of the interview the interviewer wrote up a short summary of the participants opinions and relevant nonverbal impressions all interviews except two 2 were recorded and subsequently coded using atlasti 70 the participants were given numbers so that they can remain anonymous and quotations from their responses have been translated from chinese into english the participants were selected by a purposive sampling method under the principle of maximum diversity first we targeted and categorized three groups of young people locals urban migrants and rural migrants second within each group we recruited a sample with maximum diversity in terms of age gender occupation education income level life course housing and living arrangements and intergenerational transfer experience in a few cases both partners of the couple were present during the interview and they were registered as one case parental participants were recruited along the same lines we recruited parents with a range of experiences with regard to equity transfers a minority of the parental participants were parents of young adult participants that were also recruited in such situations parents and young adults were interviewed separately from each other more details on the participating parents can be found in appendix 2 participants were approached through snowballing method starting with personal contacts this approach was taken because the topic of this research is both private and sensitive and recruiting from a pool of acquaintances helps build trust we kept on recruiting research participants in these three groups with an eye to variety in other respects until information saturation was reached at that point information from participants started repeating itself and no new themes pertinent to our research questions came to the fore even when new participants with a different background were recruited in total 22 young adults aged from 24 to 41 and nine parents aged from 49 to 60 were interviewed eleven of the 22 young participants had received an intergenerational transfer from their parents of the nine parents that were interviewed six had provided an intergenerational transfer to their children the gendered intergenerational transfer of housing assets the patrilineal tradition leads to different strategies for saving and housing planning with salient differences between families with male or female children families with male children would plan a home for the sons well in advance of marriage and start saving money for that purpose families with female children on the other hand rarely make any proactive financial arrangements however on top of gender family size matters as well as the next two sections will show in multichild families if a family has both male and female children which is the case for many rural migrants the parents only prepare for their male childrens home in our home town it is all like this parents would prepare a home for their sons houses are cheap in my home town so my parents just bought a home for my two brothers it is more expensive in chongqing so my mom can only help me with mortgage down payment … no help to daughters in my home town normally parents wouldnt support daughters as they will marry out 1 3 however for young migrants who plan to buy a home and settle down in the city resources received solely from the mans family are often not enough the young couple would ask for help from the wifes family too in such circumstances resources from the husbands parents are often a gift while help from the wifes family is implicitly an interestfree loan after we decided to buy a home we asked our parents with how much money they could help us my parents gave me all their savings so after the home was ready they move in with us and left their rural home but in my family this is a loan i borrowed from my parents my brother and my sister we repay them later a gift from the males side and a loan from the females side form a combination that also applies to case 21 as the research participants point out this combination is a direct result of the patrilineal tradition and the linkage between parents housing duties and adult childrens eldercare responsibility i think this has something to do with the traditional household structure because my wife is daughter and her parents from deep of their heart believe that they should rely on their son for age support it also has something to do with the culture for home purchase traditionally it is the responsibility of the males family the females family would not be taking care of this stuff even nowadays in many singlechild families in singlechild families the female participant in case 21 is correct in suggesting that even in those singlechild families from an urban background a gender discrepancy still exists parents of a male child start planning for their sons home a long time in advance if their financial situation allows it these young men become homeowners when they are still in college or immediately after they start their first job often it is the parents who come up with the down payment and the young men pay the monthly installments on the mortgage after marriage the wives of these homeowning young men would move in with them my parents paid the down payment i paid the monthly installment our main purpose is to prepare a home for future marriage another motivation is investment after i graduated from college and start to work in this hospital my parents offered me all their savings and asked me to buy a home families with only daughter tend not to plan for their childs future home as they consider it the responsibility of her future husbands family but some parents register their daughters name as the proprietor of their own home unlike similar behaviors in families with a male child these homes are not devoted to the daughters use for independent living or marriage it is more like a strategy to secure support from the daughter by assuring the property as bequest in the future i think my daughters and her husbands home is her husbands familys responsibility we can contribute a share but her husbands family should contribute more my parents wont buy a home for me they think after marriage it is the husbands responsibility… but they registered their home under my name that is to avoid transfer costs in the future but it is still their home i never feel that is my home… after my divorce my father did not allow me to use it because he did not want me to divorce in chinese culture the male children are primarily responsible for providing old age care to their parents it is in exchange for this responsibility that they receive intergenerational transfers however in situations where male age supporters are not available such as in multichildren families with no sons or in singlechild families with only a female it is possible for female children to receive such transfers this is most clearly illustrated by case p8s explanation on why she insists on helping both her daughters in acquiring home ownership i have to prepare some money for my old age and we should also help my younger daughter since we had helped our older daughter … we dont have that fortune to have a boy the only thing we can do is to help our daughters nowadays the duty of supporting aging parents is the same for sons and daughters young womens opportunities to accumulate housing assets even though parents with female child rarely take the initiative for providing intergenerational transfers there is room for young women to negotiate and maneuver this section describes three different possibilities that young women have to accumulate housing assets based on the availability of parental support and their own earning power some young women secure housing assets independently before marriage while others secure assets together with their partners after marriage finally in the absence of parental support and own earnings some women cannot accumulate any assets and therefore become financially dependent on their partners below each of these three situations are described in more detail seek help from parents some of the young women in our research successfully established independent home ownership while they were unmarried this means that no matter what happens to their marriage in the future whether they remain unmarried or get divorced their residence and financial safety net is stable they can hardly establish such a position without parental transfers however in other words an independent housing asset for women usually means independent from husband and marriage but in fact dependent on parents this is nevertheless a privileged position for young women and requires the concurrence of several circumstances in our research the cases 03 13 and 14 belong to this group they all have an urban background and are the only child in their families they are the initiators of the intergenerational transfer that they received from their parents with which they have a close relationship that is characterized by a high level of trust 1 3 i know that housing prices in china also in chongqing will rise and my working place is far away from my parents home it took me one hour one way very inefficient so i proposed to my parents that i want to buy a home and i convinced them after i decided to settle down in chongqing i immediately started home viewing and i asked my parents to help me … i think a woman should have her own home although people said the man will provide you with accommodation after marriage but i would feel unsecure if i would not have my own home my relationship with my husband is good but i still want my own home one important reason why these women received support from their parents lies in their mothers personal experience in the patriarchal families and their concern for their daughters financial independence in marriage our idea as parents is to prevent the man from looking down upon our daughter from putting financial pressure upon our daughter my daughter shouldnt be financially dependent on her husband coowning with husbands if owning a home before marriage is not feasibleand that is very often the casebuying a home together with their husband and becoming a coowner is another possibility for married women to accumulate some housing assets in order to claim a share in home ownership either the wife or her parents would need to contribute a share of the purchase price when young women want to use their own income they would probably only have the chance to do so if the couple were to decide to buy a second home and if they had sufficient income to do so that is because many young men already own a home before marriage and these homes in most cases are fully paid for by the husbands parents or jointly by the husband and his parents thus the couples motivation to buy a second home other than for holidays upgrading or investment would be to strike a balance between the financial interests and powers of the husband and the wife we purchased another home earlier this year the home we currently live in is after all purchased by my husband and his parents but the new home is ours my husbands and mine making a financial contribution is not the only way to justify a womans claim to the marriage home as women play a major role in unpaid housework and care in the view of many men and women such services justify womens rights to family property although my income is much lower than my husbands i dont feel inferior to him he makes money outside but all the domestic work like child care depends on me he offers money and i offer labor i think if the woman wants to have a share in the marriage home she should share the responsibility it does not mean that this woman must work but she should fulfill her duties at home for example taking care of the child and the elders in some cases women get compensated for their domestic services and chores by getting access to the assets that are accumulated in the house in which they live consider for example the first marriage of case 16 and case 02s current husband although the husbands brought in the full amount of money that was needed to purchase that marriage home they registered their first wife as the only owner and thus after the dissolution of their first marriage the property went to their exwife case 16 explained his rationale like this women are more vulnerable lets say if our marriage didnt work out as a man even if i am 50 years old i still have chances but for a woman where does her sense of safeness comes from only from the man besides her man what else she can count on however justifying home ownership through a womans care and services is not standard institutionalized behavior only if the husband voluntarily registered the wife as the home owner at the moment of purchase and does not retract this registration in a divorce court afterwards the woman has a right to the property concerned thus a womans ownership or coownership through domestic service is at the mercy of the man it is thus important for women who do not have parental support in asset transfer and particularly so for those who do not get good pay in the labor market either to select a financially capable and virtuous husband i wont consider a man who doesnt have a high income but it is not only about income it is also about his moral quality i am lucky i have dated my current husband in high school he raises no suspicions in me he has a good income and he is willing to support me financially when the kids approached the age of school he said we should buy a home and let our child go to a good school so he bought a home and registered me as the owner dependent wives women who did not receive parental help and did not make a direct financial contribution to the home generally do not accumulate housing assets instead they depend on their husbands housing assets if the marriage is stable there is no problem but if anything goes wrong and the marriage breaks up these women may end up without any monetary compensation thus nonowning wives are more vulnerable in the marriage than owning wives fearing homelessness some women are forced to stay with a violent partner or in an unhappy marriage in my first marriage my exhusbands mom purchased a home for him so after we married we moved into that dwelling then after i divorced him i moved out after my older sister got divorced she is in hardship so i invited her to live in our home and we support her spending i helped her to look for jobs and her daughter coming to study in chongqing now she has found a stable job and she has moved out 1 3 some women miss the chance to make a financial contribution to the marriage homefor example if this home has already been purchased outright by the mans parents for these women it is very hard to reverse the situation even if they have a paid job purchasing another home is the only option open to this group this is exactly the situation case 02 faced in her first marriage since the husband already owned a home and had no immediate incentive to buy another one the wife needs to have substantial earning power to initiate such a purchase andor at the same time be able to convince her husband or parents to contribute too because women are mostly responsible for the housework their income is usually spent on daily consumption rather than saved up to buy another home the parents play an important role in helping young women with the accumulation of housing assets not only can they give financial assistance they can also offer child care thereby enabling the young women to continue a fulltime career because there is almost no public child care in china and private child care is expensive and untrustworthy many families rely on grandparents to care for young children if for reasons like health or migration the grandparents are not available the young mother would have to stay home to take care of the child in this situation the woman would make no financial contribution to the household so it may be harder for her to claim a share in the family assets especially when the husband is struggling to shoulder the housing costs alone we asked if my parentsinlaw would like to move in with us and help us with child care but they dont want to they dont want us to be too dependent on them so my wife stayed at home for child care…when we were buying our marriage home it was so hard i asked help from my parentsinlaw but they didnt help us they are not rich either i have no choice my name is on the property certificate so i have to work hard and repay the mortgage debt by myself… so now i am the owner of our home conclusion the literature shows that parental background and the availability of intergenerational transfers largely determine the chances that young adults will be able to attain home ownership this paper has elucidated the mechanisms underlying these factors by exploring the relationship between intergenerational transfers and gender we chose to position our empirical study in china a country with severe housing affordability problems and a persistent patrilineal family tradition the empirical study for this paper was carried out in chongqing southwest china although we dont claim that chongqing is representative for china as a whole we do think that the mechanisms that are described in our paper have a broader relevance for chinese society utilizing 31 indepth interviews from the city of chongqing we investigated two questions how and why does the gender of the recipient affect the negotiation of housingasset intergenerational transfer and against this backdrop what are young womens possibilities to accumulate housing assets our study in chongqing has elucidated the gendered practice of intergenerational transfers for home ownership in china in multichild families parents prepare for and transfer housing assets to sons prior to or at the moment of marriage whereas they would at best provide interestfree loans to daughters upon request in singlechild families parents would not prepare a housingasset transfer for their daughters as they expect their daughters future husband and his family to do so under these circumstances ownership of housing assets before marriage is much less common among women than among men and not only do women bring fewer assets into the marriage they also have a disadvantaged position in the labor market therefore the family home is often in the possession of the man and the accumulation of housing assets during the marriage is difficult for women consequently women face the risk of losing access to their family home and being without assets if their marriage status changes against this background young women in chongqing embark on three different scenarios for housing asset accumulation based on their parental resources and their own earning power when parental help is available some young women successfully establish independent housing assets while they are still single their control over these assets is not subject to changes in their marriage status furthermore without utilizing parental resources women can still establish coownership with their husband by sharing in the mortgage payments in many cases however a woman can only become a coowner if the couple buys a second home as the first one is often purchased by the husband and his parents finally some women do not possess any housing assets for them not only is financial help from parents out of reach but their own earning power is constrained by the fact that they have no help with child care and household chores the social status of chinese women has improved substantially in the last half a century due to the economic independence they get from labor market participation at the same time their lagging behind in holding housing assets becomes a new source of inequality our research shows that womens disadvantage in holding housing assets is not only caused by their lower earning power in the labor market but also and probably more so by gender discrimination in the provision of intergenerational transfers this discrimination is rooted in chinas traditional patriarchal power relationships these relationships were mitigated by the socialist movement between the fifties and the seventies but are coming back now that private ownership of housing has become the norm in the postreform chinese social coordination system there is an increased emphasis on family reciprocity and home ownership which reinforces the gender gap in housing assetowning between men and women in this paper we introduce the conceptual framework of social coordination and we use this framework to analyze how chinese men and women have differentiated opportunities to access home ownership and to accumulate housing assets this framework uses a holistic approach to analyze the mutual influences between welfare state family reciprocity home ownership and gender future analyses based on this framework may help to understand how social policies and housing policies influence gender relations and fertility rates or to understand how gender divisions influence the sustainability of the housing system and welfare state the social coordination framework can also be helpful in comparative studies that aim to explain the different institutional choices and outcomes of different countries personal or couple annual income chinese yuan 1 below 50000 2 50000100000 3 100000500000 4 5000001000000 5 above 1000000 n no answer d personal or couple total assets chinese yuan 1 below 50000 2 50000100000 3 100000500000 4 5000001000000 5 10000005000000 6 appendix 1 see table 3 personal or couple annual income chinese yuan 1 below 50000 2 50000100000 3 100000500000 4 5000001000000 5 above 1000000 n no answer c personal or couple total assets chinese yuan 1 below 50000 2 50000100000 3 100000500000 4 5000001000000 5 10000005000000 6 above 5000000 n see table 4

after three decades of housing reform in china housing assets constitute a sizable share of family wealth but are distributed unevenly as registered homeowners are predominantly male this is partly because males generally have higher incomes than females and can therefore contribute more to the financing but also because males receive more intergenerational transfers on the basis of 31 indepth interviews from chongqing this article seeks to answer two questions 1 how and why does the gender of the recipient affect the negotiation of intergenerational transfers and 2 what are young womens possibilities to accumulate housing assets the research findings show that young women either ask their parents for help to secure housing assets before marriage or they attempt to coown a home with their husbands after marriage women who do not succeed in either of these strategies do not accumulate housing assets and thereby risk their rights to the home if their marriage is dissolved

background it is critical to consider the fact that most prison inmates are parents the mass incarceration of parents in the united states is a rapidly growing problem with issues of race and ethnic disparities and poor outcomes for children of incarcerated parents mass incarceration impacts child mortality and population health women with family members who were currently incarcerated had increased odds of being obese having had a heart attack or stroke and being in fair or poor health incarceration of a woman or her partner in the year before birth was shown to be associated with higher odds of maternal hardship and poorer perinatal health behaviors many female prison inmates have had incarcerated adult family members during childhood as well as high rates of neurological impairment in adulthood hundreds of millions of people worldwide are affected by neurological disorders and the extension of life expectancy with ageing populations in both developed and developing countries are likely to increase the prevalence the world health organization has determined that dementia is a public health priority dementia is a syndrome that affects memory thinking and behavior the number of people living with dementia worldwide is currently estimated at 356 million and is projected to double by 2030 and more than triple by 2050 increased susceptibility for dementia and cognitive decline that is reported later in life after traumatic brain injury may result from brain tissue loss that increases throughout the chronic postinjury phase suggesting that tbi accelerates the rate of brain aging and atrophy tbi most often resulting from accidents violence and falls is the leading cause of death and disability in children and young adults worldwide resulting in loss of many years of productive life disability and neurobehavioral problems health promotion is particularly important for neurological disorders by identifying those at risk and providing resources for rehabilitation and prevention of the projected escalation in order to break intergenerational cycles of physical and emotional trauma and criminal behavior it is imperative to continue to better understand factors contributing to it protective factors against violence perpetration such as measures related to parental expectations and connectedness with parents and other adults are difficult to achieve when adult family members are incarcerated family disorganization dissolution and violence which are often the case when an adult family member is incarcerated can be risk factors for childhood abuse there are numerous effects of adverse childhood experiences on physical health including neurobiological findings such as memory impairment and long term health risks adverse childhood experiences significantly increased risk of many healthharming behaviors for physical inactivity obesity attempted suicide and neurological decline having an incarcerated parent during childhood has been shown to be associated with numerous poor health outcomes in young adulthood including depression posttraumatic stress disorder anxiety cholesterol asthma migraines hivaids and fairpoor health because little is understood about longterm neurobehavioral outcomes of children with incarcerated adult family members the aim of the researchers was to elucidate the impact of having incarcerated adult family members during childhood on neurobehavioral health throughout the lifespan of females methods design and sample because of the high rate of incarcerated adult family members in the lives of female prison inmates and high rates of neurological impairment in this population a secondary analysis was conducted of data from private interviews and examinations to understand how having incarcerated adult family members during childhood could influence neurological health throughout the lifespan a modified casecontrol design was used to compare female prison inmates who had incarcerated adult family members during childhood to female prison inmates who did not have incarcerated adult family members during childhood adult female prison inmates were randomly recruited from both minimum and maximum security sections of a prison in a midatlantic state in the united states all data were collected during private interviews and examinations conducted by the first author detailed methods have been reported the sample size determined based on the parent studies was adequate to provide power to find a moderate effect with n135 female prisoners and alpha 05 eightyone percent of eligible inmates volunteered to be in this study the study was approved by the institutional review boards of the principal investigators institutions and all participants signed written informed consents procedures were conducted in accordance with federal regulations for the conduct of research with prisoners measures incarcerated adult family members during childhood were selfreported muenzenmaiers scale was slightly revised to assess frequency and severity of sexual and physical abuse before age 18 it has reported validity and reliability in tests of women of similar age ethnic background and education including mentally ill women higher scores indicate greater frequency and severity of abuse other data collection included abuse that resulted in health care treatment they were also asked if any items on the abuse scale occurred since age 18 and when it occurred last selfreports were verified by evidence of physical injury and records when available general health and specifically neurological histories and physical examinations were evaluated by a certified neurorehabilitation clinical nurse specialist in accordance with standards that were validated by two neurologists and a neuropsychologist documentation and other examination evidence to support histories provided by each inmate was investigated such as neurological deficits and cranialfacial scars or palpable areas of skull damage consistent with selfreports of traumatic injuries and other neurological histories analysis statistical methods included frequencies ttests and graphical checks childhood abuse scores and number of neurological histories and neurological examination abnormalities were dichotomized by the mean to indicate high scores compared to low scores logistic regression statistical analyses were then used to compare adult female prison inmates who had incarcerated adult family members during childhood to those who did not for each of the main variables results of 135 adult female prison inmates 99 had at least one adult member of their extended family incarcerated when they were a child hispanic and african american inmates had disproportionately high rates of incarcerated adult family members during childhood there were no significant differences in age years of education or violent crimes committed by participants who had incarcerated adult family members during childhood and those who did not bivariate logistic regression revealed that having at least one incarcerated adult family member during childhood was related to having been a victim of childhood sexual abuse greater total childhood physical and sexual abuse scores greater number of neurological history reports per person prior to the current crime such as traumatic brain injuries and greater number of neurological examination abnormalities per person in adulthood compared to those without incarcerated adult family members neurological histories andor neurological examination abnormalities were evident in 95 of this random sample of female inmates other than traumatic brain injuries neurological histories included exposure to lead andor other toxin stroke seizures central nervous system infection cns tumor having been the product of a complicated pregnancy and delivery migraine survived cardiopulmonary resuscitation was struck by lightning other loss of consciousness such as due to choking myasthenia gravis andor had undergone a neurosurgical procedure each neurological history report was added for a total number of neurological history reports per person for example someone with 3 tbis was coded as 3 recurrent tbi was particularly prevalent with most occurring during high risk behaviors such as while they were under the influence of alcohol or other substances neurological examinations corroborated with neurological histories with the most frequently occurring deficits including cranial nerve deficits extremity weakness gait abnormalities rapidly alternating movement deficits less than 3 word recall memory deficits cranial facial scars and palpable evidence of skull injury females with incarcerated adult family members had a significantly earlier age of their first criminal conviction though there were a greater number of suicide attempts per person in the group with incarcerated adult family members the difference was not statistically significant obesity was not significantly higher for those with incarcerated adult family members during childhood inmates described a series of events often childhood abuse contributing to their lack of regard for themselves and others often resulting in substance abuse and high risk behaviors for accidents altercations infectious disease transmission and ongoing neurological decline history of having been a victim of greater frequency and severity of childhood abuse placed one at greater risk of abuse in adulthood abuse in adulthood was significantly related to a greater number of neurological histories and neurological examination abnormalities abuse in adulthood was related to greater risk of suicide attempts discussion more than half of adult female prison inmates had at least one adult member of their extended family incarcerated when they were a child adult female prison inmates with at least one incarcerated adult family member during childhood were 2 times more likely to have been a victim of childhood sexual abuse 32 times more likely to have higher total childhood physical and sexual abuse scores 27 times more likely to have more neurological history reports prior to the current crime such as traumatic brain injuries and 26 times more likely to have more neurological examination abnormalities in adulthood compared to those without incarcerated adult family members having been a victim of greater frequency and severity of childhood abuse placed female prison inmates at 26 times greater risk of being abused in adulthood females abused in adulthood were 13 times more likely to have neurological histories and almost 15 times more likely to have neurological examination abnormalities neurological impairment is related to selfdestructive high risk behaviors for further neurological decline such as for hiv transmission and altercations that can result in further neurological decline in this population of female prison inmates abuse in adulthood results in 3 times greater risk of suicide attempts history of childhood sexual abuse and suicide attempts places adult female inmates at greater risk for obesity furthermore recent abuse in adulthood and tbis are related to violent criminal behavior in female prison inmates in addition to the obvious neurological impairment associated with tbi there are multiple mechanisms through which childhood sexual abuse can contribute to adverse brain development and behavioral dysfunction strengths and limitations because this was a secondary analysis and not the original research question researcher bias was not a risk cause and effect cannot be determined by this design because it was a cross sectional study we cannot determine in all cases if neurological impairment occurred before or after childhood abuse because children at particular risk are those with special needs that may increase caregiver burden however the correct temporal sequence occurred with adult family members incarcerated during childhood and childhood abuse occurring prior to the current incarceration and neurological examinations most neurological histories also occurred later in life and continued to result in a spiral downward to greater neurological decline related to increased high risk behaviors such as those leading to accidents or altercations resulting in recurrent tbis furthermore the number of neurological history reports describes mainly the frequency of recurrent tbis per person but not the severity or anatomical location of the injuries direction for future intervention and research sadly in the decades since the closure of longterm mental health facilities throughout the united states and decrease in longterm inpatient neurorehabilitation incarceration rates escalated with the vast majority of prisoners suffering from mental health problems that include both psychiatric as well as neurological conditions mental health facilities had previously provided for critical longterm needs of not only those with psychiatric conditions but those with neurological conditions as well prison health systems must accommodate for the high prevalence of neurological impairment of female prison inmates who have often also been victims of childhood abuse it is critical to break the cycle of events in the ongoing downward spiral related to the lack of regard for self and others which leads to high risk behaviors for recurrent tbi and contributes to lifelong neurological decline because female prison inmates in this population often receive short sentences and are frequently incarcerated and released prison health systems could play an important role in helping to break the cycle contributing to ongoing neurological decline screening for neurological impairment and attempts to separate patients with some neurological disorders from other prisoners may help the vulnerable population of female prison inmates from being exposed to criminal role models further injury andor violence contributing to exacerbations of their condition prisons provide public health opportunities to reach medically underserved communities in the united states yet health care systems alone cannot resolve this multifactorial problem wildeman and western argue that criminal justice reform alone will not solve the issues related to school failure joblessness untreated addiction and mental illness that lead to increased incarceration and that criminal justice reforms alone would repeat the mistakes made in the united states during the prison boom by addressing serious social problems with criminal justice policies these problems require greater commitments to education public health and employment opportunities of lowskilled men and women mental health is a critical area that requires serious attention in order to address incarceration rates and their longterm consequences for fragile families that contributes to ongoing neurological decline nurse mentoring can play a role in this vulnerable population of children with incarcerated parents with public health initiatives to address highrisk behaviors in this often forgotten segment of the population further research is needed to determine the best interventions to rehabilitate those who have sustained a tbi in order to prevent neurobehavioral problems resulting in incarceration recurrent tbi and to prevent lifelong neurological decline in this vulnerable population of children throughout their life span conclusions our findings have international implications as neurological decline is projected to be an increasing worldwide public health threat in aging populations it is critical to recognize those at risk in order to plan prevention efforts parental incarceration impacts the longterm neurobehavioral health of children along with being role models adult family members promote a safe environment contributing to the physical emotional and neurological health of children throughout their lifespan children in extended families with incarcerated adults are a vulnerable population where initiatives are critically needed to prevent longterm consequences including lifelong neurological decline this is especially true for disproportionately higher rates of black and hispanics in the united states those who work with these children can play an important role in teaching them coping skills to prevent emotional and behavioral disorders and improve resilience to adversity to prevent the cascade of events contributing to ongoing neurological decline children with incarcerated adult family members need support from their community particular attention is needed to help prevent high risk behaviors due to lack of regard for self and others that results in ongoing neurological decline throughout the life span of vulnerable populations of adult children of incarcerated adult family members those with incarcerated adult family members during childhood experienced greater frequency and severity of childhood abuse than those without incarcerated family members those with incarcerated adult family members during childhood had greater neurological deficits on physical examination than those without incarcerated adult family members

a secondary analysis of data from adult female prison inmates in the midatlantic united states defined relationships between having incarcerated adult family members during childhood and neurological outcomes of 135 inmates 99 73 had one or more incarcerated adult family members during childhood regression analyses revealed that having incarcerated adult family members was related to greater frequency and severity of childhood abuse and higher incidence of neurological deficits in adulthood especially related to traumatic brain injuries compared to those without incarcerated adult family members along with being role models adult family members impact the neurological health of children throughout their lifespan with the projected increase in prevalence of neurological conditions in the growing aging population in both developed and developing countries who 2015 it is critical to define risk factors in order to target prevention strategies with the growing rate of incarcerations it is critical to understand the impact this has on children in the families of incarcerated adults most studies of children with incarcerated adult family members describe psychosocial outcomes yet little is understood about the longterm neurological health implications of having an adult family member incarcerated during childhood the aim of the researchers was to elucidate the impact of having incarcerated adult family members during childhood on females and to define associated neurological health throughout their lifespan the purpose of this study was to test our hypotheses that having incarcerated adult family members during childhood places one at greater risk of becoming a victim of abuse and increases risk for neurological impairment that results in ongoing high risk behaviors leading to subsequent incarceration and neurological decline throughout the lifespan of females

career family and workforce mobility an interdisciplinary conversation this paper focuses on how two disciplines sociology and career development make visible different aspects of the complex intertwined and dynamic phenomena of career family and workforce mobility an abundant literature in these fields has acknowledged the ongoing challenge in understanding how the individual family and employment cohere in postmodern times despite this extensive literature the work on boundaryless careers and the connection of this work to an understanding of mobility between organizations both disciplines are yet to fully integrate issues of labor market mobility within theorising on work and career the worker and family to move in this direction this paper integrates concepts from both disciplines including the concept of mobility from the sociology literature and the increasing relevance of constructivism within the career development literature in acknowledgement that some of these concepts will be new they will be explained initially to set a context for the reader urry critiques much social science as amobile arguing that the mobility turn offers a different way of thinking through the character of economic social and political relationships urrys concept of mobility focuses on the development of sociality and identity through networks of people ideas and things which are always moving and changing cresswell describes this mobilities paradigm as acknowledgement of increased levels and forms of mobility in the world leading to a kind of thinking that takes mobility as the central fact of modern and postmodern life the focus here is on mobility in the horizontal sense of spatial relocation rather than the vertical sense of social mobility career advancement or change of employer these two dimensions can become intertwined when considering workforce mobility in the sociology literature the new mobilities paradigm emphasizes how movement is central to many lives and many organizations similarly researchers in the field of career development have become interested in the increasing influence of globalization and labor market mobility on individuals career decisionmaking a contextual worldview is increasingly underpinning the theoretical base of career development this worldview emphasizes the importance of the multiple layers of an individuals context in individuals career decisionmaking proponents of this worldview critique the ongoing focus on career and work relationships as being relevant only to individuals and somehow analytically separable from other relational structures and intersubjective ties rather the contextual worldview emphasizes the crucial nature of an individuals multiple and complex relationships and intersubjective ties which loom large in career decisionmaking within this worldview careers are constructed within familial social historical cultural geographic and sociopolitical systems in which individuals live this current article contributes to the special issue in focusing on a broader conceptualization of career mobility and in describing conceptually the importance of family and workforce mobility as factors relevant to both individual and organizational career growth by synthesizing aspects from both the sociology and career development literatures this article highlights the importance of family as the prime unit of analysis to understand the mobility choices and dispositions of individual workers and the impact of these decisions on organizations it therefore emphasizes the importance of attending to the relationships between individual factors and organizational factors in career growth and organizational growth it is often whole families which are made mobile and it is a family which needs to reconstitute lives in multiple institutions first this article documents the growing imperative to be mobile within the context of changes and challenges in more global workplaces and explores calls for a greater interdisciplinary approach to examining career the article then reviews conceptual and empirical literature from both sociology and career development to identify common ground and possible articulations the thesis of this article is that in a changing world of work governments organizations and associated fields of scholarship need to embrace broader considerations with regard to expectations of workforce mobility despite workforce mobility having both individual and organizational impetus and outcomes it is often the family which bears the brunt of workforce mobility it is noted early in this article that the literature in this space to date has focused on heterosexual families and that attention needs to focus on other families the context changing global workplaces and the mobility imperative population mobility has become an attractive policy goal for nations organizations and corporations to protect economic competitiveness and to foster productivity flexibility and responsiveness for example a recent inquiry by the australian productivity commission a key australian government advisory body builds from the premise that labor mobility is an important element of a wellfunctioning efficient and flexible labor market its authors argue that by improving the match between employers and workforce geographic labor mobility can contribute to economic efficiency and ultimately to community wellbeing through higher incomes the authors of deloitte australias these deloitte projections accord with those in the price waterhouse coopers report talent mobility 2020 pwc predicts a significant shift in mobility patterns as workers from emerging markets operate more globally producing a noticeable change in the global talent pool and its flows although technology might play a key role the authors note it will not erode the need to have people deployed on the ground the pwc report also highlights the greater sophistication and complexity of mobility assignments and the need for strategies which will meet changing career and workforce expectations of organizations and employees workforce mobilization extends within and across national boundaries strategies of economic regionalization have scaled up labor markets by reducing barriers to movement to allow people and businesses to pursue opportunities emerging elsewhere globally these strategies include financial incentives for organizations and ease of international movement for workers within countries a number of strategies such as housing employment tenure and schooling preferences for children are employed to incentivize workers to move to less favorable locations however there is evidence that some of these schemes to mobilize people have failed to attract sufficient numbers of workers for meaningful lengths of time a number of international reports have demonstrated the importance of family considerations in career decisionmaking which includes workforce mobility a european commission report noted that while the majority of europeans think moving is good for the economy the labor market and individuals fewer think it is good for families similarly the canadian employee relocation councils global mobility survey reporting data from 24 countries found that family and young children are cited as the main barriers to mobility the australian productivity commission reported that government schemes to move professional workers into rural and remote areas had limited effect doherty shield patton mu emphasized that with the considerable problems involved in moving for all family members incentives offered by government and organizations need to be cognizant of individual life cycle circumstances rather than presumed cohort attractions and benefits as the 21 st century world of work increasingly implicates mobility as part of career opportunity so mobility is relevant to career decisionmaking new theoretical understandings in career development psychology emphasize the importance of an individuals context especially family as a key influence in career decisionmaking this interconnectedness challenges our field to develop interdisciplinary responses to understanding these phenomena the next section will introduce calls for interdisciplinary approaches and in particular the imperative to connect concepts from sociology and career development psychology an interdisciplinary approach to careers collin outlined the multidimensional and multilayered nature of career as a lived phenomenon commenting that studies of career need to reflect this complexity broad conceptualizations of career studies embrace a wide array of disciplines including philosophy economics psychology organizational behaviour industrial psychology personnel selection and retention vocational education psychiatry sociology education industrial relations and human resource management however scholars continue to pursue questions about career from within their own disciplinary theoretical and methodological frames resulting in a separation and lack of exchange there have been multiple calls for a greater connection in career studies in particular dany commented keeping in mind that careers unfold in inhabited worlds could help to have both convergence and diversity to sustain the integrative approach we are calling for collin drew an important distinction between multidisciplinarity interdisciplinarity and transdisciplinarity with multidisciplinarity several disciplinary perspectives come together to work independently on the same problem and are unchanged in themselves when they disperse with interdisciplinarity their collaboration may result in the building of bridges between them or going even further integration between them and the formation of a new hybrid discipline collin then defined transdisciplinarity as the use of theories concepts and approaches from one or more disciplines as an overarching conceptual framework to address issues in a number of disciplines using these definitions the conjuncture of disciplinary approaches presented in this paper demonstrates an example of interdisciplinarity provoked by a complex object of study and precipitated by an interest in the processes on the individuals side that make workforce mobility thinkable and doable practitioners of a sociology of reflexivity treat intraindividual deliberations as a social phenomenon while a contextual approach to career development demands attention to context and related influences in this way the sociological and psychological gazes extend and intrude into each others traditional territory because the research problem demands a complex response that neither discipline can deliver alone thinking from the field of sociology the mobility turn in sociology can articulate with other work that has probed the growing demand for reflexive negotiation between individuals their relational ties and their social context to illuminate strategic life decisions such as career mobility becks thesis of institutionalised individualisation argues that through global waves of neoliberal policy governments have divested themselves of the responsibility to provide default social structures for the population as a collective instead transferring responsibility onto families and individuals to make their own way for example families with children need to make specific investigation into choice of school as previous assumptions that all government schools provide the same educational opportunities can no longer be guaranteed beck and beckgernsheim extend this perspective to understand the impact of institutional individualisation on families emphasizing that the erosion of predictable social scripts forces families to reflexively improvize how the family unit can work in its contextual circumstances mobility decisions thereby become one avenue for managing risk and optimizing life chances of individuals and families in an increasingly uncertain world the increased complexity however is that these mobility decisions need to consider all family members however institutions tend to engage with family members as individuals not as a cohesive unit archers sociology is interested in the internal conversation that weighs up opportunities and risks presented in the social context to design life projects because this is the process that mediates between society and the individual archer notes how structural constraints and enablements deter or encourage certain projects so any outcome is the result of the interplay between the individuals agency and what their social context enables that is reflexive projects the response by individuals is not just rational choice rather it is emotional tapping their deep concerns archer uses the term dovetailing to capture the way these occupational concerns must mesh or accommodate family concerns the sociology derived life course perspective has provided a scholarship in which careers extend beyond occupational concerns and into other aspects of peoples lives such as family careers and marking progressions through family forms and structures moen and sweet drew on this perspective to frame their discussion of work and family moving the discourse from one of individuals to a focus on dynamic relationships between roles and among individuals as lives unfold over time in tandem and in particular contexts these authors emphasized the need to move away from the workfamily dichotomy to focus on the complex interface among social structures social changes and individual biographies which are careers they emphasize the contextual changes which highlight the disjunctures where careers intersect with existing gender occupational labor market and workforce changes family work and mobility while there is an expanding sociological literature regarding the familywork interface there has been less focus on familywork and mobility although some empirical work has tracked the emergence of new spatial arrangements for family households precipitated by work demands or opportunities the embeddedness of individuals and families in existing work contexts and in social networks has been identified as deterrents to whole of family relocation so families are experimenting with new residential arrangements to achieve stability for children and access to mobile career opportunities levin described the new family form of living apart together van der klis and karsten considered the gender imbalance of commuter families which enable parents to seize distant work opportunities and preserve solid local roots for family life schneider and limmer highlighted the growing demand for jobrelated mobility of various scales in germany and its impact on family and community life while haslam mckenzie documented the flyin flyout family form in remote australia whereby typically the male partner works in a remote location with little social infrastructure over a compressed working period returning to the family home for breaks green initially documented the long commuting solution adopted by british dual career families to keep the family together but in more recent work green reported the emergence of dual location households luck and ruppenthal compared the mobility culture of different european nations and birth cohorts while hardill documented the contingent tradeoffs within the family unit when transnational career opportunities present gendered implications of mobility at the macro sociological scale these solutions have raised concerns about their reinvigoration of an asymmetrical gendered division of labor in the home and the further entrenchment of traditional female roles the impact of family mobility on womens careers is well documented bielby and bielby reported that wives are more likely to relocate for the sake of their husbands job than for their own although pixley reported that this tradeoff is related to respective income levels roberts emphasizes that womens family careers often disrupt their employment careers in particular in the way some womens careers had been unhinged by needing to relocate because their husbands jobs required this the well documented trailing spouse pattern also highlights how it is more typically the female parent who compromises her career stakes in the collectives interest haasler confirms that women in dual earner households are still responsible for managing the households especially if they also have young children families with children families with children especially when they reach school age have another layer of complexity to work through studies that document how jobrelated mobility can relocate the worker away from the family home implicitly demonstrate the normative reluctance to relocate households with schoolaged children there is some evidence that whole family mobility can be detrimental to schooling outcomes an australian study provides data on whole family relocations their sample included military personnel and core public service professionals in australia groups for whom career progression is often conditional on frequent mobility for these families this strategy of whole family mobility typically worked until children reached critical junctures in their education at this point the military interviewees described how family priorities tipped sometimes at the expense of military career advancement other times at the expense of the military career itself however the public service professionals understood the mobility expectations within their career structures and were largely able to plan for broader family educational considerations however the existing literature largely fails to account for those families who choose to remain together while on the move for career purposes taken together these different sociological studies thus fail to account for the conundrum at their intersection how the immobilitystability typically valued for children can at times be set aside in the pursuit of an individual family members career opportunities there is a crucial process of intersubjective bargaining and risk calculation within family units that mediates individualized career strategy the new mobility paradigm in sociology in conversation with other social theory can inform not just greater understandings of mobility patterns and their differences but also reveal how families are constituted in and by the web of accommodations and intersubjective bargains that both enable and constrain the individuals career project the next section reviews literature from the discipline of career development psychology to examine these phenomena through a different disciplinary lens thinking from the field of career development the field of career development has been challenged for its theoretical focus on intraindividual influences to the neglect of the broader environmental context this focus has prevented a stronger analysis of the individuals relational connections however it is increasingly being recognized within the career development psychology literature that an individuals career is impacted not just by the macro societal context in which they live but also by the micro social circumstances that emerge as work and family lives intersect a contextual worldview emphasizes that how events are viewed is linked to the perspective of each individual with development conceived as an ongoing process of interaction between the person and their environment career work within the contextualist worldview focuses on individuals interacting with multiple intrapersonal influences and with those from their social and environmental contexts a number of theoretical discussions have developed from this worldview collin raised the concept of the family friendly career and advocates for a systems approach to conceptualize a family friendly career in increasingly mobile times drawing on systems theory patton and mcmahon developed the metatheoretical systems theory framework of career to demonstrate the importance of all levels of an individuals system and the relative influences of these levels on an individuals career the stf is composed of several key interrelated systems including the intrapersonal system of the individual the social system and the environmentalsocietal system the processes between these systems are explained via the recursive nature of interaction within and between these systems change over time and chance the individual system is composed of several intrapersonal content influences which include gender age selfconcept health ability disability physical attributes beliefs personality interests values aptitudes skills world of work knowledge sexual orientation and ethnicity influences representing the content of the social system include peers family media community groups workplace and education institutions environmentalsocietal system influences include political decisions historical trends globalization socioeconomic status employment market and geographical location family and work decisions in expanding on their notion family relatedness of work decisions greenhaus and powell emphasize the relevance of family to a large number of work decisions they also note the relationship between family situations and work decisions and in particular the effect of context in which individuals live explaining that these contexts will affect work decisions differentially for each individual echoing the systems identified in the stf these authors identify individual context the organizational context and the societal context however there is little attention specifically to mobility related family career decisions in the work of patton and mcmahon and greenhaus and powell a number of authors have extended the fields understanding of relationships and career development emphasizing that their theoretical ideas have been derived in particular from what they term the relational cultural paradigm the term relational in career development is largely associated with the assumption that humans are relational beings for whom developing and sustaining meaningful connections with others is a core activity in contrast thinking relationally is built into the sociological gaze that will orient to the constitutive relations built into structures categories and fields it is not just between people influence of changing social context of work in addition to these reconceptualizations much of the social context of work has been changing forcing a rewriting of previous understandings of career processes the emphasis in the emerging 21 st century career has shifted from the organization to the individual and as such has reinvigorated the emphasis on the individual in discussions of career this shift is reflected in new notions of protean and boundaryless careers the concept of protean career refers to the notion that to adapt and survive in a changing world the individual needs to be selfgenerating that is protean managing the intersection between selforganizing and social phenomena or in charge of hisher own career however this theoretical work again deemphasizes the important role of context and in particular family in career decisionmaking a more relational intersubjective lens emphasizes the interface between adults work and relationships in multiple ways womens careers although much of the career development literature has focused on workfamily conflict and stress for both women and men in managing competing roles empirical work overwhelmingly suggests that women remain more likely to change their career paths and forego workplace opportunities because of family responsibilities although governments in many western countries have implemented key policy levers in support of both male and female participation in the workforce such as family leave child care support and flexible work arrangements these have been introduced more in connection with pressures for all citizens women and men to be economically independent schultheiss and richardson and schaeffer critique such policy as privileging paid market work over unpaid work such as caring for children ageing parents and other loved ones especially at a time when care of the elderly is a pressing social issue while the mobilities turn in the social sciences has impacted a number of disciplines this brief review has indicated that the application of mobilities studies to career development is less evident within this literature the focus has been on boundaryless careers and identifying a definitional focus for career change in terms of job change organizational change occupational change and career mobility mobility in this field refers more to change within a professional field change across occupational groupings and change which may include geographical mobility short or long term national or international within individuals careers the challenge for this field is to account for how multiple factors interact to produce or deter spatial mobility while analytically each factor offers some explanatory power ultimately the phenomenon is explained in how these facets cohere and dovetail in lived experiences of individuals and families future research interdisciplinary themes the conceptual and empirical literature from both sociology and career development acknowledges the challenges involved in understanding career mobility as the complex interplay between labor market workplace mobility individual and family however both fields of scholarship are yet to fully explore this new nexus this section offers key themes for future research from this brief interdisciplinary theoretical and empirical conversation and proposes fields of inquiry for research these themes include the pressure the mobility imperative places on womens domestic and family roles and the gender balance in intersubjective compromises around career mobility for dual career couples the influence of children in families career mobility decisionmaking and different rationales and improvisations around career mobility finally this section proposes some methodological considerations womens careers family and workforce mobility the impact of the family career on the female career has been documented in both literatures with the compromise in paid work and career progress primarily being made by the female even when there are no children the international studies reported in bimrose et al document the extensive and complicated nature of the interaction between womens unpaid and paid work experiences similarly research has consistently shown that it is most often the womens career trajectory which is compromised when a mobility opportunity presents itself although pixley reported data that income levels may moderate this most documented literature continues to present the traditional view as the nature and structure of the workforce continues to change and with the expectation that womens career projects will come to exert more priority in family decisions research into career decisions of women and men over the life course and in particular in relation to mobility decisions will be vital for understanding relevant influences such data will also be highly important for individuals deliberating on career mobility and for organizations developing policy frameworks for womens careers and for working to attract and retain a mobile talent families with children and workforce mobility it has been documented from both sociology and career development perspectives that families with children especially schoolaged children face significant barriers with respect to mobility if they prioritize educational opportunity for their children doherty et al showed how mobile children could accrue cumulative educational complications from institutional discontinuities over their familys mobility history similarly this research demonstrates that parents modified their own career aspirations and therefore income potential to protect the stability of their childrens education such impacts of worker mobility absorbed by children and the family unit have received scant attention within both the sociology and career development literature and would be worthy of additional research a focus on the family unit living mobility highlights the intersubjectivity of this social unit and the compromises being made by all members these data derived from all family members would again assist organizations to prepare attractive packages to attract mobile workers in addition tracking the educational progress of children of mobile families would assist in understanding this phenomenon further family strategies to accommodate workforce mobility a third theme emerging in both literatures is the family strategy and improvizations around mobility through different family models or workable solutions families are experimenting with new residential arrangements to achieve stability for children and access to mobile career opportunities such as dual location households and flyin flyout solutions further research could monitor what costs and benefits accrue to the family and society more broadly under these improvizations for example research needs to examine work and career related outcomes in addition to individual and family matters with respect to attachment family connectedness wellbeing and stressors of each family member experiencing these divided households these data when compared with family members experiencing whole of family mobility would assist organizations drawing on mobile workers to develop support strategies these data would also assist in understanding career decision influences career mobility is not always about moving on to get ahead doherty et al demonstrate that both the military personnel and the professionals in their study recognize that mobility was helpful for career progression however there are other drivers for and against mobility much labor market mobility planned by organizations is only designed to provide short term labor for particular project needs in this way mobility decisions for individuals and their families might be about achieving or maintaining employment or enriching family life not just career advancement there are additional risks and uncertainties in more speculative career mobility that warrant further research methodological considerations for research this review of these literatures emphasizes the importance of learning from paradigms that intersect around research problems and developing an interor multidisciplinary focus for career mobility research this more complex theoretical mix could accommodate and profit from both a range and a synthesis of research methodologies from both disciplines the empirical studies reviewed in this article included interviews with individuals and couples at different life and career stages narrative enquiry and surveys some asking point in time questions and others asking respondents to reflect back on key mobility decision points doherty describes a method of narrative interviewing of family members and the construction of an orchestral score which provides a visualisation device for documenting narrative data incorporating a focus on family challenges the individualism inherent in many considerations of career and labor market mobility whole of family research highlights the relationship between mobility and family stages in particular the life stages of children other areas which demand a focus include investigating family pressures for elder care and examining all family forms the dimension of time or timing in terms of life course or family phase would enrich any understanding of career mobility such a research agenda will need a diverse and adaptable methodological toolkit less devoted to disciplinary purities and more devoted to the research problem from the field of career development blustein emphasizes that one might need to sacrifice precise linear models for the complex murky nature of working life that exists among family commitments shifting political factors radically transforming economic structures and complex and nuanced cultures blustein calls for research to move beyond quantitative surveys and to pursue narrative as a research approach although holdsworth suggests narrative may be problematic in gathering data from children and adolescents from the life course sociology literature moen and hernandez describe strategies and techniques for capturing the embeddedness of individuals within the lives of others as linked lives at any one point in time and as social convoys over time they note the need for social groupings and relational units as prime units of analysis rather than the individual and suggest gathering individual variables in addition to couplelevel variables these authors propose gathering family longitudinal data as follows household composition household income age and education styles of decision making family conflict frequency and nature and frequency of social network contact concluding comments this exploration of conceptual and empirical work from two disciplinary fields has demonstrated that the complexities of family solutions to career mobility undo the apparent simplicity of delivering a worker to a new worksite although organizations and governments work to develop policies that incentivize mobility including transport infrastructure housing employment conditions and tax incentives these will not necessarily address the private concerns and priorities of families within a world where career opportunities increasingly implicate mobility this article has focused thinking around this influence through the disciplines of sociology and career development it is evident that each field could learn from the other and we suggest that socially complex problems such as workforce mobility will benefit from multidisciplinary conversations which articulate and mesh theories and methodologies from each field indeed cresswell has argued that mobilities research has linked the fact of movement across scales and in a way that links the humanities at one end to the sciences to the other current mobilities research includes scholars from multiple fields and the fields of sociology and career development discussed in this article are but two more integrative work incorporating theorizing and methodologies from both the humanities and the sciences will contribute to a maturing of our understanding of the complex interaction between individual family and the social and economic contexts in which careers develop

the purpose of this article is to synthesise conceptual and empirical work from the fields of both sociology and career development to explore how issues of career family and workforce mobility are necessarily interrelated the use of work from sociology and career development demonstrates that the complexities of family solutions to career mobility undo the apparent simplicity of delivering a worker to a new worksite although organizations and governments work to develop policies that incentivize mobility including transport infrastructure housing employment conditions and tax incentives these will not necessarily address the private concerns and priorities of families the article argues for an interdisciplinary approach to better understand the intersubjective complexities implicated in the growing phenomenon and expectation of worker mobility and suggests both areas and design strategies for further research

despite the gradual decline in the prevalence of smoking over the past half century smoking has persisted as the number one cause of preventable deaths in the usa smoking is significantly linked to several cancers as well as various cardiovascular metabolic and pulmonary diseases 1 smoking cessation is associated with reduced risk of cardiovascular disease among heavy smokers 2 and reduced mortality risk among individuals with coronary heart disease 3 some individuals however those we call recalcitrant smokers continue to smoke despite having smokingrelated conditions for example twothirds of cancer survivors continue smoking after cancer diagnosis 4 and after having a myocardial infarction around half of the smokers continue smoking even though this is linked to adverse health impacts and low quality of life 5 vulnerability to nicotine addiction might be a reason why some individuals with such adverse health conditions continue smoking 6 yet cumulative evidence shows that low socioeconomic position and stressful experiences are wellknown predictors of the initiation and cessation of smoking as well as relapses 78 such life circumstances that affect smoking habits may originate in early life 9 10 11 the association between earlylife adversities and recalcitrant smoking might be transmitted through lifecourse factors yet we are aware of only one study that has tested such a hypothesis 12 some earlylife adversities are more strongly and adversely tied to adult health for women than men for example the link between child abuse and laterlife mortality 13 however we have little knowledge of whether women and men respond differently to earlylife adversities in terms of the likelihood and mechanisms of smoking recalcitrance to shed light on these issues we investigate to what degree earlylife adversities are associated with the risk of recalcitrant smoking psychosocial factors that explain the association and gender differences in any observed associations background earlylife adversities and smoking earlylife adversities include a host of negative experiences that may occur in childhood low socioeconomic status family instability and abuse are among the most commonly occurring earlylife adversities that we know of 14 15 16 such earlylife experiences affect health and wellbeing throughout the life course including the risk of smoking behaviors for example growing up in a lowses family increases the risk of smoking initiation and the likelihood of smoking in adulthood 9 for women experiencing physical or sexual abuse in childhood increases the risk of regularly smoking cigarettes by 14 years of age 10 and of smoking in early midlife 11 similarly exposure to family instability such as growing up in divorced families increases the risk of smoking and the number of cigarettes smoked for women 17 few studies however have investigated whether earlylife adversities are associated with more harmful smoking behaviors such as smoking despite having a serious medical condition only one study to our knowledge has found a significant doseresponse association between earlylife adversities and smoking among individuals who have smokingrelated illnesses and symptoms including heart disease chronic lung disease and diabetes 12 this study was based on a community sample of adults who completed a standardized medical evaluation at a health maintenance organization so the findings may not be generalizable to broader populations additionally this prior study focused on a cumulative number of exposures of all observed adversities 12 thus offering no insight into the unique effect of each domain of adversity moreover its use of crosssectional data obviated the possibility of investigating extensive lifecourse pathways linking earlylife adversities to recalcitrant smoking gender differences in the effect of earlylife adversities women might be more vulnerable than men to earlylife adversity in terms of laterhealth outcomes although the association varies by type of adversity and health outcome for example women but not men who experienced parental divorce in childhood smoked more 17 for women but not men childhood abuse increases the risk of laterlife mortality 13 an inverse association between childhood ses and laterlife body mass index is stronger for women than men 18 yet men but not women who grew up in lowses families are more likely to consume unhealthy foods in midlife 19 no study has yet examined gender differences in the association between earlylife adversities and recalcitrant smoking yet we have reason to believe that gendered patterns exist a long line of research about boys sensitivity to economic hardship leads us to speculate that males smoking behaviors might be more affected by low childhood ses boys are more adversely affected by growing up in economically deprived households including experiencing less hopefulness selfesteem and confidence about their future 2021 in response to their increased vulnerability to economic hardship boys tend to act out with more disruptive behaviors rather than with an emotional response which may in turn increase harsh parental discipline for boys but not girls 2223 due to harsh parenting practices and rejection from parental figures young boys may be more likely to turn to peer groups that encourage more socially disapproved acts such as smoking 24 such unhealthy behaviors established in early life may continue into later life in contrast family instability and abuse in childhood might have unique consequences for womens smoking both family instability and childhood abuse are connected to impaired interpersonal relationships during adulthood 2526 and the adverse impact might be stronger for women than men 2728 gender differences may stem from highly gendered socialization processes during childhood where the differential emphasis is placed on closeness with others sex role theorists contend that girls but not boys are socialized to place great emphasis on forming and maintaining close interpersonal ties with others 2930 as a result interpersonal relationships may originate from and cause emotional experiences for girls significantly more than for boys and this may extend into adulthood 31 women are more likely than men to believe that smoking can be used to manage negative emotions and act as a coping tool for previously experienced stressors 32 therefore unstable and abusive relationships in childhood may increase the risk of recalcitrant smoking for women potential pathways linking earlylife adversities and recalcitrant smoking cumulative inequality theory suggests that adversities during childhood shape opportunities and risks over the life course in turn affecting laterhealth outcomes 33 the lifecourse pathway model 34 suggests that earlylife circumstances may influence subsequent material social and psychological lifecourse factors that may contribute substantially to the risk of smoking behavior there is a wellestablished association between earlylife adversities and decreased psychological wellbeing usually in the form of depressive symptoms that extend decades beyond early experiences 35 studies based on clinical samples found that among cancer patients depressive symptoms are a significant predictor of persistent smoking 36 and smoking relapse 37 therefore depressive symptoms could be an important pathway linking earlylife adversities to recalcitrant smoking a prior study however found that the mediating role of depression is not large 12 other lifecourse factors may help us understand why experiencing earlylife adversities is associated with recalcitrant smoking for example adult ses individuals who experienced earlylife adversities are less successful in school and in the labor market 38 and they have more financial difficulties in later life 39 compared to individuals with high ses those with low ses are more likely to smoke and less likely to quit smoking 7 some studies have found that after adjusting for adult ses the association between childhood ses and adult smoking is attenuated to nonsignificance suggesting that ones adult ses may be significantly associated with current smoking more so than childhood ses 4041 moreover childhood adversities can lead to further hardships and stress exposures in later adulthood 42 psychological stress including exposure to stressful life events and chronic and financial strain is associated with the persistence of and relapse into smoking behaviors 743 a recent study has shown that stressful events impacting family members are also associated with smoking in midlife 8 indicating the important role of network stress on an individuals health behaviors another important intervening mechanism is an individuals motivation to quit smoking which may be bolstered by social support studies have found an association between high ses and smoking cessation possibly through desire intention or sense of duty to stop smoking 44 the observed associations may in part be attributed to individuals from low ses having lower levels of purpose in life 45 a psychological asset that helps individuals prioritize longterm goals over immediate ones such as engaging in unhealthy behaviors 46 moreover social support best helps individuals stop smoking when the support is consistent and nondirective 47 yet individuals who experienced earlylife adversities report lower levels of social support in adulthood such as not having a spouse partner and decreased perceptions that ones family is supportive 2648 hypotheses of the current study based on this extant literature we hypothesize that earlylife adversities will be statistically significant predictors of the risk of individuals recalcitrant smoking we expect that some earlylife adversities will be more influential for women than men specifically we hypothesize that socioeconomic disadvantage will be more strongly associated with the risk of recalcitrant smoking for men than women while unstable and abusive relationships in childhood will be more strongly associated with the risk of recalcitrant smoking for women than men using selected psychosocial factors from the literature we then test hypothesis 3 psychosocial factor will mediate the positive association between earlylife adversities and recalcitrant smoking given that little is known in terms of predictors of recalcitrant smoking throughout these analyses we pay close attention to those lifecourse factors that are significantly associated with recalcitrant smoking as well as gendered patterns in the associations method sample data for this study come from the midlife development in the united states study a national survey designed to assess the role of social psychological and behavioral factors in understanding differences in mental and physical health midus began in 19951996 with noninstitutionalized englishspeaking adults aged 2574 in the 48 contiguous states 49 national random digit dialing with oversampling of older people and men was used to select the main sample and a sample of twin pairs the study also includes a random subsample of siblings of individuals in the main sample and oversamples from five metropolitan areas in the usa midus consists of a twostage survey a telephone interview and a selfadministered questionnaire approximately 89 of the sample completed the twostage survey at wave 1 followup interviews with midus respondents were completed in 20042006 the longitudinal retention rate for wave 2 was 75 after adjusting for mortality additional information about sampling enrollment and longitudinal retention is documented elsewhere 50 the present analysis uses data from the 4932 individuals who participated in both the initial and the followup survey compared to individuals who died or were lost to followup at wave 2 those who participated in both waves were more likely to be white female married more highly educated and to report having better health this attrition may result in selection bias between waves 1 and 2 measures earlylife adversities include socioeconomic disadvantage family instability and parental abuse by maximizing available information in midus we created the index of low childhood ses which is an average of standardized scores of six indicators mothers and fathers education mothers and fathers occupational prestige score as measured by duncans socioeconomic index 51 welfare status and financial level growing up family instability is a binary indicator based on the question did you live with both of your biological parents up until you were 16 possible reasons for a negative response include parental death separation or divorce parents not living together and never knowing a biological parent for childhood abuse respondents were presented with a battery of items from the modified version of the conflict tactics inventory 52 respondents were asked how often they had endured each of the following forms of abuse which fall into three listsdomains list a list b and list c list a includes items related to emotional abuse while items in lists b and c represent physical abuse the response options included 1 never 2 rarely 3 sometimes and 4 often the correlation between emotional and physical abuse was 73 by averaging the 15 items we created an index of childhood abuse recalcitrant smoking in midlife to identify recalcitrant smokers we followed the threestage process described in fig 1 we first obtained smoking status through a question at wave 1 next we identified those eversmokers who developed or had at least one of the following illnesses or symptoms at wave 2 that may be exacerbated by smoking ever had heart problems suspected or confirmed by a doctor ever had a heart attack ever experienced or been treated for a stroke in the past 12 months ever experienced or been treated for hypertension in the past 12 months ever experienced or been treated for asthma bronchitis emphysema or other lung problems in the past 12 months ever experienced or been treated for diabetes or high blood sugar in the past 12 months or ever had cancer finally we identified recalcitrant smokers as those who have ever had smokingrelated illnesses but indicated during the wave 2 interview that they smoke regularly the logic to identify recalcitrant smokers is consistent with prior work 12 lifecourse mediators based on prior studies we included six mediators linking earlylife adversities to smoking status in midlife education financial strain mood disorder recent family problems purpose in life and marital or cohabiting status for education respondents reported their highest grade of school or year of college completed response categories ranged from 1 no schoolsome grade school to 12 phd md or other professional degree the index of financial strain is an average of standardized scores of four indicators current financial situation control over financial situation availability of money to meet basic needs and level of difficulty paying bills mood disorder is a binary variable that indicates whether a respondent has major depressive disorder or generalized anxiety disorder both disorders were assessed through phone interviews that used the screening versions of the world health organizations composite international diagnostic interview version 10 53 major depressive disorder and generalized anxiety disorder were defined according to criteria specified in the third revised edition of the american psychiatric associations diagnostic and statistical manual of mental disorders consistent with prior work 8 we created an index of family problems using 30 items that capture whether three major family members had problems during the past 12 months in any of the following 10 areas health alcohol use substance use finances work school job legal issues marriage or other relationships response options were yes or no we summed the scores from the three family members a purpose in life index was created using a threeitem version of ryffs scale of psychological wellbeing 46 on a scale from 1 strongly disagree to 7 strongly agree participants responded to three statements i live life one day at a time and do not really think about the future some people wander aimlessly through life but i am not one of them and i sometimes feel as if ive done all there is to do in life purpose in life was the average of these three items the low reliability of the index is due in part to the small number of items sensitivity analysis shows that substantial findings are consistent across a 7item version in wave 2 vs a threeitem version in wave 1 thus we used the index from wave 1 to ensure the temporal order between the mediator and outcome marriedcohabiting is a binary variable based on a question asking whether the respondent was married or living with someone we created family support using four questions reflecting positive relations with family members how much do members of your family really care about you how much do they understand the way you feel about things how much can you rely on them for help if you have a serious problem and how much can you open up to them if you need to talk about your worries possible responses included 1 not at all 2 a little 3 some and 4 a lot given that the average score of the four items was positively skewed we created a binary indicator of high family support if the average score was equal to 4 we included three demographic confounders from wave 1 which are associated with smoking status age as a continuous variable race and gender racial and gender statuses were created using selfidentified racial status and sex analytic strategies descriptive statistics were calculated using twotailed ttests for continuous indicators andχ 2 tests for binary variables we used sequential logistic regression models to estimate the effect of earlylife adversities on the risk of each of the three irreversible stages toward recalcitrant smoking one must be a smoker then develop a smokingrelated illness and then continue smoking despite having such a health condition as shown in fig 1 these three stages consist of the following transitions the first transition is a choice between being a smoker or not the second transition is having a smokingrelated illness or not among those who smoke and the third transition is a choice between being a recalcitrant smoker or not among smokers who have a smokingrelated illness at each stage the model predicts the effects of earlylife adversities on the next transition using the sample from the prior transition as stage 1 p logit 1 stage 2 p logit 1 and stage 3 p logit β 03 β 13 x where βs are regression coefficients logit 1 exp 1exp and x represents earlylife adversities at the last stage presented we created a series of nested models to investigate the lifecourse factors that explain why individuals exposed to earlylife adversities become recalcitrant smokers given that we have multiple exposures to earlylife adversities and mediators we proceeded as follows first we estimated the effect of each adversity and lifecourse factor on recalcitrant smoking individually we then added all three adversities together to investigate the additive effects of each adversity on recalcitrant smoking if the additive effect of an exposure was significant we examined the mediation effect of the exposure via lifecourse factors in the following models only the lifecourse factors found to be significant in the baseline models were added to model 1 as potential mediators one at a time the final model includes all exposures and mediators in order to examine the mediation effects via all combined lifecourse factors and to identify lifecourse factors which have a significant effect net of other covariates coefficients from nested nonlinear probability models are not comparable because of unobserved heterogeneitythat is the variation in the dependent variable that is caused by variables that are not observed 54 therefore to ensure the comparability across nested models in logistic regression we used the karlsonholmbreen method 55 and then computed the percentage of the mediation effect relative to the total effect via each all mediators the khb method adjusts coefficients by separating the variation that is caused by omitted variables to yield estimates comparable across predictors all continuous predictors were standardized at the mean with the sd equal to 1 the analysis was stratified by gender and gender differences in direct effects of earlylife adversities and indirect pathways were tested by pooling data from both genders and testing gender interaction terms the sequential model which we have used for a primary method is a conventional model for addressing this type of dependent variable with multiple stages however this model cannot address possible selection biases due to excluding nonsmokers and nonsmokers and healthy smokers to handle the possible selection biases we used the heckman model 56 as a sensitivity analysis given that the heckman model only addresses two stages we confined our sample to smokers and replicated the analysis of stage 3 the results from the heckman model which handles possible selection biases are not substantially different from the results from sequential models all control variables and mediators have 1 2 of data missing on average we handled missing data for these confounders using standard practices of multiple imputation 57 to adjust for the possible selection bias between waves 1 and 2 in terms of sociodemographic characteristics we weighted the remaining sample by the inverse of the probability of dropping out given characteristics such as race gender marital status and education detailed procedures are provided elsewhere 5859 robust standard errors were used to correct for intrafamily correlation given that multiple individuals are from the same family as a result all analyses employed multiple imputation a poststratification weight and robust ses due to clustering all analyses were implemented using stata 150 60 except gender differences in indirect pathways which were analyzed with mplus 80 61 results baseline characteristics by smoking status as displayed in fig 1 49 of respondents who participated in wave 2 were identified as eversmokers around half of them reported that they had at least one disease or symptom that might be exacerbated by smoking among respondents who had a smokingrelated illness onefourth continued smoking despite having such an adverse health condition the prevalence of recalcitrant smoking was around 7 in the midus sample the likelihood of being recalcitrant smokers was slightly higher for women than men table 1 displays the results from bivariate analyses that tested whether all variables used in the analyses varied by the stages toward recalcitrant smoking in the comparison between nonsmokers and eversmokers eversmokers were more likely than nonsmokers to have experienced low ses abuse and family instability in childhood eversmokers tended to be male and older compared to nonsmokers among respondents in stage 2 those who had a smokingrelated illness were older and more likely to have experienced low childhood ses than those who did not have a smokingrelated illness among respondents with a smokingrelated illness individuals who continued smoking experienced more adversities in early life than those who quit smoking they also showed lower levels of resources that tend to inhibit smokingsuch as education purpose in life family support and living with someoneand higher levels of risk factors of smoking including financial strain mood disorder and family problems recalcitrant smokers however were more likely to be younger and female than those who quit smoking after having a smokingrelated illness earlylife adversities and being an eversmoker table 2 shows the odds ratios and confidence intervals of the sequential response model at stages 1 and 2 we estimated the effect of each adversity in baseline models and then estimated the effects of all three adversities in the additive model results from logistic regression models in the association between earlylife adversities and eversmoking are shown in table 2 in baseline models we found that all three adversities were significantly related to an elevated risk of eversmoking for both genders when all adversities were considered simultaneously childhood abuse and family instability were significantly associated with eversmoking for women while all three adversitieslow ses childhood abuse and family instability remained statistically significant for men earlylife adversities and having a smokingrelated illness earlylife adversities continued to be significant predictors in the second stage that is having a smokingrelated illness however only some earlylife adversities appeared statistically significant in the second stage specifically the results from additive earlylife adversities lifecourse mediators and being a recalcitrant smoker for the third stage we investigated earlylife adversities and psychosocial factors that help us understand why some individuals with a smokingrelated illness continue to smoke while others quit for women results from baseline models in table 3 show that the risk of recalcitrant smoking is higher for women who grew up in low ses and unstable families the unique effects of these two earlylife adversities remained statistically significant even after all earlylife adversities were estimated simultaneously in model 1 there are five psychosocial factors that are significantly related to elevated risk of recalcitrant smoking for women at baseline higher levels of education higher levels of purpose in life living with a partner more financial strain and mood disorder in mediation analyses we found that education has a significant indirect effect on the association between childhood ses and recalcitrant smoking for women by accounting for around 79 of the association after controlling for education the unique effect of childhood ses was no longer statistically significant regarding the unique effect of family instability on recalcitrant smoking there are no lifecourse factors that show significant indirect effects for men in table 4 low ses in early life is associated with an increased risk of recalcitrant smoking in the baseline model yet neither childhood abuse nor family instability had a significant effect on recalcitrant smoking the results from baseline models showed that the risk of recalcitrant smoking for men is inversely associated with purpose in life high family support and living with a partner yet the risk is positively associated with family problems in the mediation analysis we found that no lifecourse factors have significant indirect effects on the association between low childhood ses and recalcitrant smoking in the final model which includes all earlylife adversities and psychosocial factors we found that the effect of family instability remained significant and that there were two lifecourse factorslower and not living with a partner were independent factors that explained why male smokers continued smoking despite having a smokingrelated illness in terms of the direct effect of earlylife adversities in the final models we found that gender differences were not statistically different the indirect pathway from childhood ses to recalcitrant smoking through adult education was stronger for women than men even after accounting for all other potential mediators discussion our study yielded three major findings we found that individuals who experienced childhood adversities are more likely to be recalcitrant smokers in midlife there are gendered patterns in the type of earlylife adversities that uniquely shape the likelihood of being recalcitrant smokers based on prior research on childhood development 20 we expected that males smoking behaviors would be more strongly affected by socioeconomic position in childhood indeed we found an inverse association between childhood ses and the probability of being recalcitrant smokers particularly for men theories of gender socialization and sex roles 29 further guide us that abusive and insecure relationships in early life might harm women more than men we found that family instability is significantly associated with the increased risk of recalcitrant smoking for women but not for men prior research on substance abuse calls for more interventions that target those with childhood trauma 62 interventions that target women while addressing both substance abuse and complex trauma produce more favorable outcomes when compared to programs that only address substance abuse 6364 in a similar vein smokingcessation interventions for recalcitrant smokers who experienced earlylife adversities might be more effective if the program provides coping skills for managing earlylife trauma more research is needed regarding whether genderspecific interventions would improve outcomes guided by cumulative inequality theory 33 and the lifecourse framework 34 we hypothesized that there are psychosocial factors that explain why some individuals continue to smoke despite having a smokingrelated illness we found that education in adulthood substantially explains why women who grew up in lowses families are more likely to be recalcitrant smokers however even after accounting for all potential mediators the direct effect of some earlylife adversities remains significant in particular family instability is a robust predictor for women while childhood ses is a robust predictor for men for men the mediating role of education in the association between childhood ses and recalcitrant smoking is negligible none of the potential mediators substantially explain why women who grew up in unstable families tend to be recalcitrant smokers in later life we interpret our findings in line with the biological embedding model that is earlylife adversity induces significant developmental changes in children modifying the maturation and responsiveness of physiological systems and developmental changes 65 earlylife adversities may alter brain areas that govern executive functioning and reward systems 66 which may result in fostering impulsiveness and unhealthy coping behaviors such as smoking 67 moreover we cannot exclude the possibility that data limitations may affect the significance and strength of mediators given that all mediators were measured in midlife although we carefully selected the mediators based on the literature we acknowledge the possibility that these mediators may not be unique to the earlylife adversity there may be other potential mediators that future researchers should consider there are noteworthy lifecourse factors that independently explain why middleaged individuals continue to smoke in the face of a smokingrelated illness for both genders the risk of recalcitrant smoking is low for those who live with a partner our findings are in line with the literature on the positive aspects of marriagecohabitation on smoking behaviors 68 we also found genderspecific lifecourse factors in line with research on the health benefits of education 69 education plays a role in recalcitrant smoking for women although it is established that smoking prevalence is higher among those with lower education 70 our findings expand prior work by indicating that education predicts a more harmful form of smoking that is smoking despite having serious medical conditions particularly for women we also found that the risk of recalcitrant smoking was higher when men have family members who struggle with their own health substance use finances work or marriage these findings are in line with the principles of linked lives 20 and stress crossover 71 that is family members who suffer from their own problems may provide less support and more strain which may inhibit mens smoking cessation like prior work 3637 mood disorders matter for womens recalcitrant smoking but the effect is not significant when an extensive set of mediators is taken into account several methodological limitations should be acknowledged first given that midus lacks information on when respondents developed smokingrelated conditions we cannot establish the temporal order between the initiation of smoking and the development of a smokingrelated illness however around 90 of eversmokers in midus began regularly smoking before age 25 and most smokingrelated conditions are likely to develop in later life thus we assumed that in the vast majority of cases respondents would have begun smoking long before they developed a smokingrelated illness second indicators of earlylife adversities are vulnerable to recall bias and some indicators of earlylife adversities may not fully capture difficulties that individuals encounter in early life for example family instability is measured with a single indicator so the diverse causes duration or severity of the adversity were not measured moreover the measure of childhood abuse only includes emotional and physical abuse but not sexual abuse which is more common among women 72 given the significant association between sexual abuse and smoking particularly for women 11 this would lead to conservative estimates of the effect of childhood abuse third we have created indexesfor example family problemsby summing a wide array of indicators across different family members our findings thus do not provide more specific information relevant to smoking habits finally although we have included potential variables that are carefully selected from the literature we cannot rule out the possibility that there still remains confounding by unmeasured variables a common limitation in observational research in conclusion using a longitudinal study of middleaged us adults we observed that disadvantaged environments and stressful experiences in early life might increase the risk of recalcitrant smoking moreover the nature of earlylife experiences may affect girls versus boys differently in terms of their risk of such a harmful smoking behavior future research should continue to examine how and why earlylife adversities and potential mediators operate differently for men and women to reduce the prevalence of such an intractable smoking habit our results call for interventions for recalcitrant smokers who were disadvantaged in early life supplementary material supplementary material is available at annals of behavioral medicine online authors statement of conflict of interest and adherence to ethical standards the authors declare that they have no conflict of interest authors contributions cl led the conceptual and analytic design analyzed the data and drafted and revised the article lh helped to formulate the initial idea conducted preliminary analyses drafted parts of the manuscript and contributed to the revision process sp designed conducted and drafted parts of the method section and contributed to the revision process ethical approval all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional andor national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards informed consent informed consent was obtained from all individual participants included in the study

background little is known about lifecourse factors that explain why some individuals continue smoking despite having smokingrelated diseases purpose we examined a the extent to which earlylife adversities are associated with the risk of recalcitrant smoking b psychosocial factors that mediate the association and c gender differences in the associations methods data were from 4932 respondents 53 women who participated in the first and followup waves of the midlife development in the us national survey earlylife adversities include low socioeconomic status ses abuse and family instability potential mediators include education financial strain purpose in life mood disorder family problemssupport and marital status we used sequential logistic regression models to estimate the effect of earlylife adversities on the risk of each of the three stages on the path to recalcitrant smoking eversmoking smokingrelated illness and recalcitrant smoking results for women low ses odds ratio or 129 106155 and family instability or 173 114262 are associated with an elevated risk of recalcitrant smoking education significantly reduces the effect of childhood ses yet the effect of family instability remains significant even after accounting for lifecourse mediators for men the effect of low ses on recalcitrant smoking is robust or 148 110200 even after controlling for potential mediators there are noteworthy lifecourse factors that independently affect recalcitrant smoking for both genders not living with a partner for women education and for men family problems conclusions the findings can help shape intervention programs that address the underlying factors of recalcitrant smoking

countries primary among these factors is perceived racial discrimination there have been three reviews of this expanding literature in the past 10 years and all of them have reached similar conclusions discrimination is associated with worse mental and physical health these reviews provide the background for the current study which examines the relations between discrimination and physical health status versus healthimpairing behavior discrimination and physical health the relation between discrimination and mental health is straightforward discrimination leads to an increase in negative affect which can produce a decline in mental health selfreports of discrimination have been associated with elevated anxiety and depression as well as anger and hostility pascoe and richmans metaanalysis identified 105 studies that included measures of discrimination and mental health status they produced a weighted average correlation of 20 between discrimination and mental health outcomes almost all of these studies were crosssectional however schulz et al found that increases in selfreported discrimination predicted increases in depression and decreases in perceived overall general health pascoe and richman also identified 36 studies reporting a relation between discrimination and indicators of physical health the average correlation in these studies was 13 although the correlations between discrimination and mental vs physical health were not significantly different pascoe and richman suggest that the relation with mental health may be somewhat stronger others have reached the same conclusion pointing out that the effect of discrimination on physical health may be robust but it takes longer for discrimination to produce physical health problems than either distress or hostility the primary reason is that the former relation is mediated by the latter and therefore may not appear in crosssectional analyses in fact both the first and second paths of the discrimination → distress → health problems linkage have been shown repeatedly but almost always in separate studies discrimination and substance use discrimination also affects health status through its effects on healthimpairing behaviors pascoe and richman identified 13 studies that linked discrimination with unhealthy behaviors such as substance use and found an average correlation of 18 several of these studies included prospective data gibbons et al found that discrimination assessed at age 1011 predicted substance use five years later in a panel of black adolescents in the family and community health study a similar relation between discrimination and problematic substance use was also found among the parents of these black children in fact discrimination was the strongest predictor of problematic use of all of the factors that were assessed with the parents including multiple types of stressors and contextual factors in addition analyses with both the parents and the adolescents found that the relation between discrimination and use was mediated by change in distress in other words discrimination at t1 predicted an increase in anxiety and depression from t1 to t2 and this increase in distress was associated with an increase in selfreported use mediation of the relations between discrimination and substance use anger vs distress a subsequent series of studies with the fachs sample using both survey and experimental methods suggested that the discrimination → use relation may be more complex than originally thought when anger and hostility were added to the models as mediators discrimination predicted changes in both distress and anger as expected however the path from distress to use was no longer significant in essence it was replaced by the path from hostility to use more specifically for the parents discrimination at t1 was associated with an increase in hostility at t2 and this change predicted an increase in problematic use three years later the same pattern appeared with the adolescents t1 discrimination was associated with elevated anger and distress but only anger predicted use five years later there was no effect of distress experimental evidence in a followup lab study a subsample of the fachs adolescents was asked to envision one of the following a discriminatory experience a stressful nondiscriminatory experience or a neutral experience and then their mood states and willingness to use drugs were assessed relative to the two nondiscriminatory scenarios discrimination was associated with an elevation in both anger and depression as well as drug willingness however anger but not depression was associated with drug willingness consequently only anger mediated the impact of discrimination on willingness similar results were reported by stock gibbons peterson and gerrard who used the cyberball paradigm as a way to manipulate perceived discrimination in this case black young adults who thought they had been excluded by whites in the cyberball game reported more perceived discrimination and more willingness to use substances and the relation between the two of them was mediated by anger differential mediation internalizing vs externalizing reactions there is precedent in the literature for the differential mediation hypothesis ie anger hostility is more strongly related to substance use whereas distress is more strongly related to health problems but the evidence is mostly indirect first distress is often associated with avoidance of risky behaviors in contrast anger externalizing behavior has generally been associated with risktaking including substance use whitbeck et al measured discrimination and affect among american indian adolescents and found that discrimination was associated with both internalizing and externalizing symptoms but only the latter were related to substance use bardone et al found that conduct disorder predicted healthrisk behavior including risky sex and alcohol and drug use but not health problems in contrast anxiety predicted medical problems but not substance use overview most reviews of the discrimination health literature have included a call for additional prospective studies of the relations among discrimination negative affect and health outcomes in order to determine why discrimination has pronounced effects on both physical and mental health literature reviews have also recommended examination of additional affective reactions as mediators of the relation between stress and physical health problems the current research examined these relations in a panel of black women across four waves of data spanning eight years analyses examined cumulative discrimination as a predictor of both health status and healthimpairing behavior controlling for other types of stress the following differential mediation hypothesis was made perceived discrimination is associated with increases in both physical health problems and problematic substance use however the former relation is mediated by change in internalizing reactions whereas the latter relation is mediated by change in externalizing reactions methods sample fachs is an ongoing study of psychosocial factors related to the mental and physical health of black families there were 889 families in the first wave half from iowa and half from georgia each family had an adolescent who was in 5th grade at t1 and selfidentified as african american or black and a primary caregiver most of the parents were the biological mothers of the adolescents because there were so few male primary caregivers the current study focused only on the women 680 of whom answered enough items across the four waves to be included in the analyses retention across the four waves was 80 the women had a mean age of 37 years at t1 45 at t4 their mean level of education was high school graduate approximately 65 of them were single mothers recruitment and procedure recruitmentfamilies were recruited from rural communities suburbs and small metropolitan areas with mostly lower and middle class families in iowa and georgia of those families contacted 72 provided data median family income at t1 was 20803year 33 of the families were below the poverty line for further description of the fachs sample and recruitment see cutrona et al simons et al procedureall interviewers were african americans who had received extensive training interviews lasted about 3 hours and required two visits they included a computerassisted personal interview as well as a structured psychiatric diagnostic assessment participants received 100 at t1 to t3 and 125 at t4 average time between waves was t1t2 22 months t2t3 and t3t4 36 months informed consent was obtained from all participants the research was approved by the irbs at each institution measures time of assessmentmediator variables were assessed at t1 and again at t3 discrimination was measured at t2 the two health outcomes were assessed at t1 and then slightly different versions were assessed at t4 covariates were all assessed at t1 wave of measurement for each construct is noted below in parentheses perceived racial discrimination participants completed a 13item modified version of the schedule of racist events this measure one of the most commonly used in the discrimination literature describes various discriminatory events and asks how often respondents have experienced each type of event eg how often has someone said something insulting to you just because you are african american lifetime measures like these appear to be more effective than daily measures at predicting health problems the 13 items were randomly parceled into three indicators of the latent construct distress these items began during the past week how much have you felt hopeless depressed discouraged like a failure worthless for depression and tense uneasy keyed up for anxiety each item included a 3point scale 1 not at all to 3 extremely the distress latent construct had these two indicators hostility t1 t3 we used a definition of hostility which is common in the health literature that includes two components behavior and affect the umcidi assessed seven types of antisocial behaviors four of which pertained to physical violence and harming others there were several questions for each type of behavior if the participant endorsed one or more items for a behavior she was considered to have engaged in that category the total number of categories was summed resulting in a score of 0 to 4 anger was assessed with a single item you dont get upset too easily from 1 strongly agree to 4 strongly disagree thus once again there were two indicators in this case one for aggression and one for anger problematic alcohol use our focus was on problematic drinking at t1 and t4 we used a question about amount of alcohol typically consumed at each sitting during the last year we also used four questions from the umcidi about experiencing problems due to alcohol use fighting problems at work being arrested and being harmed while under the influence in addition at t4 the interview included eight items regarding bad experiences in the past year due to alcohol use thus for the problematic drinking latent construct there were two indicators at t1 and three indicators at t4 health status was assessed with two single items at t1 and t4 and a physical functioning scale assessed only at t4 the singleitem measures were a current overall health status in general would you say your health is from 1 excellent to 5 poor which has been shown to be a good predictor of both morbidity and mortality and b have you had a serious illness or injury in the past year the scale comprised five items assessing the extent to which health status andor pain interfered with physical functioning within the last 4 weeks from 0 no not limited at all to 2 yes limited a lot covariates five variables were included as covariates because they have been linked with physical health status and substance use in previous studies age ses negative life events financial stress neighborhood risk covariates and exogenous constructs were allowed to correlate and the relations between all of the covariates and the endogenous constructs were estimated results descriptives overallmore than 90 of the sample reported experiencing some discrimination approximately 25 reported high amounts at each wave reports of alcohol problems were somewhat above the norm for women this age more so at t4 than at t1 the most common physical functioning problems were pain interfering with activities and limitation of activities due to health problems change over timeto examine change repeated measures anovas were conducted on the four outcome constructs that were assessed at t1 and then again at t4 overall health status declined whereas problematic drinking increased the other two items amount of alcohol typically consumed and serious injury illness in the past year did not change significantly overall effect of t2 discrimination evidence of the effects of discrimination can be seen in the odds ratios involving t2 discrimination and the t4 outcome measures for these analyses the outcome measures were dichotomized eg alcohol problems and functional disability present overall health status controlling for the five covariates the odds ratios werelifetime problematic alcohol use or 188 overall health status or 155 functional disability or 150 structural equation model the primary analysis involved semin the model paths were specified from t2 discrimination through the t3 mediators controlling for the t1 measures of each to the t4 outcome measures of health status and problematic use also controlling for their t1 measures measurement modela confirmatory factor analysis was first conducted to test the fit of the measurement model all constructs except for covariates were specified as latent variables with the indicators mentioned above the cfa provided a good fit to the data χ 2 50661 comparative fit index 94 tuckerlewis index 92 root mean square error of approximation 045 several zeroorder correlations for the covariates and exogenous variables are worth noting four covariates were correlated with health problems at t4 rs ranged from 15 for negative life events to 25 for financial stress all five covariates were correlated with t4 problematic alcohol use correlations among the latent constructs can be seen in table 1 consistent with previous research discrimination was related to both distress and hostility at t3 more important and consistent with expectations t3 hostility correlated more highly with drinking problems than with health problems whereas the reverse was true for t3 distress rs 34 with health problems vs 19 with drinking problems χ 2 1 958 p 002 predicting change in distress and hostilitythe structural model also fit the data well χ 2 50761 x 2 df ratio 222 cfi 95 tli 92 rmsea 042 lagrange multipliers were used to detect any unspecified paths that could improve the fit of the model there were none stability paths for both distress and hostility were strong in spite of the high stabilities t2 discrimination did have positive relations with change in both distress and hostility at t3 βs 20 and 27 respectively predicting change in health problems and substance usetogether the variables in the model explained 40 of the variance in t4 health problems and 59 of the variance in t4 problematic alcohol use these figures include the stabilities of the two outcomes which were also very high over the eight year period nonetheless discrimination predicted change in both constructs indirectly first for health status t1t3 distress predicted δ health problems and as expected discrimination had a positive indirect relation with δ health problems through δ distress β 04 regarding substance use t1 to t3 hostility had a direct positive relation with t4 problematic alcohol use controlling for t1 use β 20 the anticipated indirect effect in this case from t2 discrimination through δ hostility to t4 use was also significant β 03 summarychanges in distress were significantly associated with changes in physical health status but not changes in problematic alcohol use the opposite was true for changes in hostility 1 discrimination was associated with a increases in distress and hostility b a decline in physical health status and that relation was indirect through the increase in distress and c an increase in problematic alcohol use and that relation was also indirect through the relation between discrimination and hostility discussion discrimination and negative affect prospective relationsas in previous studies discriminatory experiences were associated with more distress and more hostility this was the case at t2 t3 and all other waves as well these prospective relations maintained controlling for a number of covariates or confounders each of which was also related to distress andor hostility together with experimental evidence showing the same basic pattern in controlled laboratory settings this suggests as many have claimed or assumed in the past that discriminatory experiences are responsible for increases in negative affect among blacks how that change in negative affect translates into health problems and health behaviors is a more interesting and more novel question also addressed by these data distress vs hostilitythe relation with discrimination was significant for both types of negative affect in previous studies with younger fachs participants that relation was much stronger with hostility than with either anxiety or depression 2 that was less the case with these black women discrimination did correlate more highly with hostility than with distress however the relation with distress was fairly strong this suggests that years of experience with discrimination may result in higher levels of depression whereas the latter was not 2 in previous experimental studies with young black adults selfreports of anger were higher than depression after envisioning a discriminatory experience and after being excluded by a group of white players in the cyberball computer game anger and hostility in black adults given its potential importance from both an etiological and intervention perspective identifying factors that predict type of affective reaction to discrimination among blacks and other minorities is worthy of future empirical attention in this respect these data support the contention of lerner et al that the relation between negative affect and health is both manifold and complex and so is best understood by examining different kinds of emotional reactions separately discrimination and health behavior vs health status externalizing and substance usethe relations between distress vs anger and change in problematic use adds to previous research showing that it is externalizing more than internalizing reactions to discrimination that link these aversive experiences with substance use problems the increase in hostility fully mediated the association between cumulative discrimination and change in problematic alcohol use this suggests that the change in problematic use was a reaction to the anger produced by the discriminatory experiences in fact many of the women who acknowledged substance problems also reported high amounts of both discrimination and hostility at t2 moreover previous research with the children of these fachs women provided evidence that their substance use is reflective of a coping process the discrimination → use relation was stronger for adolescents who endorsed the utility of substance use as a coping mechanism thus substance use may reflect an effort by these women to mute the anger that comes from chronic exposure to discrimination physical healthprevious analyses have suggested that the nature of the discrimination distress relation is as it was specified in the sem perceived discrimination → distress more than the inverse what the current results add to that research is the prospective health component reports of lifetime discrimination at t2 predicted change in distress which then predicted change in health status three years later controlling for negative life events financial stress and neighborhood risk as well as age and sesall of which predicted health problems by themselves this prospective relation provides further evidence of the important effect that discrimination can have on the physical as well as the mental health of black women future directions immunocompetence and cortisolseveral relations in these data appear to be worthy of further empirical attention because the discrimination measure assessed lifetime experiences the fact that it predicted change in health status is consistent with the belief that it is the cumulative effect of discriminatory experiences that has the greatest impact on health presumably this impact involves the immune systemexposure to discrimination over time and the reactions it produces can lead to reduced immunocompetence this relation will be monitored in future waves of fachs levels of cortisol secretion may also play a role in these relations internalizing after stressful events is associated with higher levels of cortisol and this tendency is exacerbated by rumination about the events elevated cortisol levels over an extended period of time increase the risk for a variety of health problems including weight gain diabetes and cardiovascular disease finally previous studies have also found associations between discrimination and diseases such as coronary heart disease that relation was not consistent in this data set however the prevalence of chd was low most likely due to the age and gender of the sample these relations among discrimination rumination and cortisol secretion are important and should be explored in future studies both lab and survey substance use and physical healthalthough their drinking was causing problems for some of these women there is no clear evidence that this problematic use was having an effect on their physical health in fact the two were negatively correlated at t4 albeit weakly most likely this will change over time for some of themprolonged heavy use often leads to health problems but at this age it does not appear that the substance use was associated with any health problems even for the women who experienced a lot of discrimination one reason for this may be that alcohol and drugs mute negative affect and they can also inhibit selffocused rumination both of which can lead to health problems the longterm relations among substance use and physical health will also be tracked in future waves of fachs limitations several limitations of the study need to be acknowledged first the sample included only black women mostly middleaged living in iowa or georgia black men or other minorities may respond differently than black women to discrimination in fact there is some evidence that men are more likely than women to respond to anger and hostility with substance use which suggests the discrimination use relation may be stronger for black men second all of the data came from selfreports selfreports of substance use have been shown to be valid and reliable and selfreported morbidity has been shown to be a better predictor of mortality than is physician diagnosis especially among african americans nevertheless future studies should include both genders as well as efforts to validate participants responses to the kinds of measures used in this research third the relation between distress and health status may be due partly to response style those who report more negative affect are more likely to see their current health status in a negative light the fact that both previous distress and health status were controlled mitigates this concern still it must be considered fourth the t3 hostility and t4 problematic drinking constructs each contained a lifetime measure because the control for each was assessed at t1 there is the possibility that some of the change detected in the t3 hostility construct actually occurred before discrimination was assessed andor that some of the change in t4 problematic drinking occurred before t3 hostility was assessed thus although the discrimination → anger → use relation has been shown in several previous studies there is some uncertainty with regard to the temporal ordering of those constructs in these analyses finally because the t1 and t4 outcome measures were not identical we cannot draw any conclusions about absolute changes in health status other than the fact that overall perceived health status declined significantly it is also worth noting that problematic drinking increased significantly this is not surprising given that it was a lifetime measure however the amount of increase is unusual during this period of life more important this increase in problematic drinking was strongly related to discrimination 3 conclusion perceived racial discrimination is associated with increases in internalizing and externalizing reactions among black women however these two reactions appear to have different health consequences increases in internalizing are associated with deterioration in physical health status including limits on functioning and increases in general morbidity increases in externalizing are related to more substance use problems together these relations affect overall mental and physical health and in so doing may contribute to the relative disparity in health status experienced by african americans in the us correlations among latent constructs

objectiveprospective data tested a differential mediation hypothesis the relations found in previous research between perceived racial discrimination and physical health status versus healthimpairing behavior problematic substance use are mediated by two different types of affective reactions internalizing and externalizing methodsthe sample included 680 african american women from the family and community health study m age 37 at time 1 45 at time 4 four waves of data were analyzed perceived discrimination was assessed along with anxiety and depression internalizing and hostility anger externalizing as mediators and physical health status and problematic substance use drinking as outcomes resultsstructural equation modeling indicated that discrimination predicted increases in both externalizing and internalizing reactions these affective responses in turn predicted subsequent problematic substance use and physical health status respectively also controlling for earlier reports in each case the indirect effects from discrimination through the affective mediator to the specific health outcome were significant and consistent with the differential mediation hypothesisexternalizing reactions among black women but these reactions are related to different health outcomes changes in internalizing are associated with selfreported changes in physical health status whereas changes in externalizing are associated with changes in substance use problems discussion focuses on the processes whereby discrimination affects health behavior and physical health status

introduction young peoples early sexual encounters are primary markers of the transition to adulthood because they occur at the time of marriage or because they bring with them opportunities for further emotional and relational development as well as the possibilities of marriage andor parenthood however it is widely recognized that early initiation of sexual activity predisposes adolescents to negative sexual and reproductive health outcomes such as unwanted pregnancies and sexually transmitted diseases indeed desire to understand the determinants of early sexual activity among young people the hivaids pandemic and the need for evidencebased interventions to delay coital activity have led to an extensive pool of literature on adolescent sexual behavior both in the developed and developing world abstinence one of the three facets of hiv prevention efforts relying on the abc approach has been a point of controversy indeed the efficacy and practicality of abstinence promotion efforts in the us have been called into question engaging in the debate surrounding the promotion of sexual abstinence among adolescents is not our aim as the issues are welldocumented rather we examine early sexual initiation in a context where hiv infection early pregnancies and associated impacts on schooling and other negative sexual and reproductive health outcomes remain constant threats to the wellbeing of young people in addition the youth upon which this paper is based are situated in a context where sexuality education continues to be highly contested with parents and school systems reluctant to introduce such education teachers inadequately prepared to deliver it a large number of children out of school and a political climate largely averse to the very notion of young people as sexual beings theoretical framework we examine predictors of first sexual activity among adolescents living in slum and nonslum settlements in nairobi kenya through the theoretical lens of the protectionrisk conceptual framework the conceptual framework describes the relations of protective factors and risk factors to involvement in problem behaviors such as drug use alcohol abuse delinquency and early sexual intercourse experience briefly the model posits that protective factors lower the probability of engaging in problem behaviors by providing models for conventional behavior controls against problem behaviors and an environment that supports conventional behavior protective factors may also mitigate the effect of exposure to risk factors risk factors on the other hand increase the probability of problem behaviors by providing models for and opportunities to engage in deviant behaviors as well as increasing personal vulnerability we acknowledge that sexual behavior in itself is not a problem behavior nonetheless the primary focus of the study is precocious sexual initiation which we view as potentially qualifying as a problem behavior it is problematic in the slum context because it largely occurs much earlier than among other population subgroups and in a context where hiv prevalence is almost three times the national prevalence the fact that younger adolescents are less likely to have adequate knowledge on how to protect themselves against unwanted pregnancy and stis or about how to handle interpersonal relationships that include sex is evident from the very high hiv prevalence rates among adolescents in africa in a region that accounts for almost 70 of all cases of hivaids in the world approximately half of all new infections occur among young people aged 15 to 24 further we would argue that the prevailing culturallysupported abstinence message for young people creates a general perception of sexual activity in this age group as deviation from acceptable behavior although the conceptual framework adopted in this paper was developed in the united states it has been successfully applied in several countries and within different cultures jessor and colleagues in a crossnational study employing this conceptual framework to examine adolescent involvement in problem behaviors observed that while chinese and american adolescents differed on descriptive and theoretical measures the models of association were similar in both countries in both samples the model accounted for 45 of the variation in problem behavior involvement addition of marijuana use and sexual activity to the problem behavior measure in the us sample increased the proportion of variance accounted for by the model to 51 a more recent study by vazsonyi and colleagues in georgia and switzerland also observed crossnational generality in the application of the model vazsonyi and colleagues tested the application of the model in explaining adolescent engagement in alcohol and drug use as well as other deviant behavior such as theft and vandalism although the authors considered sexual behavior as a problem behavior it was not included in the models because sexual behavior data were not collected in georgia for religious reasons while the application of theoretical frameworks developed in one context to a different setting has been questioned jessor in a recent editorial challenges scholarly overemphasis on the influence of cultural differences on theoretical explanations in his words sensitivity to cultural differences stems in part from our awareness of entire disciplines such as anthropology that have long taught us about the uniqueness of different cultures and societies and that have brought their sometimes exotic practices to our attention indeed jessor contends that while we may observe differences in theoretical constructs across cultures or nationalities the relations between these constructs should remain unchanged bearing in mind jessors argument and given the successful application of the model in various settings we apply it in this kenyan context but remain cognizant of the importance of local realities limitations of previous studies a review of the existing literature highlights several shortcomings of many of the studies that investigate adolescent sexuality first most studies in subsaharan africa utilize crosssectional data which simply examine relationships between sexual debut and other variables longitudinal data would help us move towards addressing causal linkages since we can control for timing of various events and covariates that precede sexual debut second data from the commonly used demographic and health surveys and other demographic surveys do not contain adequate information to allow examination of the effect of psychosocial protective and risk factors on sexual behavior third analyses using dhs data to address differences between slum and nonslum areas require use of a proxy measure of slums since dhs data do not distinguish slums from nonslums this paper uses data from the actual slum and nonslum geographic locations lastly many sexual and reproductive health studies focus primarily on females and cover only those aged 1519 and often do not include very young adolescents however recent evidence shows that significant numbers of very young adolescents in subsaharan africa are sexually active and yet they lack sufficient knowledge about sexual and reproductive health objectives the aims of this study are twofold first we seek to identify predictors of first sexual activity among adolescents in slum and nonslum neighborhoods in nairobi second we assess whether protective and risk factors at the individual and social levels have comparable levels of effectiveness for older versus younger adolescents as well as for adolescents living in slum settlements and those living in poor but nonslum neighborhoods highrisk urban neighborhoods may form a unique context which poses challenges for the sexual and reproductive health of young people nairobis slum settlements for example are characterized by poor sanitation and housing congestion a lack of basic infrastructure such as roads inadequate public services such as water education and health furthermore widespread unemployment violence and insecurity are the norm within these settings evidence from studies conducted in nairobis slums indicates that the median age at first intercourse is much lower in these slum settings and that slum dwellers fare much worse in terms of risky sexual behavior when compared to their wealthier urban counterparts or those living in rural areas indeed zulu and colleagues observed a 5 year difference in age at first sex between those who grew up in the slums and those who grew up in other parts of the city further even after controlling for religion age and schooling women who grew up in slums were significantly more likely to have initiated sexual intercourse at a younger age and to report multiple sexual partners it is plausible that programs designed for more advantaged neighborhoods may flounder when confronted with the vast neighborhood disadvantage that slums represent roche and colleagues found for instance that in socioeconomically disadvantaged us neighborhoods parental rules were associated with a lower likelihood of sex initiation however in more advantaged neighborhoods parental rules were positively associated with sex initiation there is a general need for information about factors that trigger or lead to first sexual activity in disadvantaged african settings knowledge of the effects of parental monitoring and peer models are an important initial step to developing recommendations for young people and parents in africas urban slum contexts this study draws on longitudinal data collected in 2005 and a year later under a larger study designed to explore various schoolingrelated issues including the association between school participation and risky behaviors the longitudinal nature of this study allows us to examine the relationship between transition to first sex during the twowave interval and antecedent sociodemographic and risk and protective factors measured during the first wave of data collection among a sample of adolescents aged 1219 years we hypothesize that adolescents who transition into first sex between the two waves will be older more likely to live in slum versus nonslum areas and to be out of school we also postulate that those who report fewer friends who engage in conventional behavior lower levels of parental monitoring and a greater proportion of friends who engage in unconventional or risky behavior will be more likely to make the transition methods study design participants and procedures the data used in this study are drawn from two waves of the education research program a longitudinal populationbased study in two slum and two nonslum settlements in nairobi kenya the study is nested in the nairobi urban health and demographic surveillance system which collects routine health and demographic data from over 60000 individuals living in more than 21000 households in two slum areas in the city the erp has been following children aged 519 years in these two slum communities as well as in two other nonslum communities since 2005 jericho is a low income area while harambee is a lower middle income area however most of the inhabitants in both communities are employed in the formal sector data are collected using five modular questionnaires that address specific issues 1 the household module identifies individual households to which children belong household members and household characteristics 2 the primary school module collects information on school characteristics 3 the parent or guardian module asks about parental involvement in school activities and in the childs life as well as parental perceptions of the kenyan free primary education initiative that was introduced in 2003 4 the child module assesses each childs schooling status and experiences informal training and apprenticeship as well as general behavior and lastly 5 the child schooling module collects information on each childs enrollment in school and schooling history each of the sections is regularly updated with the child schooling module being updated every term while the other modules are updated annually the behavior section of the child module is completed by respondents aged at least 12 years and the section must be completed with the child as the respondent this paper primarily uses data collected using the child module which includes measures of perceived levels of parental monitoring perceived peer behaviors and selfreported substance use and sexual behavior at the first wave 284 females and 303 males reported that they had ever had sex nine percent and 83 of females and males respectively who were virgins at wave 1 had transitioned into first sex by wave 2 the mean age of respondents at wave 1 was 150 years for males and 149 years for females over 70 of the respondents were living in one of the two slum settlements over 80 of males and females were enrolled in school during wave 1 measures outcome variableat both waves of data collection respondents were asked whether they had ever had sex three groups of adolescents are defined virgins those that reported in both waves that they had never had sexual intercourse transition those that experienced first sex between the two waves and nonvirgins those that reported that they had ever had sex at wave 1 demographic and psychosocial characteristics of all three groups are summarized in table 1 the primary outcome variable for the analyses is whether a respondent transitioned into first sex between waves 1 and 2 explanatory variables social context protective factorsthe measures of social context protective factors are parental monitoring and peer models for conventional or prosocial behavior perceived parental monitoring is measured using 9 items that assess the respondents perception of how much their parents or guardians know about the following where the child spends time on weekday evenings with whom the child spends weekday evenings where the child spends time on weekend evenings with whom the child spends weekend evenings what the child does during hisher free time how the child spends hisher money what tv programs videos or films the child watches what books novels or magazines the child reads and the childs best friend possible responses are never know sometimes know usually know or not applicable not applicable responses were treated as missing values about 1 of adolescents had missing values on three or more items scores on the scale were summed up to give an index score ranging from 0 to 18 with higher values reflecting greater perceived parental monitoring cronbachs alpha was used to assess internal consistency of scores a measure of the extent to which related items on a scale are correlated and assesses whether these items produce similar scores cronbachs alpha values range from 0 to 1 with increasing values indicating greater consistency of item scores the cronbachs alpha for scores on the parental monitoring scale was 088 peer models for conventional or prosocial behavior was measured using four items the proportion of friends who get good marks in school participate in sports or other school activities attend churchmosque and want to go to secondary school university or college possible responses are none of them some of them most of them dont know or not applicable dont know and not applicable responses were treated as missing values social context risk factorsa composite measure of peer models for unconventional behavior was used to assess risk factors at the perceived social context level this measure of models risk was based on a 5item measure of perceived peer involvement in unconventional behavior that is how many friends drink alcohol run away from home have gotten into trouble with police have had sex and use drugs like marijuana khat or glue possible responses are none of them some of them or most of them individual level risk factorsrisk factors at the individual level included general deviance nonpenetrative sexual contact and substance use general deviance was measured through 7 items that assess the number of times the respondent had engaged in the following activities in the 4 months preceding the survey stayed away from home without parental permission started a fight stolen or tried to steal something carried a weapon for protection hit or threatened to hit an adult delivered or sold drugs and delivered or sold alcohol possible responses are never once 2 or 3 times 4 or 5 times 6 or more times or refused refusals were treated as missing values less than two percent of adolescents refused to respond to these questions and were treated as missing values scores on the scale are summed up to give an index score ranging from 0 to 28 nonpenetrative sexual contact and substance use were measured as dichotomous variables sociodemographic characteristicswe also examined the association between transition into first sex between wave 1 and wave 2 and several sociodemographic characteristics age at wave 1 schooling status at wave 1 slum versus nonslum residence and number of adolescents in the household separate analyses for slum and nonslum residence did not show any significant differences between study sites thus the models shown here do not include study site as a predictor variable information on ethnicity was lacking for nonslum residents who are not part of the nuhdss preliminary analysis using data from respondents in the slum areas showed that ethnicity was not significantly associated with transition into first sex thus we do not control for ethnicity in the models reported here statistical analysesdata were analyzed using stata version 92 univariate statistics were computed to describe the respondents psychosocial behavioral and sociodemographic characteristics as well as sexual experience two thousand three hundred and twenty four adolescents completed the behavior section of the education child module in both waves one hundred ninety respondents retracted their initial report of ever having had sex and were excluded from analyses the final sample size is therefore limited to the 2134 adolescents with consistent sexual behavior data in both waves of these respondents 1358 were categorized as virgins 189 made the transition to first sex while 587 were nonvirgins at wave 1 two hundred seventy nine respondents who reported first sex at wave 2 but gave an age at sexual debut that was younger than age at wave 1 were recoded as nonvirgins logistic regression models were employed to identify correlates of transition to first sex among the subset of adolescents who reported that they had never had sexual intercourse at the time the baseline survey was conducted baseline measures were used to predict transition into first sex at the multivariate level data were analyzed separately for males and females we run three sets of logistic models separate models for younger versus older adolescents separate models for slum versus nonslum residence and models including interactions terms for age group and slum residence ensuing findings should be interpreted in light of several limitations first the duration between the two waves of data collection is about a year and since the actual month of first intercourse is unknown it is not possible to investigate the effect of these predictors on the actual timing of first sexual intercourse within that interval second there are only two waves of data having information on the actual timing of first intercourse over multiple waves of data collection would enable us to better understand and explain the process of making the transition to first sex lastly the available data has relatively few measures of risk and protective factors that could influence initiation of sexual activity results descriptive analyses among females who made the transition to first sex the median age at first intercourse was 18 years for those living in nonslum areas and 15 years for those living in slum areas on the other hand among males the median age at first intercourse was 17 years for those living in nonslum areas and 15 years for their counterparts residing in the slums table 1 summarizes the demographic psychosocial and behavioral characteristics of the adolescents at wave 1 according to their sexual behavior status nonvirgins were significantly older than both the virgins and those who transitioned into first sex adolescents who transitioned into first sex between the two waves were on average older than those who remained virgins the three groups did not differ on the proportion living in slum versus nonslum areas nonvirgins at wave 1 were more likely to be out of school among females a significantly lower proportion of those making the transition to first sex were enrolled in school at wave 1 compared to virgins virgin and transition females did not differ in terms of peer models for conventional behavior and reported levels of parental monitoring however nonvirgin females reported significantly lower levels of peer models for conventional behavior and perceived parental monitoring than either group males who transitioned into first sex reported lower levels of peer models for conventional behavior and lower levels of parental monitoring than their virgin counterparts females who transitioned into first sexual activity reported more peer models for unconventional or risk behavior than their virgin counterparts while males who made the transition to first sex reported more peer models for unconventional behavior than their virgin counterparts the difference in means was only marginally significant virgins and those who transitioned into first sex did not differ on deviant behavior however nonvirgin respondents were significantly more likely than either group to report other delinquent behavior slum and nonslum dwellers differed on several protective and risk factors both males and females living in nonslum areas reported significantly more peer models for conventional behavior than their peers in the slums females in the slums reported higher levels of parental monitoring but lower levels of peer models for unconventional behavior than their nonslum peers a greater proportion of females living outside the slums reported nonpenetrative sexual contact and substance use than their counterparts in the slums both males and females living outside of slums reported lower levels of delinquent behavior than slum residents multivariate analysis results from the logistic models are presented in tables 345 table 3 shows the results of the models by age group and sex the results of the models by area of residence and sex are presented in table 4 and models including interactions terms for age group and slum residence are showed in table 5 six categorical variables and four continuous variables were used in the models for the categorical variables the odds ratio represents the chances of making transition to first sex for the specified category in comparison with the reference category for the continuous variables the odds ratio indicates the odds of transitioning into first sex for each unit increase in the corresponding variable odds ratios greater than 1 indicate a greater likelihood of making the transition to first sex while odds ratios lower than 1 indicate lower chances of making the transition to first sex twotailed pvalues are presented in the tables for females aged 1215 years only perceived parental monitoring and delinquent behavior had a significant effect on the chances of becoming sexually active among girls in this age group for each additional unit increase of parental monitoring and delinquent behavior the chances of transitioning to first sex increases by 10 and 40 respectively for girls aged 1619 only peer models for unconventional behavior was found to significantly influence the chances of having first sex specifically for each additional unit increase in the index assessing peer models for unconventional behavior the chances of becoming sexually active increases by 80 for 1215 year old males only residence was significantly associated with transition to first sex slum residents were 10 times more likely to become sexually active than their counterparts living in nonslum areas similarly for males aged 1619 only residence had a significant effect on the odds of losing virginity with those living in nonslums being 33 times more likely than their counterparts in slum areas to have transited to first sex in the second set of logistic models for separate analyses by area of residence age group is significantly associated with transition to first sex among males and females living in nonslum areas and females in slum areas as expected older adolescents were significantly more likely to have made the transition to first sex among females living in nonslum areas parental monitoring and peer models for unconventional behavior also predicted transition into first sex among their male counterparts no other variables besides age group were significantly associated with transition to first sex for females and males living in slums peer models for conventional behavior and delinquent behavior were associated with transition to first sex for both females and males there was a significant interaction between age group and slum residence among females young girls living in nonslum areas were significantly less likely to make the transition to first sex than females aged 1619 years living in slums wald tests to examine differences between coefficients for the interaction terms showed that 1215 year old females living in nonslum areas were also less likely to make the transition to first sex than 1619 year olds living in nonslum areas among males 1215 year olds living in nonslum areas were significantly less likely to make the transition to sexual activity than males aged 1619 years living in slums however compared to males aged 1619 years living in slums males in the same age group living in nonslum areas were significantly more likely to make the transition to first sex there was no statistically significant difference between younger and older males living in slums wald tests to examine differences between coefficients for the interaction terms showed that 1215 year old males living in nonslum areas were less likely to make the transition to first sex than 1215 year olds living in slum areas and 1619 year olds living in nonslum areas in summary age and slum residence were found to significantly predict transition to first sex in general older age and slum residence were associated with greater odds of making the transition to first sex among females living outside slums school attendance was associated with lower odds of making the transition to first sex than being out of school a high level of parental monitoring was associated with greater odds of making the transition among females living in nonslum areas and among younger females having peer models for conventional behavior was negatively associated with the likelihood of transitioning to first sex for males and females living in slum areas on the other hand peer models for unconventional behavior were a risk factor for girls aged 1619 and females living in nonslum areas discussion this paper uses longitudinal data to examine predictors of transition to first sex among adolescents aged 1219 years in slum and nonslum areas of nairobi kenya it focuses on the association between transition to first sex and sociodemographic characteristics as well as risk and protective factors measured during the first wave of data collection the study provides a unique perspective of transitions to first sex by comparing the experiences of adolescents living in both slum and nonslum areas unlike previous studies on sexual behavior in slum settings this paper examines the association between transition into first sex and psychosocial variables such as perceived levels of parental monitoring peer models for conventional or prosocial behaviors and peer models for unconventional or antisocial behaviors consistent with previous research showing that slum dwellers fare much worse in terms of risky sexual behavior than their peers living outside slums we observe that adolescents living in the slum areas initiate sexual activity about three years earlier than their nonslum counterparts between the two waves of data collection younger adolescents aged 1215 years living in slum areas were significantly more likely than their nonslum counterparts to make the transition into first sex yet slum dwellers do not necessarily fare worse in terms of the presence or absence of protective and risk factors as defined herein understanding attributes of the social context of urban slums that facilitate precocious sexual initiation may be essential for effective programs aimed at mitigating early sexual initiation in slum communities dodoo and colleagues for instance have noted that cramped living conditions in urban slums limit privacy as parents are often forced to share sleeping space with children thus exposing children to sexual activity early on in life further exposure to parental sexual activity may weaken adult control over their childrens sexual behavior space constraints may also force young people to move out of parental homes to their own dwellings prematurely providing them with opportunities to engage in risk behavior away from parental watch interestingly we observe that for males aged 1619 years those living in slums were less likely to make the transition to first sex than their counterparts living in nonslum areas how do the circumstances differ for this group this study found that the median age at first sex was 15 among males living in slum areas compared to 17 years among their counterparts living in nonslum areas we posit that males living in slums who despite all odds remain virgins beyond the typical age of first intercourse in the slums may be more likely to be resilient to pressures to engage in sexual intercourse indeed for adolescent males living in slum communities peer models for conventional behavior significantly reduce their likelihood on making the transition to first sex among girls living outside slum areas being in school was associated with a lower likelihood of making the transition to first sex compared to being outof school previous studies among 1219 year old kenyan adolescents 1422 year old south african youth and among 1524 year old ivorian youth have also found school enrolment to be associated with a lower likelihood of sexual activity as in other studies the impact of schooling on sexual behavior appears stronger for girls than for boys we are unable to ascertain whether sexual and reproductive health education is provided in the schools represented in our sample knowledge of whether a school has sex education would have provided insight into whether being in a school that offers sex education delays initiation of sexual activity as noted by kaufman and colleagues the impact of education on sexual behavior may differ significantly for boys and girls the stronger effect of schooling on sexual behavior among girls in nonslum areas compared to boys may also reflect the possibility of greater dropout among girls due to pregnancy meaning that sexually experienced girls are underrepresented in school samples however mensch and colleagues argue that pregnancy is unlikely to be the primary reason for disruption of schooling for young girls because the same factors that lead to dropouts also lead to early childbearing given the potential success of schools in protecting girls there is clearly a need for more schoolbased research and gender analysis in order to understand the dynamics therein and to determine how the possible benefits derived by girls from the school setting can be extended to boys as well having peer models for conventional behaviors such as friends who perform well in school who desire to advance their education and who participate in prosocial activities such as sports or religious activities was associated with a lower likelihood of transitioning into first sex for males and females living in slums in addition for females aged 1619 and females living in nonslum areas increasing numbers of friends engaging in delinquent behaviors was associated with increased chances of making the transition to first sex by wave 2 as boys and girls make the transition from childhood to adolescence identification with peer groups becomes critical peers therefore serve as important models of appropriate behavior and also influence the extent to which young people engage in risk activities including risky sexual behavior our findings are consistent with previous studies showing peers behaviors and attitudes to be associated with adolescent sexual behavior however we are cautious to assert that peers necessarily influence adolescent sexual behavior and acknowledge that adolescents may choose friends who share similar qualities and values as themselves high parental monitoring at wave 1 was associated with greater odds of transitioning into first sex by wave 2 for females aged 1215 years and females living in nonslum areas this is contrary to expectations that high parental monitoring would deter young people from engaging in risk behaviors such as precocious sexual activity however it is consistent with some of the literature high parental monitoring could derive from parents perception that a child is more likely to engage in risk behavior furthermore high parental monitoring may be perceived by young women as unwarranted or overzealous strictness which could in turn lead to actions that symbolize their own autonomy rodgers for example in a study among school going adolescents in the united states found that sexually active females who perceived their parents as being psychologically controlling were more likely to engage in high risk sexual behavior than those who perceived their parents as being less controlling given that first sexual intercourse is not always desired and rates of coerced sexual activity are reportedly higher in urban slums due to widespread violence and insecurity in these settings the results of this analysis are insightful a populationbased survey conducted in kibera slum in nairobi for instance found that 43 of girls and 15 of boys aged 1019 years reported that they were coerced into their first sex within this context understanding factors that may predispose young boys and girls to early sexual activity is important for efforts to reduce high std and hiv prevalence among adolescents in subsaharan africa our findings underscore the importance of considering the social and environmental contexts when examining pathways to first sexual intercourse among adolescents we argue that there is need to focus on very young adolescents particularly those growing up in resource poor settings or those who are out of school as these young people may be more likely to make the transition to first sex and hence be more vulnerable to negative health outcomes stemming from precocious sexual activity the paper also highlights the need to strengthen parents capacity to adapt their parenting strategies to the needs of their changing evolving adolescents

while early sexual experiences are a key marker of the transition from childhood to adulthood it is widely acknowledged that precocious initiation of sexual activity predisposes adolescents to negative health and psychological outcomes extant studies investigating adolescent sexuality in subsaharan africa often rely on crosssectional data lacking information on the socialpsychological underpinnings of adolescent behavior through the theoretical lens of the protectionrisk conceptual framework this paper draws on two waves of longitudinal data collected from 2134 adolescents to examine sociodemographic psychosocial and behavioral predictors of transition to first sex among adolescents living in slum and nonslum settlements in urban kenya we employ logistic regression models to examine the effect of antecedent sociodemographic and risk and protective factors measured during the first wave of data collection on transition to first sex by the second wave we observe that transition to first sex is influenced by age slum residence perceived parental monitoring and peer behavior we also find evidence for coupling of risk behaviors study findings underscore the need to focus on very young adolescents and those growing up in resource poor settings as these young people may be highly vulnerable to negative health outcomes stemming from precocious sexual activity

narrow focus on drugs and tests chief among these is the push for development of novel antimicrobials for example the latest report from the independent review on antimicrobial resistance chaired by jim oneill emphasised the need for delinking drugs profitability from sales volumes 4 5 this builds on other recent work such as that by the think tank on international affairs chatham house which has outlined alternative business models to similarly change the current financial models for encouraging and supporting research and development in new antibiotics 6 meanwhile in practice in the united states there has been an extension to marketing exclusivity accelerated review and a relaxation of requirements for approval by the food and drug administration 7 although this leniency may have increased the development and launch of new antibiotics there is worrying evidence that such fast tracking may generate considerable adverse effects 8 critical of course is the basic fact that because resistance to an antimicrobial begins as soon as it is developed new agents can never be the sole solutionand certainly not necessarily the most cost effective or sustainable mechanisms to promote the sustainable use of antimicrobials are also needed but work has increasingly focused on rapid diagnostic tests to support the more appropriate use of antimicrobials this was a key topic in the previous report from oneills review 9 research councils uk is also supporting diagnostics development 10 and the influential longitude prize is to be awarded to whoever first develops a specific rapid diagnostic tool but even if such tests are developed they can only ever be a partial solution and their value will be negated by systemic factors such as outofpocket payments increasing the risk of a course of antimicrobials not being completed and relative costs making it more likely that antimicrobials would be used without the test as antimicrobials are often very cheap these and other factors all point to sustainable antimicrobial use requiring considerable behavioural cultural political and economic change rather than just use of a diagnostic test to identify whether an infection is viral or bacterial or whether it is a sensitive or resistant infection new vision needed this is not to suggest that social aspects are being ignored however trends in activity in the balance of funding between basic and social science and in political and popular opinion indicate that the vision for tackling antimicrobial resistance is provenance and peer review not commissioned not externally peer reviewed thebmjcom feature speeding new antibiotics to marketa fake fix

antimicrobial resistance has reasserted itself on the national and international agenda as a critical threat to public health and health systems it undermines the very foundations of modern healthcare from joint replacements to chemotherapy threatens to reverse the decline in mortality and morbidity from infectious diseases jeopardises animal health and welfare and poses potentially crippling financial effects 1 2 it is intrinsically a biological phenomenon which has perhaps naturally led to much of the discussion on tackling it being driven from a biological and broader scientific perspective however the conditions promoting or militating against the biological mechanisms of antimicrobial resistance are deeply social shaped by cultural political and economic processes such social aspects include • the ways farmers vets and regulatory systems manage livestock production for human consumption • how regulatory and fiscal frameworks incentivise or deter antimicrobial development production and use • how the public and healthcare professionals understand value and use antimicrobials • the context in which animals and humans interact and • the ways in which particular groups of people are exposed to particular microbial infections 3 actions to reduce and control antimicrobial resistance will therefore involve change in social practices but at present the discourse and critically the investment of time money and intellectual capital are heavily biased towards technological solutions

the benefits of positive solitude in late life chair yuval palgi cochair ehud bodner discussant dikla segelkarpas positive solitude is the capacity to choose spending time by yourself in a positive manner this session provides a wide glance on the advantage of this capacity at the second half of life the session will try to present new theoretical perspectives regarding this capacity the lectures will give an opportunity to follow the directions in which research in this new field is being developed the first lecture by palgi will describe the theoretical background for the study of positive solitude and will provide new findings from the positive solitude scale that was lately develop by the authors the second presentation by bodner will describe how emotional regulation through music moderates the relationship between mindfulness and positive solitude the third lecture by zambrano garza is contributing to the understanding of solitude in the interpersonal domain based on dyadic diary study demonstrates that more voluntary solitude was associated with more positive affect of the partner and more negative solitude was related to more negative affect of partner the forth lecture by segelkarpas will focus on the contribution of positive solitude and loneliness on negative aspects of mental health finally the fifth presentation by jennifer lay will show use natural language processing to identify solitude experiences from older adults reports we will conclude the session by discussing future research directives for the implementation of positive solitude in the field of gerontology such as the development of interventions that may enhance the tendency for positive solitude in old age

virtual reality vr has become increasingly accessible for older adults providing opportunities for interventions that address loneliness and social isolation in longterm care however the effectiveness of vr programs can be influenced by various factors such as the backgrounds preferences and capacities of the target population this qualitative study investigates the acceptability and feasibility of a recreational vr program for social engagement in two canadian longterm care homes since january 2023 the study involved 20 residents with various levels of cognitive and physical impairments who participated in weekly vr group sessions facilitated by staff ethnographic observation and videorecorded conversational interviews were conducted with residents during the vr sessions we also conducted 10 focus groups with 20 staff members four patient partners were involved as coresearchers in the team we performed the thematic analysis with patient partners we identified three themes 1 storytelling builds residents sense of self 2 positive emotions persist even when the video is forgotten and 3 vr empowers residentresident and staffresident connections the findings demonstrate that using vr in longterm care settings is feasible and acceptable for older adults with different cognitive and physical impairments vr programs have the potential to enhance social engagement and support residents personhood as a meaningful activity by improving inclusion social engagement comfort and recognition of their identity future research could explore the longterm impact of vr experiences in addressing social isolation and loneliness among older adults in longterm care

introduction prolonged or complicated bereavement has long been a controversial category in the field of psychiatry a turning point in the recognition of the category has been the inclusion of persisting complicated bereavement disorder as a provisional category in dsm5 and the adoption of prolonged grief disorder in the forthcoming icd11 these developments make it timely to examine the relationship of complicated bereavement and posttraumatic stress disorder disorders that are both triggered by traumatic losses we investigate the pattern of overlap of the two constellations by applying latent class analysis to data from a sample of west papuan refugees displaced by mass conflict and persecution to neighboring papua new guinea events such as atrocities extrajudicial executions and other forms of politically motivated killings commonly expose refugees to traumatic loss and personal threat experiences that are known to trigger both ptsd and complicated bereavement further amongst refugees from collectivist cultures disruptions to family and kinship groups eviction from ancestral lands and displacement to foreign and deprived environments may accentuate symptoms of identity confusion and alienation that are intrinsic to both ptsd and complicated bereavement we anticipated therefore that amongst west papuan refugees identity confusion would be prominent amongst symptoms of a combined pattern of complicated bereavement and ptsd the adapt model offers a framework for examining the mental health impact of conditions of insecurity disrupted interpersonal bonds and undermining of the sense of identity amongst refugees the model identifies five support systems eroded by mass conflict and displacement including safety and security interpersonal bonds and networks justice roles and identities and existential meaning two of these systems are recognized as central to mental health in the national institute of mental health research domain criteria framework consistent with the rdoc the adapt model attempts to bridge the divide between a descriptive or nomothetic approach to identifying mental health problems and an idiographic framework in which personal development and collective experiences shape and give meaning to subsequent psychological reaction patterns the adapt model therefore provides a framework for a transdiagnostic approach in which overlapping symptoms of ptsd and complicated bereavement may represent a meaningful response to concurrent exposure to complex ecological and social experiences such as mortal threat traumatic loss and disruptions to identities and roles although several studies have investigated the relationship between ptsd and complicated bereavement in highincome countries there is a dearth of parallel research into the topic conducted amongst refugee populations although complicated bereavement was largely distinguishable from ptsd in a study amongst bosnian refugees the two constellations overlapped in relation to the domain of intrusive memories in a sample of mandaean refugees in australia lca identified a comorbid complicated bereavement and ptsd class in addition to pure complicated bereavement and ptsd classes respectively although suggestive of the importance of a combined complicated bereavement and ptsd class amongst refugees the data did not clarify the psychosocial factors that may be specific to that pattern the long history of persecution that west papuan refugees have experienced has exposed many members of the community to traumatic loss mortal threat disruptions to identities and a sense of belonging since the invasion and annexation of the territory by indonesia over 50 years ago the occupying military has committed widespread atrocities including torture disappearances extrajudicial imprisonment and mass displacement of communities in an attempt to suppress the lowgrade armed resistance war waged by indigenous groups seeking national independence for the territory successive waves of west papuan refugees have crossed the border into neighboring png the largest concentration resettling in kiunga a remote town near the border with the homeland the community in kiunga lives in constant fear of incursions by hostile elements from across the nearby border in addition they face multiple deprivations relating to geographical isolation harsh living conditions including food and water shortages arising from floods and drought and lack of employment opportunities and services the absence of mental health services in the region means that west papuan refugees have not been exposed to international concepts of trauma ptsd or complicated bereavement the aims of our study were to identify a subpopulation of refugees with a combined constellation of complicated bereavement and ptsd and to assess whether that pattern is associated with a specific profile of past and ongoing adversities using lca we tested the following hypotheses in this crosscultural setting it would be possible to identify subpopulations with relatively independent clusters of ptsd and complicated bereavement respectively thereby supporting contemporary international classification systems in addition there would be a class manifesting combined symptoms of complicated bereavement and ptsd the latter class would be characterized by prominent symptoms of identity confusion and alienation and a distinctive pattern of traumatic events postmigration living difficulties and background psychosocial disruptions would characterize the complicated bereavementptsd class method full details of the methodology are provided in online supplementary material 1 sample between march and september 2016 a full household survey was undertaken of all adult west papuans living in the nine villages where the community is concentrated in kiunga we included persons originating from west papua or born to at least one west papuan parent the analytic sample comprised all those with whom we made contact noting that 183 of the community were traveling in other parts of png during the entire course of the study ethics ethical permission for the study was provided by the university of new south wales human research ethics committee and the medical research council of png ethics committee measures the refugee mental health assessment package is a comprehensive tool assessing psychosocial factors and common mental disorders amongst refugees details of the qualitative and psychometric steps taken to develop adapt and test the mental health measure in a study amongst west papuan refugees have been provided previously symptoms of complicated bereavement and ptsd details of the qualitative methods used to adapt the symptom measures to the culture are provided in online supplementary material 1 these steps included the development and testing of modules to assess complicated bereavement and ptsd symptoms using items consistent with both dsm5 and icd11 criteria trauma and stressors based on our qualitative inquiries we identified five items representing traumatic loss each scored 1 if present we adapted the humanitarian emergency settings perceived needs scale procedure interviews were conducted by a field team in bahasa indonesian english and tok pisin the field interviewers were drawn from the west papuan community and the team was managed by a west papuan refugee the team received 3 weeks intensive training from a clinical psychologist followed by 3 months of piloting the interview in the field statistical analysis we applied lca to data from the whole sample to identify subpopulations of west papuans manifesting differential patterns of complicated bereavement and ptsd we applied the bayesian information criterion sample sizeadjusted bayesian information criterion and the akaikes information criterion to assess the fit of serial models in addition we applied the vuonglomendellrubin and the lomendellrubin adjusted likelihood ratio tests to compare successive models we applied the principle of parsimony the degree of class separation homogeneity of posterior probabilities within classes and the interpretability of the classes to assist in deciding on the final model we ranked conditional probabilities according to recommended criteria as high moderate or low we applied multinomial logistic regression to compare the classes with the traumatic event and pmld counts and the asi dimensions collinearity required that we tested the three predictors in separate regression models analyses were performed in stata version 13 and mplus version 7 results sociodemographic characteristics the sample included 486 adults the mean age being 358 years half the sample had completed primary school education and 95 held postschool degrees or certificates over half originated from west papua the remainder being offspring of west papuan parents the west papuan born had lived in kiunga for a mean of 156 years the majority of the sample had indeterminate status as displaced persons 146 were png citizens and 28 held permissive residency status which conferred the right to remain in png with some restrictions a quarter reported one or more loss in the past 12 months and a third experienced a traumatic event thereby meeting dsm5 entry criteria for either pcbd or ptsd or both tables 1 and2 detail exposure to loss and traumatic events as well as pmlds the mean score for exposure to pmlds was 182 latent class analysis lca supported a fourclass solution specifically model fit indicators improved up to and including the fourclass model but only marginal gains were achieved by increasing the number of classes beyond that point the decision to adopt the fourclass solution was supported further by the vlmr and the lmr adjusted likelihood ratio tests which showed no statistical changes when progressing from a four to five class model given these findings and the interpretability of the classes we adopted the fourclass model the four classes comprised a complicated bereavement class a posttraumatic bereavement class including items of complicated bereavement and ptsd a ptsd class and a lowsymptom class table 4 shows the posterior probabilities for symptoms of complicated bereavement and ptsd in relation to each class in the complicated bereavement class eight complicated bereavement symptoms exhibited high endorsements by over half of the sample and the remaining 10 items received moderate endorsement items in the high probability range included core bereavement characteristics of yearning preoccupations with the deceased and intense feelings of sorrow and emotional pain in contrast all symptoms of ptsd in this class fell into the lower level of moderate or low probability range in the combined posttraumatic bereavement class comprising 10 of the sample respondents rated most items of complicated bereavement and ptsd in the high probability range specifically for complicated bereavement probabilities for 15 out of 18 symptoms exceeded 060 and the remaining three fell between 059 and 015 and for ptsd 16 of 20 symptoms exceeded probabilities of 060 and the remaining four fell between 059 and 015 for complicated bereavement high probability items included core features of preoccupations and persistent yearnings but also extended to maladaptive appraisals bitternessanger interpersonal problems and emotional numbness the high probability items for ptsd in this class included flashbacks intrusive thoughts internal and external avoidance and anhedonia symptoms falling into the moderate range included for complicated bereavement feelings of confusion emptiness and a diminished sense of identity and for ptsd concentration difficulties insomnia startle response and hypervigilance in the ptsd class seven items fell into the high range including intrusive memories psychological reactivity avoidance anhedonia detachment irritability and posttraumatic amnesia and the majority fell into the moderate probability range of 059 and 015 in this class virtually all complicated bereavement symptoms fell into the low probability range in the low symptom class comprising two thirds of the sample most symptoms of both complicated bereavement and ptsd yielded low probabilities multinomial logistic regressions table 5 presents the findings of the three multinomial logistic regression models the fourclass lca structure represented the no statistically significant effects were evident for sociodemographic factors in any of the three regression analyses the only significant predictor for the complicated bereavement class was the asi domain of disrupted interpersonal bonds and networks in contrast the combined posttraumatic bereavement class was associated with higher exposure to traumatic loss events pmlds and greater disruptions in the asi domains of interpersonal bonds and networks and roles and identities the ptsd class reported higher exposure to traumatic loss events and was unique in its association with the asi pillar of safety and security in common with the posttraumatic bereavement class the ptsd class reported greater disruptions in the asi domain of roles and identity discussion lca yielded a fourclass solution comprising three morbid classes and a low symptom class the latter accounting for over twothirds of the sample the three morbid classes each representing roughly onetenth of the sample comprised a complicated bereavement class a combined posttraumatic bereavement class and a ptsd class notably the posttraumatic bereavement class was characterized by a distinctive combination of symptoms related to identity confusion and alienation members of the posttraumatic bereavement class reported high levels of adversity reflected in traumatic losses postmigration living difficulties and disruptions to two of the adapt psychosocial support domains of interpersonal bonds and networks and identity and roles in support of conventional international classification systems separate classes emerged for complicated bereavement and ptsd respectively in keeping with theory the asi domain of disruptions to bonds and networks was associated with the complicated bereavement class whereas erosion of safety and security was related uniquely to the ptsd class the ptsd class also reported disruptions in roles and identities and exposure to high levels of traumatic loss prior to discussing our findings we consider the strengths and limitations of the study we applied a rigorous sampling approach identifying west papuans according to the triangulation of census data and a wholeofhousehold survey we achieved a high response rate even when absentees from the catchment were accounted for although kiunga is the largest settlement of west papuans in png restriction of sampling to one location limits the generalizability of our findings the study is crosssectional cautioning against drawing causal inferences from the analyses undertaken memory biases could result in either overor underreporting of past traumatic events in addition exposure to trauma may increase the tendency to report mental health symptoms there is also a risk of transcultural error in measurement when undertaking studies of this type to limit the risk we followed a systematic mixed methods approach to develop and adapt our measures to the culture and context our qualitative inquiries suggested that the key mental health constructs of ptsd and complicated bereavement were well recognized by west papuan refugees even though the population lacked familiarity with international terminology for classifying these reactions specifically west papuans recognized all the icd and dsm symptoms of complicated bereavement applying a specific term in bahasa indonesian to describe the syndrome in their culture to avoid excessive complexity we did not include other diagnostic categories such as depression which could be salient in generating symptoms of identity confusion and alienation because of restrictions in the sizes of the respective latent classes we could only compare each morbid class with the nolow symptom class in our logistic regression analyses in addition in applying multinomial regression analysis collinearity amongst our three predictors required that we assess the impact of traumatic loss events pmlds and the asi domains separately caveats notwithstanding our findings offer support for our key hypotheses conventional classes of complicated bereavement and ptsd emerged from the lca the asi domain of disrupted bonds and attachments was associated with the complicated bereavement class as would be anticipated notably the ptsd class reported high levels of exposure to traumatic losses consistent with the criteria of international classification systems in addition the ptsd class reported greater erosion of the identity and role domain of the adapt model supporting the importance of identity disturbance as an integral component of the ptsd reaction the key finding was that 10 of the sample exhibited the combined posttraumatic bereavement pattern importantly the characteristics that were accentuated in this class extended beyond core ptsd and complicated bereavement symptoms to those that fall broadly under the domain of identity confusion and alienation including maladaptive appraisals bitternessanger interpersonal problems emotional numbness feelings of confusion and emptiness and a diminished sense of identity it is notable that most of these symptoms were identified spontaneously by west papuans participating in the preliminary focus groups there are compelling reasons why west papuans would highlight symptoms of identity confusion and alienation the society psychological medicine is grounded in an agrarian collectivist culture in which personal identity is strongly bound up with ties to the family kinship group and traditional lands the longstanding campaign of repression pursued by the occupying military has led to major disruptions to this traditional way of life mass immigration into west papua from other parts of indonesia has added to the sense of threat to the national identity of the indigenous people in addition the group participating in our study comprised a population displaced to a remote town across the border where they experienced ongoing deprivations fear and a sense of marginalization overall the history of persecution appeared to be mirrored by the pattern of symptoms of grief fear and alienation represented by the symptoms of the posttraumatic bereavement class it also is notable that there is a correspondence between the identified symptoms of identity confusion and alienation within the posttraumatic bereavement class and elements of complex traumatic stress disorder described amongst survivors of human rights violations and abuses in the western literature our findings build to efforts to bridge the gap between idiographic and nomothetic models of understanding of traumatic stress by demonstrating the connection between ecological factors in this instance politically motivated psychosocial disruptions trauma and ongoing stressors and a distinctive pattern of combined ptsd and complicated bereavement observed at the individual level this approach helps to counter the tendency to regard mental health symptoms as solely serving the function of signifying the presence of predefined categories of mental disorder our findings have important clinical implications although there is some evidence in support of the efficacy of cognitive behavioral interventions in treating complicated bereavement in nonrefugee populations no culturally adapted interventions of this type have been systematically trialled amongst refugees given that 20 of participants had heightened symptoms of complicated grief there is a pressing need to develop and test appropriate therapies for this reaction pattern amongst refugees in addition our findings challenge the prevailing tendency to focus on single diagnoses in the refugee field by demonstrating the relevance of comorbid presentations which may require more comprehensive psychological interventions specifically in addition to the focus on issues of safety and traumatic loss refugees with the posttraumatic bereavement pattern may require special attention to issues of identity confusion and alienation failure to focus on the latter issue may account in part for low levels of success reported in some studies treating socially isolated and alienated refugees with complex symptom presentations there may be value therefore in formulating and trialing a specific approach to psychological intervention that focuses on elements of both complicated bereavement and ptsd for refugees that show the combined pattern conclusions we identified a combined class comprising complicated bereavement and ptsd amongst refugees in which symptoms of identity confusion were prominent that class reported a distinctive profile of exposure to past trauma postmigration stressors and psychosocial disruptions more generally the study illustrates the value of investigating connections between comorbid patterns of mental health symptoms and distinctive profiles of trauma postmigration stressors and longerterm psychosocial disruptions that refugees have experienced defining these relationships may assist in shaping and refining psychotherapeutic interventions to meet the specific needs of subpopulations of refugees supplementary material the supplementary material for this article can be found at

background refugees are at risk of experiencing a combined constellation of complicated bereavement and posttraumatic stress disorder ptsd symptoms following exposure to complex traumas associated with personal threat and loss features of identity confusion are central to both complicated bereavement and ptsd and these characteristics may be particularly prominent amongst refugees from traditional cultures displaced from their homelands families and kinship groups we investigate whether a combined pattern of complicated bereavement and ptsd can be identified amongst west papuan refugees participating in an epidemiological survey n 486 response rate 858 in a remote town in papua new guinea methods latent class analysis was applied to derive subpopulations of refugees based on symptoms of complicated bereavement and ptsd associations were examined between classes and traumatic loss events postmigration living difficulties pmlds and psychosocial support systems results the four classes identified comprised a complicated bereavement class 11 a combined posttraumatic bereavement class 10 a ptsd class 11 and a low symptom class 67 symptoms of identity confusion were prominent in the posttraumatic bereavement class compared with the low symptom class the combined posttraumatic bereavement class reported greater exposure to traumatic loss events or 243 95 ci 111534 pmlds or 224 95 ci 10146 disruptions to interpersonal bonds and networks or 33 and erosion of roles and identities or 218 conclusions refugees appear to manifest a combined pattern of complicated bereavement and ptsd symptoms in which identity confusion is a prominent feature this response appears to reflect the combined impact of high levels of exposure to traumatic losses pmlds and disruption of relevant psychosocial systems

introduction there is increasing evidence that nonmedical opioid use has spread beyond urban areas in the us 1 2 3 4 while the modal route of administration for nonmedical opioid use varies geographically 5 for those who develop a serious drug abuse disorder intravenous injection is common this transition increases risk of bloodborne viral infections most especially hiv and the hepatidites and opioid overdose 6 7 8 9 since harm reduction services such as syringe exchange programs have been implemented in urban areas exposure to these services among nonurbandwelling people who inject drugs is likely to be negligible nevertheless because many nonurban injectors report going to urban locales to buy andor inject drugs we hypothesised that this might result in exposure to harm reduction programs with resultant increases in prevention knowledge and reductions in unsafe injection practices that result in bloodborne infection or overdose the association between knowledge about a given health threat risk behaviour and disease state has been well established and is supported by theoretical models 10 11 12 13 14 most recent research that specifically examined hiv knowledge in the us has focused on populations such as immigrants residing in the us 15 pwid residing in nonurban areas are insufficiently studied both in terms of their knowledge and degree of risky behaviour recent us studies suggest that hepatitis knowledge levels are lower than those for hiv 16 17 18 19 20 hcv infection is often perceived as a harsh inevitability particularly relative to risk of hiv infection 192122 and a realistic one for pwid in the us where prevalence rates range from 31 to 95 depending upon when and where the data were collected 19 23 24 25 26 most pwid are infected with hcv within the first two years of initiating injection drug use 2728 recent declines in both hcv incidence and prevalence 28 29 30 notwithstanding there is continued concern about increased hcv risk in nonurban locales 31 32 33 several national and international studies have sought to describe injectionassociated risk behaviours particularly with respect to hcv infection 23 34 35 36 37 38 where hcv incidence is increasing among nonurban young pwid in the us 33 there are conflicting reports concerning the association between awareness of hiv or hcv infection and injectionassociated risk behaviour some studies noting no association 243940 and another finding a tendency to reduce risk behaviours when individuals are aware of their infection 41 contextual factors such as relationship status withdrawal symptoms 42 lack of access to harm reduction services 30 and drug type 43 were associated with increased injectionassociated risk behaviours given the lack of recent information regarding knowledge about risk behaviours associated with and seroprevalence of injectionassociated infections among pwid residing in nonurban locales we recruited and enrolled pwid residing in the nonurban towns of fairfield and new haven counties in southwestern connecticut of the 51 towns and cities in the two counties six have populations ranging from approximately 80 to 144 thousand inhabitants the remainder have considerably less with over twothirds having populations less than 30 thousand and are considered nonurban municipalities located within proximity to larger northeast cities we compared individuals who injected drugs most often in urban locales to those who injected drug most often in nonurban locales and tested four hypotheses 1 pwid who inject most often in urban locales will have lower income less job stability higher rates of incarceration longer injection careers and larger injection networks 2 they will be more knowledgeable about hiv viral hepatitis and opioid overdose risk and prevention 3 they will have lower levels of unsafe injection practices greater use of existing harm reduction services and lower rates of opioid overdoses and 4 they will have higher seroprevalence rates for hiv hbv and hcv and lower rates of recent opioid overdose methods the suburban health education research and prevention alliance study was a mixed methods longitudinal study of adult pwid stably residing nonurban towns in fairfield or new haven counties of connecticut we were interested in understanding the potential influence of most frequent injection venue upon injectionassociated risk behaviours knowledge about hiv hepatitis and overdose risk and prevention and hiv hbv and hcv seroprevalence hence all participants resided in nonurban locales but varied in terms of the locale where they most often injected in the previous six months our four hypotheses were based on the notion that primary injection venue will influence individuals exposure to and adoption of harm reduction strategies the current report is limited to analyses from the final baseline dataset more information concerning study methods can be found in previous publications 4445 all participants provided informed consent prior to enrolling in the study and received up to 60 for completion of the baseline assessment the yale human investigations committee reviewed and approved the study and all associated materials measures participants completed a twopart semistructured baseline interview the first part conducted by trained staff was a facetoface interview to collect geospatial data more easily obtained through openended discussion and the use of maps participants then completed the second part using audio computerassisted selfinterview software after completing both parts of the interview a trained phlebotomist obtained a 46 ml blood sample from participants and instructed them to return for their test results in two weeks independent variables included most frequent injection locale in the past six months sociodemographics health and substance abuse treatment history social support use of harm reduction services and involvement with the criminal justice system minority representation was low but commensurate with the towns demographics the race ethnicity variable was therefore dichotomised participants completed six clinical measures including those items from the addiction severity index 48 49 50 that are needed to calculate the seven subscales three consumption questions from the alcohol use disorders identification test 5152 brief pain inventory 5354 center for epidemiological studies depression scale 55 and beck anxiety inventory 5657 the outcomes of interest for the four hypotheses included injection venue hiv hepatitis and overdose knowledge injectionassociated risk behaviours and hiv hbv and hcv infection status the knowledge variable was calculated as the percent of correct responses to 42 truefalse items concerning hiv and hepatitis transmission and prevention and overdose recognition and response that we have used in previous studies 175859 to reduce the potential for type i error due to multiple comparisons a dichotomous composite injectionassociated risk behaviours variable was calculated based on participants reports of having engaged in at least one of the six risk behaviours during the 30 days sera were prepared and stored at 20°c subsequently thawed and tested using serological test kits hbv testing included screening for core and surface antibodies and for surface antigen participants received their results in a facetoface posttest counselling session if positive for antibodies to hiv hbv surface antigen or hcv they were referred for confirmatory testing at a certified laboratory where they could then be referred for treatment if the confirmatory test was also positive study staff counselled participants on strategies to prevent viral transmission and those who were negative for all three hbv tests were informed that they were susceptible to infection and advised to receive the threedose vaccination series statistical analysis we initially tested for potential differences between the 438 participants who responded to the item concerning most frequent injection locale and those who did not no differences were noted for sex race education or employment status involvement with the criminal justice system or any of the six risk behaviours assessed nonresponders were significantly more likely to be married to address the first hypothesis we calculated chisquare and students ttests to assess for potential differences in characteristics between participants who reported having injected most often during the previous six months in nonurban vs urban locales to address the remaining three hypotheses primary injection locale was included as an independent variable when testing the three outcomes of interest initially we conducted a series of bivariate logistic analyses to assess the relationship between primary injection venue the other independent variables and the outcomes of interest of knowledge injectionassociated risk behaviours and viral infection status a series of bivariate linear regression analyses were similarly conducted to determine the association between primary injection venue other independent variables and knowledge level variables with a p 025 in the bivariate analyses were excluded from the three multivariable analyses injection venue was included in all models as the primary independent variable of interest a backward selection procedure was used to sequentially eliminate covariates that did not remain significant the significance level for inclusion in the multivariable models was defined as p 005 all statistical analyses were performed using sas results a detailed description of the study sample is available in previous publications 4445 briefly the majority of participants was nonhispanic white and male the raceethnicity proportions were white 837 hispanic 87 african american 63 other 13 one participant refused the question in testing whether pwid who injected predominantly in urban areas differed on sociodemographic factors from their nonurban counterpart we found few differences between the two groups save that those injecting most often in urban locales were younger by almost six years had been injecting nearly three years less and were less likely to have health insurance regardless of location most had been in substance abuse treatment at least once and had a criminal record almost all participants reported having been arrested at least once 800 of whom reported incarceration periods longer than that necessary to post bail the mean total number of arrests was 91 and 31 were for drug violations the mean number of incarcerations extending beyond the time necessary to post bail was 57 no betweengroup differences were noted for gender race education employment status monthly income or the size of participants injection networks for the past six months knowledge level for the total sample was poor no one answered all 42 items correctly and the overall mean score was 595 the hypothesis that pwid injecting in urban locales would have greater knowledge about hivaids hepatitis and opioid overdose was not supported in bivariate or multivariable analyses more knowledgeable participants were significantly more likely to be white have at least a high school education and have had at least six injection partners in the past six months with respect to injectionassociated practices 905 of participants identified heroin as their preferred drug 649 reported having purchased drugs most often in urban areas in the past six months while 228 relied upon home delivery regardless of where participants purchased their drugs 624 reported that they injected most often in their own home within the previous 30 days most pwid purchased syringes at pharmacies 37 reported receiving most of their syringes from either of the two existing syringe exchange programs and 78 reported receiving any syringes from a syringe exchange program on average participants injected slightly more often than twice per day and frequently reused their own syringes when asked about six injectionassociated behaviours nearly half the sample reported having engaged in at least one during the previous 30 days the most commonly reported risk was sharing drug although sharing of drugmixing or rinse water was also common almost a third reported having ever experienced an overdose and among these individuals it was common to have experienced more than one based on the assumption that pwid who injected most often in urban locales were more likely to have been exposed to harm reduction programs than were those who injected most often in nonurban locales we hypothesised that the former group would be less likely to engage in at least one of the six injectionassociated risk behaviours and would experience fewer nonfatal opioid overdoses neither group had much exposure to harm reduction programs and our hypotheses regarding injectionassociated risk behaviours and overdose experience were not supported in the multivariable model those who injected most often in urban settings were almost twice as likely to engage in at least one injectionassociated risk behaviour as their nonurban counterpart older participants and males were less likely to engage in injectionassociated risk behaviours we hypothesised that hiv hbv and hcv seroprevalence would be significantly higher among those who injected most often in urban locales seroprevalences for the total sample were 236 for hbv 392 for hcv and 11 for hiv there were too few cases of hiv to perform any inferential test and bivariate associations of injection locale with either hbv or hcv infection were nonsignificant discussion this report presents the primary analyses from the suburban health education research and prevention alliance project a comparison of knowledge levels injectionassociated risk behaviours and the prevalence of hiv hbv and hcv infection between pwid residing in nonurban areas of southwestern connecticut who primarily injected in urban locales and those who did not to our knowledge this is the largest longitudinal study of active injectors from a nonurban region of the us we tested four hypotheses none of which were supported by the data suggesting that nonurban pwidregardless of primary injection venueare not being reached by existing syringe exchange or harm reduction programs this may possibly be attributed to insufficient opportunities for nonurban pwid to come into contact with such programs due to limited hours of operation or geographic coverage or it may be due to a lack of awareness of the existence of such programs among nonurban pwid limited advertising by the programs in urban areas and none in nonurban regions the existing harm reduction interventions may be poorly suited to the information and resource needs of this population or other as yet unidentified factors additional research is needed to understand how best to effectively reach and intervene with pwid residing in nonurban locales the findings raise two concerns prevention knowledge and exposure to harm reduction services and resources is low and injectionassociated risk behaviours were highly prevalent there are only two official harm reduction programs in the region both are located in major urban areas have limited hours and access to these services via public transportation is not possible from all areas or may require up to 45 minutes to reach by private car innovative strategies are therefore needed to disseminate harm reduction information and resources to this population pharmacies may represent one such novel venue for expanding nonurban harm reduction efforts beyond merely selling syringes 60 although there is a 1992 law permitting syringe sales without the need for a prescription in connecticut 6162 implementation of harm reduction interventions such as training pwid about injection hygiene or overdose prevention and response remain relatively scarce in nonurban locales smartphone technology such as textbased programs that provide regular messages concerning methods to improve injection hygiene strategies for coping with cravings and information about access to local harm reduction and substance abuse treatment programs may be another strategy for implementing interventions targeting nonurban pwid expansion of home delivery of syringes and other safe injection supplies beyond the large cities where most harm reduction programs operate is strongly recommended and essential in preventing further spread of hcv which is already at 40 at the structural level policy changes aimed at counteracting the prevailing nimby attitudes 63 64 65 66 and increasing the number of substance abuse treatment and syringe exchange programs located in nonurban locales are recommended in connecticut syringe exchange programs are limited to operating only in the jurisdictions within which they have been approved changing the policy to permit home delivery to a larger region may be another approach to expanding access we also recommend that the existing exchanges be converted to distribution centres where the number of syringes distributed is based upon need rather than a strict oneforone exchange as is currently the case hiv hepatitis and overdose recognition and prevention knowledge was higher within larger injection networks and suggests that there may be diffusion of health promotion information within these networks this may in turn provide another possible intervention strategy 6768 the fact that contrary to our hypothesis those injecting most often in urban locales were significantly more likely to have engaged in at least one injectionassociated risk behaviour within the previous month suggests that these individuals may have been injecting in a hurry or in a location not conducive to hygienic injection the issue that women reported engaging in injectionassociated risk behaviours more often than men was not surprising albeit disappointing many factors have been attributed to this phenomenon including inherent power dynamics between genders 69 70 71 72 suggesting the need for harm reduction interventions tailored to the specific needs of female injectors limitations there are several limitations to this study the sample is one of convenience and therefore the findings may have limited generalisability pwid with higher incomes may be underrepresented the selfreported data collected in this study are subject to recall and social desirability bias we attempted to minimise response bias by using computerised selfadministered survey methods an effective strategy to minimise the potential for underreporting of risky and stigmatised behaviours 73 74 75 we chose to employ a single composite risk variable as the outcome of interest in the multivariable analysis since the proportion of those who reported having engaged in any of the six injectionassociated risk behaviours was relatively small for most risks and we didnt wish to increase the potential for type i error associated with multiple comparisons this decision does not account for the fact that some behaviours are riskier than others and limited our understanding of the specific risk behaviours most likely associated with injection venue to offset these potential limitations we included the results of bivariate analysis for each risk behaviour in table 2 finally because all participants resided in nonurban towns no conclusions can be made about the differences between pwid residing in urban versus nonurban areas the question of whether the harm reduction information and prevention needs of nonurban pwid differ from those of their urbandwelling counterpart should be explored in future studies as should the specific contextual factors and risk dynamics that are associated with engaging in injectionassociated risk behaviours particularly for those who inject most often in urban locales and females conclusions we have previously noted that pwid residing in nonurban locales are in need of the hiv hepatitis and overdose prevention information but do not appear to be accessing traditional harm reduction programs 45 the data suggest the need to expand harm reduction services to nonurban locales novel strategies such as pharmacybased home delivery and peerled interventions should be considered as other means of expanding harm reduction initiatives in nonurban settings the positive association between hcv infection and length of injection career has been noted previously in published accounts of our study 44 as well as in a recent metaanalysis of data on urban pwid 4476 these findings underscore the continued and urgent need to intervene as soon as possible with new injectors in order to provide them with harm reduction information and services

introduction and aimslittle is known about injectionassociated risk behaviours knowledge and seroprevalence of viral infections among people who inject drugs pwid in nonurban locales in the us harm reduction services are more available in urban locales the present study examined a cohort of active pwid residing in nonurban areas of connecticut to investigate how primarily injecting in urban or nonurban areas was associated with injectionassociated risk behaviours knowledge and prevalence of bloodborne viruses design and methodswe described the sample and performed bivariate and multivariable analyses on injectionassociated risk behaviours hivhepatitisoverdose knowledge and baseline serological data to identify differences between individuals who injected primarily in nonurban locales and those who did not resultsharm reduction knowledge and use of harm reduction services were poor in both groups those injecting most often in urban settings were 188 119 298 95 confidence interval times more likely to engage in at least one injectionassociated risk behaviour than their nonurban counterpart seroprevalence rates 236 for hepatitis b virus 392 for hepatitis c virus and 11 for hiv were no different between the two groups discussion and conclusionsthe data provided little evidence that the benefits of urban harm reduction programs such as syringe exchange risk reduction interventions and education programs have penetrated into this nonurban population even among those who injected in urban locales where such programs exist harm reduction interventions for nonurban communities of pwid are needed to reduce hiv and hepatitis b and c transmission

commsphere jurnal ilmu komunikasi vol 1 no i march 2023 pp 19 issn 29871360 doi 1037631commspherev1ii855 disseminating information about the korean wave makes it easier for anyone to access information about this so that it attracts many fans and takes an interest in kpop culture itself one of the korean wave products in great demand especially for millennials is pop music or kpop one of the most popular entertainment products has lifted the economy of south korea because the south korean government itself pays special attention to the kpop industry which can be seen from the phenomenon in the late 1990s when most countries in asia experienced a financial crisis but south korea formed the ministry of culture with a special kpop department kpop became a sensation in indonesia and became popular in the 2000s many boy groups and girl groups are becoming known in indonesia in this way kpops prominence in indonesia has formed a large and solid fan base fandom itself is formed because of relationships between people who like the same thing even formed without intense fan culture and behavior or even not knowing each other the country of indonesia is one of the homes for millions of kpop lovers with the fourth largest population in the world after the united states of america the twitter account announced a list of countries that tweeted the most about kpop artists throughout 2019 indonesia was ranked 3rd after thailand and south korea apart from that for viewing youtube videos about kpop by country indonesia also occupies the second position with a percentage of 99 fans or fans are understood as a term to refer to a community or group that has the same passion for popular culture fans are usually associated with fanaticism or excessive liking referring to stuart halls thought that fans have the autonomy to give meaning to every text they consume instead of assuming that fans are passive parties stuart halls theory positions fans in the opposite direction namely seeing fans as involved parties in producing meaning however this does not require the possibility that the younger generation will develop some overly fanatical attitudes toward their idols so this fanaticism will affect the lifestyle of their fan culture quoting from the kumparan survey with data 56 of kpop fans spend 15 hours using their social media to access information about their favorite idol even up to 28 spend six more hours using their social media to see various activities of their idols so that with this phenomenon most people or nonfans think kpopers are always excessive crazy hysterical obsessive consumptive or even too generous towards their idols because they like to waste their money on buying something related to their idols such as merchandise ranging from albums photo cards and lightsticks or even chasing their idols wherever their idols go for example the commsphere jurnal ilmu komunikasi vol 1 no i march 2023 pp 19 issn 29871360 doi 1037631commspherev1ii855 super junior group has the fandom name elf the bigbang group has the fandom name vip and ikon has the fandom name ikonic however among the many kpop idols currently widely known bts can still survive as a boy group with immense fandom worldwide a kpop group that has achieved success on the international music scene currently they have fans or supporters who are strong and have a considerable influence which is called army bts was founded in 2013 by bighit entertainment agency bts began to be in demand after getting the achievements after releasing several albums that could climb the billboard charts starting with the album love yourself followed by other songs such as dynamite butter and many more furthermore it is increasingly being looked at after the love myself campaign with unicef which has the aim of helping end all acts of violence and fostering selfconfidence and more compassion for oneself and others so that they can invite their audience especially their followers to be aware of mental health issues this success is inseparable from the influence and support of its fandom namely the army thanks to their supporters bts also won international awards which made bts even more recognized such as the favorite social artist american music award 2018 and the top social media artist 2018 billboard music award the fandom even won the best fan category award at the 2018 kids choice award and the most fans at the mtv europe music award in 2019 at the american music awards bts was named the winner of favorite duo or group poprock twice in a row and tour of the years changes in fandom culture and behavior in the digital era have made fans use the internet to connect with fans even though they are in different spheres known as cyber fandom by sharing information that anyone can access anywhere cyberfandom is a fan group created virtually via the internet or social media making it easier for fans to connect with each other and share or access information related to their idols as part of the fandom of bts army uses social media to carry out its activities to interact with other army one of the social media is twitter one indonesian army fanbase account namely indomy was created in november 2017 with 200392 followers and 32916 thousand tweets seeing this indicates that activities for mutual interaction are very often carried out between army in his account we can see how the admin provides information about bts such as new song releases concert schedules voting at award events or other activities carried out by bts members so fans can interact with each other fanbase accounts aim to make a more comprehensive community that can recognize their favorite idols and are more popular on the international stage with a fanbase account audiences will find it easier to find the latest information about their idols activities such as new album releases the information of commsphere jurnal ilmu komunikasi vol 1 no i march 2023 pp 19 issn 29871360 doi 1037631commspherev1ii855 music video teaser releases concert schedule information or even voting information when their idol is nominated in an award event so fans will try to vote in various ways so that they are in the first position and win the award seeing this phenomenon with various virtual activities carried out by army and technological advances the authors are interested in researching the army fandom to see how fan culture is in the digital era on the indomy twitter fanbase account this is reflected through various response activities and the production of messages online on social media twitter indomy research methods this study uses a virtual ethnographic method using this method researchers become part of the subject by following fans activities in cyberspace moreover researchers are part of the army indomy fanbase account followers on twitter media according to rusli virtual ethnography is a method used to view users social or cultural phenomena in cyberspace even bell states that this ethnographic method is leading and essential for viewing online cyberculture phenomena christine hine in nasrullah states that virtual ethnography is a methodology used to investigate the internet and explore identity when using the internet of the many indonesian army fanbase accounts the researcher chose the twitter account indomy as the research subject for approximately three months from november 20 2022 to january 10 2023 this account is said to be an indonesian army fanbase account because of the username used and posts containing various information about bts and army with 200392 thousand followers and tweet posts that have reached 32916 thousand tweets this research focuses on all texts and media fans post on the indomy twitter fanbase account when carrying out fan culture two data collection techniques are used namely observing the indomy fanbase account and literature review of previous research as additional data to complement research information needs results of research and discussion based on the formulation of the problem above the researcher wants to know how the fan culture of the army fandom is presented through twitter media in the digital era on the indomy account with various activities ranging from mutual commentary responses replying to each others uploads made by the army fandom research finds various forms of culture fandom can be seen from four forms namely communication knowledge creativity and civic organization or power commsphere jurnal ilmu komunikasi vol 1 no i march 2023 pp 19 issn 29871360 doi 1037631commspherev1ii855 the army fandom communicates virtually through social media twitter with the same identity namely army where they are put together in the fanbase account their virtual identity can be seen from their name profile photo id name photo background and bio of each account the picture above shows bts fans namely the army showing their identity as a fandom one of which uses attributes related to their idol it can be seen that most of them use profile photos of bts members not their photos and the username shows that they also use the modified bt members name as their account this behavior is in line with what was conveyed by pertiwi where a persons identity in cyberspace may be different from the original in the world of fandom communication made within the scope of fandom is usually only understood by the members of the fandom itself which is referred to as fan speaking this fan can be in writing or symbols which can be understood by the fandom itself even in the virtual world like love purple where this sentence is interpreted as a purple heart a feeling of love and strength between bts members and army in the field of creativity it can change peoples mindset in viewing fans especially kpop fans if previously fans were called hysterical people too fanatical about their idols and even called crazy with this creativity fans also have positive things in them because fans also act as an active audience in interpreting a text creative ideas are created in it because fans become audiences who consume what is presented by the media and through the textual meanings of media content they are also actively involved in producing meanings that they implement through their works these fan works are called fan production or a product fans produce fans as audiences will take imitative actions and produce culture commsphere jurnal ilmu komunikasi vol 1 no i march 2023 pp 19 issn 29871360 doi 1037631commspherev1ii855 after consuming cultural texts left by the media fan production created by fans is diverse including memes fan edits fan fiction and many more one form of creativity that fans produce is editing which makes it more interesting fans do this for fun and to generate interaction between fans on the account 2014 a fan project is a project carried out by a fandom to support their idols and stream to increase their idols mv viewers so they enhance each other for streaming because usually in a fandom they have goals when their idol releases the latest mv they also carry out digital activities to celebrate their birthdays such as fundraising called fan donations which are intended for underprivileged or disasteraffected communities using social media this creates a new culture in fandom in activities or fandom activities that are carried out in a coordinated manner in a fan project so that the fanbase account is significant in the world of fandom which aims to provide various information so that communication interaction between fans is created in the fanbase account conclusion with the development of internet technology in fandom activities social media plays a role in disseminating information about the korean wave making it easier for anyone to access information about their idols commsphere jurnal ilmu komunikasi vol 1 no i march 2023 pp 19 issn 29871360 doi 1037631commspherev1ii855

korean pop culture kpop has succeeded in spreading its cultural products popularly to the international world this process is known as the korean wave or hallyu korean wave is a term for spreading korean popular culture through industrial products such as music style drama fashion etc the process of its spread cannot be separated from technological advances and the existence of social media such as instagram twitter tiktok youtube and so on so it can be said that social media is the primary channel for the emergence of the korean wave phenomenon purwanti 2013 with social media

introduction among the profusion of encounters faced by learners in amathole east district of the eastern cape province specifically those attending public schools settled in rural settings is lesbian gay and bisexual based school bullying consequences of this are blamed on fisttightness of teachers in offering lgbbased sexuality education to learners in their early stages of upbringing while on the other hand unesco observed that lgbbased bullying among seniorphase learners is driven by the stigma and biases emanating from cultural beliefs about gender roles masculinity and femininity that is elders indoctrination of the qualities and responsibilities of each gender causes those who still follow suit to look down on those who associate themselves with lgb this has led to episodes of bullying cases including but not limited to discrimination humiliation physical assault and sexual results in appearance misconceptions and difficulties in befriending other learners in the school setting it also emerged that nigerian schools foster heterosexuality through homophobic views and rules with the intent of marginalizing the lgb lifestyle which belittles the already minoritized group hence the scholar observed the imperativeness of implementing culturally sensitive antibullying programs to ensure the safety of lgb learners in ghanaian schools lgb learners are deprived of participating in democratic domains since they are not among the majority group heterosexuality this raised uncertainties about their sexual orientation rimes et al observed an increased suicide rate among lgb learners who were victims of stigmabased victimization in the case of south africa irrespective of the constitutional rights that were documented with the intent of protecting previously marginalized sexualities including lgb groups homophobic bullying is still extensive to a prodigious level the reason underlying this endless discrimination stigma and demonization of learners who conform to lgb identity may be the fact that the south african constitution did not document laws that directly focus on minority groups however it included them in section 9 which includes all south african residents this has resulted in a couple of the most common forms of discrimination namely verbal bullying as well as violence threats and vulnerability to heterosexism on a daily basis where lgb learners are still perceived as inferior compared to heterosexual learners as much as there is no concrete evidence or indication of higher levels of bullying among lgb learners when compared to heterosexual learners the legal resource center observed that lgb learners across the country encounter homophobic bullying not only from their peers but also from their teachers who were supposed to maintain classroom safety for each individual learner without considering gender diversity this causes lgb learners to avoid talking about being bullied as rhodes university mentioned that lgb learners have no role model to talk to and no teacher to offer support so they end up being suicidal anxious and depressed which negatively affects their selfesteem and academic performance in efforts to diminish lgbbased bullying in south african schools the department of basic education implemented an inclusive school safety framework that aimed to challenge bullying in general the fisttightness of scholars conducting research on lgbbased school bullying in the eastern cape province resulted in limited literature about the phenomenon however staff reporter on iol reported that the eastern cape is the most homophobic province in south africa yet violence against lgb individuals is more prevalent rumormongering is a form of bullying that targets lgb learners as a learner was being rumored and accused of being capable of raping other learners since she identified herself as a lesbian on the other hand most educators and administrators were brought up in a society where lgb was perceived as sodomite traditionally inappropriate and transgressive although all these proposals have been instigated cases of lgbbased school bullying and its effects are severe the above literature divulges that the root of the stigma misconceptions misjudgments and biases towards lgb learners that lead to their victimization is the lack of sexuality education especially based on sexual orientation furthermore people are still holding onto the beliefs and laws that were enacted to marginalize lgb instead of embracing the modernized era as the key to nearly everything several studies observed that teachers could play a vital role in combating lgbbased bullying with proper training and adequate resources since they will offer the education necessary for learners to understand various sexualities speak against homophobic comments and instil morality among learners as much as south africa prides itself on its constitution being the first in the world to prohibit unfair discrimination on the grounds of sexual orientation hence guarantees lesbian and gay equality literature revealed that cases of bullying that lead to severe effects including suicide are still prevalent among lgb learners problem statement numerous studies conducted recently in various countries concluded that lgb learners experience a disproportional amount of bullying when compared with their heterosexual peers this results in them experiencing lower life satisfaction physical health problems intolerance discrimination harassment and violence regarding their sexual orientation american psychological association believes that these hitches lead to learners negative psychological effects including depression which hamper their classroom concentration and academic performance on the other hand richardson and wallstead in the classroom contributes to lgbbased bullying which is blamed on discriminatory curriculum and textbook chapters that do not contain adequate information for teachers to facilitate learners with that is curriculum planners refusal to include lgbbased sexuality education in the curriculum only enhances the escalation of homophobic behaviours towards learners whose birth sex is not in line with their gender specifications furthermore teachers fisttightness in conversing or talking about important aspects of homosexuality including lgb endangers lgb learners since heterosexual learners will continue to embrace prejudice and misconceptions about their sexual orientation to this end it is significant to investigate issues that limit schools from combating lgbbased school bullying and seek methods to combat it research objectives for the researchers to successfully analyze lgbbased school bullying the following research objectives were implemented • to investigate the limitations of schools in combating lgbbased school bullying • to determine methods of combating lgbbased school bullying among seniorphase learners theoretical framework for researchers to thoroughly analyze lgbbased school bullying this study was underpinned by two theories social stigma theory entails an indepth nature of stigmabased bullying and the antibias education approach which fosters learners to familiarize themselves with gender diversity and speak against prejudicebased discrimination social stigma theory erving goffman social stigma theory elucidates stigma as the slandering of someones character through unpleasant namecalling among the three forms of stigma that were detailed by goffman is blemished individual character which includes lgbbased stigma when revealed this form of stigma may result in anxiety a ruined reputation and lifelong negative effects on the stigmatized individual nyasulu observed that qualities regarded as triggers of stigma are inculcated in societal members leading to discrimination should one reveal those qualities in a similar vein earnshaw et al asserted that influences that result in stigmabased bullying descend from the societal level to the interpersonal level and down to the individual level that is stigmabased bullying does not emerge from a random internal motive but is a descendant of a societal perspective that is meant to instil a certain doctrine among its inhabitants which is the wheel that rotates from ancient humans towards the present generation this theory is relevant to this study because lgbbased school bullying is a social phenomenon that is influenced by the societal indoctrination of qualities and responsibilities that are perceived to be normal for a certain gender which induces heterosexism and results in learners disapproval of lgb relationships for instance people resembling the dominant cultural group in the eastern cape province believe that a man is responsible for the continuity and preservation of his clan by marrying a woman who will eventually bear children so by identifying as lgb they are convinced that a man is transgressing this social doctrine as men cannot bear heirs which will probably inculcate the extinction of that particular clan by exhibiting gay qualities society concludes that one is no longer a man and does not deserve their respect and they constantly remind them in a vulgar manner which is imitated by children and practiced among lgb learners at school this results in social exclusion namecalling assaults and other forms of bullying including spreading rumours about lgb learners this incites selfdoubt and selfhate for the stigmatized to the extent of make them anxious depressed drop out of school and even consider ending their lives this gap further led to the adoption of an antibias education approach to encourage learners to accommodate gender diversity antibias education approach antibias education approach was proposed in 1989 by dermansparks and edwards with the intent of creating and maintaining a tranquil school environment by nurturing learners to understand and demonstrate positive personal and social identities familiarizing learners and promoting comfort with human diversity encouraging them to recognize unfairness and empowering them to stand against discrimination sparks believes that young schoolgirls are cognizant of privilege and powerconnected factors including gender hence they proposed abea and encouraged teachers to embrace and facilitate learners with antibias education to create a community that will be supportive of all scopes of human variables including sexual orientation this approach is relevant to this study because when applied to seniorphase classrooms it will not only introduce the concept of diversity to learners however it condemns lgbbased school bullying since the levels of misconceptions and discrimination targeted at lgb learners will be neutralized by encouraging learners to understand accept and support various sexual orientations most importantly lgb furthermore the application of abea will enable learners to be proud of who they are it is therefore imperative for curriculum planners to include antibias education in the curriculum for teachers to introduce it at learners lower phases of education this will disarm heterosexual learners minds from misconceptualizing lgb and holding on to the mentality that lgb is among the minoritized group while fostering their ability to speak against lgbbased discrimination in their respective schools and communities methodology this study adopted a qualitative research approach an interpretivism paradigm and a case study design data were elicited from purposively sampled participants using indepth interviews and researchers analyzed raw data in the form of recordings and notes with braun and clarke thematic analysis to classify emerging themes and make sense of the data researchers acknowledged and adhered to the principles of research ethics research approach paradigm and design this study adopted a qualitative research approach to collect detailed nonnumerical data and to understand the perceptions and experiences of the sampled participants researchers aim to utilize participants lgbbased school bullying perceptions and experiences to produce new concepts and themes and to observe participants feelings and behaviour to make sense of their experiences for research purposes this study is lensed through the constructivism paradigm because the researchers seek to elicit various descriptive selfconstructed ideas and perceptions about lgbbased school bullying from participants since constructivists believe that each individual constructs reality based on experiences and feelings regarding a particular phenomenon furthermore researchers intent is pinned on analyzing lgbbased school bullying which can be done by placing themselves in the participants thinking to reconstruct the intended meaning this study is designed as a case study since researchers aimed to investigate an indistinct phenomenon within its actual setting furthermore researchers employed a case study design to explore lgbbased school bullying through the views and reactions of participants who live their daily lives in the setting where the phenomenon occurs this design also helped the researchers dig through the phenomenon at hand to gain an indepth insight that later enabled us to identify ways in which the study objectives could be accomplished sampling and instrumentation for researchers to elicit data that served the purpose of this study a nonrandom purposive sampling technique was utilized this technique allowed researchers to identify and handpick samples that possess rich knowledge or experience regarding lgbbased school bullying 09 participants consisting of 4 senior phase teachers 2 female learners identifying as lesbians and three male learners identifying as gays from one secondary school were selected to participate in this study by responding to a series of interview questions researchers conducted oneonone indepth interviews with 09 purposefully sampled participants the objective for the utilization of this instrument was to elicit detailed and authentic data based on participants perceptions and experiences about lgbbased school bullying in a relaxed and unhostile atmosphere and without being influenced by others moreover this instrument enabled probing for more detailed enunciations to avoid researchers assumptions and preconceptions data analysis and ethical considerations the thematic analysis technique was utilized since it enabled researchers to code raw qualitative data gathered from the participants into analogous themes to construct a coherent theoretical elucidation of the phenomenon these themes were then aligned with the study objectives analysis and interpretation of the primary data were done by adopting the universally acknowledged sixsteps thematic analysis techniques these steps according to braun and clarke involve reading through the data for familiarization encrypting the data into themes identifying related themes revising themes naming themes and constructing theoretical elucidation creswell asserted that researchers are bound to respect participants rights desires and values therefore to be in line with the scholars assertion researchers recognized and followed walter sisulu universitys ethical considerations which include valuing the rights of the participants confidentiality anonymity consent and permission for participation to ensure this it was thoroughly explained to each individual participant that they were not obliged to participate and that they were free to withdraw their participation from the study should they need to omodan moreover each participant was assigned a fictional name to ensure his or her anonymity a male teacher was coded as lm female teachers were coded as tf female learners were coded as lf and male learners were coded as lm lastly minors were given consent forms to be signed by their parents results and discussion the findings of this paper were discussed based on the study objectives and themes that arose from the data elicited from sampled participants limitation of schools in combating lgbbased bullying among senior phase learners to respond to the first objective which is the limitation of schools in combating lgbbased bullying among seniorphase learners the following themes emerged ignorant and unsupportive teachers lgb is not recognized consistency to religion indistinct and no lgbbased bullying reports usage of same facilities as heterosexual learners ignorant and unsupportive teachers teachers unwillingness to intervene in lgbbased school bullying is identified by their ignorance when learners log lgbbased bullying cases lgb learners and parents entrust teachers with the responsibility of being the primary protectors and conflictresolution mechanisms among all learners in the school environment if this protection is unilateral that is it is only applied to the heterosexual group this indicates that the lgb populace will suffer all the consequences of having their claims ignored which include continuous harassment lf2 and lm1 shared the same emotion lf2 no one cares about us here for example i reported that learners say i have a snake and some teachers asked if i really have it i said no i dont have it and they told me to go back to the class and dont mind what they say at least they should have called them and said something or punished them for that but they never did and those learners never stopped saying i have a snake lm1 even if we report some teachers just joke about those things and never punish or call the learners that bully us to explain why they are saying those things participants demonstrated dissatisfaction with teachers ignorance of their reports the statements above indicate teachers unwillingness to intervene and take necessary steps to follow up on lgbbased bullying cases logged by lgb learners in the accusation reported by lf2 one can conclude that heterosexual learners link lgb with witchcraft which according to south african law is a criminal act since an accusation of this nature mutilates ones reputation especially if the accuser has no concrete evidence she further claimed that no action was taken to discipline such behaviour instead teachers told her to ignore such wicked allegations in a similar vein lm1 told us that teachers joke about their reports instead of intervening despite all the dreadful allegations made by heterosexual learners towards lgb learners teachers remain unbothered and reluctant to apply rational procedures to the culminate misdemeanor behaviour exhibited by heterosexual learners instead they find amusement in it it is also evident that teachers do not even confront and punish learners who spread rumours about lgb learners this might be the result of teachers shortsightedness in spotting the severity of verbal bullying hence due to a dearth of support and protection school stakeholders are unknowingly inspiring neverending episodes of lgbbased school bullying since heterosexual learners will not consider their actions unacceptable these findings are compatible with the claim of mueller james abrutyn and levin who discovered that teachers ignore their claims when lgb learners log incidents of victimization lgb is not recognized participants informed the researchers that school stakeholders do not acknowledge lgb which results in the school community forgoing anything regarding lgb depalma and atkinson and mcshane and farren observed that the dearth of dialogue among school stakeholders about lgbbased matters indicates stakeholders passive behaviour this observation is evidenced by several participants tm what really challenges us in addressing this type of bullying is the fact that we do not want to admit that here at school we have learners who associate themselves with lgb it is not even easy for us to talk about it because to me it feels like we will be introducing them to it or motivating them to become lesbians and gays and parents will see us as bad people as we are supposed to be moulding their children and not introducing them to something that is not acceptable to them tf1 the school treats all learners as they are like males are treated as males and females are treated as males we never considered treating lgb learners differently tf2 to be honest with you i have been here for four years and i have never heard any mention of lgb learners so i can say that the school is not playing a remarkable role in protecting them from being bullied by straight learners tf3 the school only addresses general bullying not bullying that is specific to a certain group for example last year the principal called all parents and guardians to discuss the bullying that was happening here they only mentioned a few forms of bullying but never mentioned lgb bullying no one has ever spoken about it at school even though some of our learners bring cases of lgb bullying to us according to these assertions participants affirmed that teachers avoid discussing lgbrelated matters at school among the plethora of challenges they encounter in their attempts to manage lgbbased school bullying this divulges the fear that teachers may be galvanizing learners inquisitive minds into adopting these previously minoritized genders which will intensify the number of lgb learners in their respective schools moreover this school only addresses all other forms of bullying except bullying that involves lgb the schools silence concerning lgbbased school bullying indicates that lgb is still considered one of the minoritized groups and treats it as if it was never supposed to exist in their respective school especially since the school is situated in a rural area even if there is one empathetic school stakeholder who would consider intervening in lgbbased school bullying shehe will be demotivated since other stakeholders will not be supportive of hisher attempts the school will continue to be a hotspot for lgbbased bullying since atkinson affirmed that silence about lgb conveys the message that lgb is not recognized consistency to religion adaptation and consistency to certain religious beliefs are unveiled as another obstacle for stakeholders to manage lgbbased school bullying this is because their religious beliefs prohibit them from protecting and supporting genders believed to have been cursed hundreds of years ago these beliefs according to street are covertly allowing lgbbased perpetration participants said tf1 juliet most of the teachers here are churchgoers they believe that jesus destroyed sodom because of issues including this lgb thing it is against their religion to stand for something jesus himself considered a sin and intended to destroy so i can say that is one of our difficulties they cannot condone something that they preach against at church tf2 the school still has old teachers who think that lgb is satanism so if i speak to them about anything related to lgb they do not consider it important participants complained about old teachers unwavering consistency with christianity which precludes them from intervening in lgbbased bullying among senior phase learners as stated by tf1 these teachers are absolutely against homosexuality since they believe in a hypothetical bible interpretation stating that jesus destroyed sodom because it was home to sinful acts samesex coupling included hence they relate lgb with satanism since they associate sinful acts with lucifer who is believed to have a bad influence on people these views are similar to those of an expelled east london teacher who according to milton report on pink news claimed that lgb learners have satans deoxyribonucleic acid the fact that teachers put their religion first instead of learners welfare is surprising it has been unleashed that teachers repudiate standing up for victimized lgb learners because their religion forbids samesex relationships while the south african council for educators ordered teachers to uphold and promote basic human rights as embodied in the south african constitution these rights include offering uniform support and protection from maltreatment to each individual learner without a second thought in the professional world teachers must be the main stakeholders who fight against discrimination and maltreatment of any learner irrespective of any circumstance instead of putting their personal interests first indistinct and no lgbbased bullying reports limiting schools endeavors to manage bullying among seniorphase learners is indistinct and there are no lgbbased bullying reports inadequate information produced by the victims of bullying is reported to be limiting school stakeholders investigation grounds in the cases brought to them on the other hand learners blame their teachers for being judgmental below are participants statements tf1 the other thing is that these learners do not usually come to us and report what happened to them but we hear rumours that lesbian or gay learners were involved in a mass fight after school or before school so it is not easy for us to deal with hearsay tf2 learners do not give us full reports of what happens to them or what has been posted about them irrespective of how hard we try to interrogate them some dont even report the case making it difficult for the teachers to intervene in such issues because we do not have the main problem to work on lf1 most learners who are among the lgb community are still scared of expressing themselves because of what others will say at school at school learners are judged of their gender we are not only bullied by learners in our grade and in our age bracket for instance i was bullied by a grade 11 learner and when i said i was going to report him he said maybe i was going to use an underground tunnel when um going home should he be punished for that i did not report him because i was afraid of him and was not even sure he would be punished because no one takes lgb seriously at school lf2 i can say that we are limiting the school because most of the time we dont report bullying to the teachers because they can be judgmental they gossip about us liking things they can just even call you to fetch them water kanti they want to show others that it is you that they were gossiping about if we were not going to be judged it would be easy for us to approach our teachers and if they would be more open about anything that happened to us lm2 some bullying cases happen on social media maam so we dont take that to school we only attend it on social media unless some learners confronted others here at school and teachers saw them or someone went to report otherwise most of us do not report things that happened on social media because they are too rude participants echoed the first tightness of learners in reporting lgbbased school bullying resulting in teachers inactivity in intervening in lgbbullying cases tf1 and tf2 elucidated that it is difficult to intervene in cases they are not so certain about because lgb learners are even more difficult to interrogate they do not want to reveal the nature of the incident as affirmed by lf1 and lf2 schoolteachers judgment induces the fear of giving full reports about bullying instances because they believe they will be exposing themselves to neverending gossip and attitudes exhibiting bias and prejudice by teachers towards them similarly ngcobo reported that learners do not have confidence in being transparent about lgbbased issues to their teachers since they fear being judged on the other hand learners do not report cyberbullying because exchanging vulgar comments on social media is a misdemeanor which may be embarrassing when shared with teachers this is one of disadvantages of learners accessibility to mobile phones especially at immature stages lf1 on the other hand articulated that she did not report bullying because she was threatened by a highergrade learner and thus feared further perpetration based on this analysis lgb learners corroborated teachers affirmations that they do not report lgbbased bullying however the reason for lgb learners to encapsulate almost all the lgbbased bullying incidences is to point at teachers reactions towards learners who identify as lgb misjudgments and endless gossip about lgb learners which result in a dearth of trust towards teachers discourage them from reporting this biasbased bullying since they believe that their cases will not be investigated and resolved these findings support kolbert et al who observed that learners are short at reporting bullying cases because they are anxious about being victimized and their teachers are incompetent at intervening in bullying cases usage of same facilities as heterosexual learners the absence of lgb facilities in school is evidenced to induce lgb learners feelings of being in a noninclusive and unsafe environment raising insecurities about their identities kosciw et al also affirmed that lgb learners avoid utilizing school bathrooms because of their hostile nature hence sharing the same bathrooms with heterosexuals is among schools limitations in managing lgbbased school bullying this is exemplified by lm3s statement lm3 the thing is we are using the same toilets with straight boys who always tell us you gay you were not supposed to be relieving yourself with us because we are men and you are supposed to be wearing skirts sharing bathrooms with heterosexual learners exposes lgb learners to bullying to a great extent as lm3 revealed discriminatory comments made by heterosexual learners when they are out to relieve themselves during break times he went on to express his feelings towards being feminized by heterosexual male learners one can conclude that school bathrooms are one of the most popular hotspots for lgbbased bullying especially among gay learners we consider this a continuing phenomenon because of their daily physical contact which results in heterosexual learners uttering unfavorable comments about gay learners to this end it is excruciatingly challenging for the school to manage lgbbased bullying because it may not be able to instantly provide toilets only meant for lgb learners methods to combat lgbbased bullying among senior phase learners the second objective which is the methods to combat lgbbased school bullying has the following themes avoid gender disclosure create awareness of gender diversity provide bathrooms for lgb learners and follow up on lgbbased bullying cases avoid gender disclosure circumventing being transparent about ones gender is believed to be one of numerous effective methods of combating lgbbased school bullying among seniorphase learners tf1 stated tf1 if learners can stop making noise about who they are that is their lgb status others will not have the reason to bully them remaining silent about ones identity is believed to be one of the methods that will end lgbbased school bullying the more learners do not divulge their identity the less heterosexual learners will have motives to victimize them as per this articulation making noise expresses that lgb learners seem not to be hideous or ashamed of their identities irrespective of how the school community feels about them based on the above analysis motivating lgb learners to stay in the closet and avoid demonstrating qualities that will make it easy for other learners and teachers to identify them as lgb will result in dropping rates of lgbbased school bullying this is because of the sentiment that sexual orientation disclosure constitutes harassment discrimination and victimization since ones gender varies from that of the majority however this study conforms to the findings of daugelli and grossman who divulged that after lesbians and gays disclosed their sexual identities they became vulnerable to being attacked and physically threatened creating awareness on gender diversity participants demonstrated imperativeness in addressing learners and teachers about the nature of lgb so they would be comfortable engaging in an open conversation about it and encouraging learners to refrain from lgbbased bullying hence domínguezmartínez and robles recommended that schools have awareness programs to promote respect and counteract discriminatory attitudes towards sexual orientation reality supported this recommendation tm the first statement demonstrated the inarguable imperativeness of encouraging teachers to accept and uniformly treat every bullying case before encouraging learners to report lgbbased bullying on the other hand tm advocated by tf3 proposed that there must be days set aside to have a word with learners to refrain from biasbased school bullying and encourage lgb learners to report all the bullying incidents distinctly lm2 and lf1 advised the school to have awareness sessions where lgb specialists will capacitate learners with every important detail about lgb and most importantly to encourage them to understand that lgb is natural just like any other gender talking sessions will broaden positive school stakeholders perspectives on diverse genders prepare them to speak freely about lgb and plant the belief that these genders are not as dangerous as they are rumored to be moreover this will persuade the demarginalization of lgb in rural schools and at least the schoolgoing population will have remarkable influence in their communities regarding the demarginalization of lgb furthermore this will decrease the rate of bias but improve lgb learners freedom to participate in schools extramural activities and their academic performance since they will no longer be anxious about bullying this finding conforms with cymru study suggesting fostering transparent discussion with learners and teachers to meet the needs of lgb learners enabling teachers to deal with sexual orientationrelated issues honestly and without judgement and providing opportunities for heterosexual learners to understand diverse genders providing bathrooms for lgb learners decision for rural schools to construct bathrooms for lgb learners sounds like a clever method to separate lgb learners from heterosexual learners and give lgb learners the desired safety and security thus the council of europe considers learners inclusion in policymaking a virtuous method since they will be able to address relevant issues including choosing appropriate bathrooms lm3 suggested lm3 i think if we can be separated from straight learners like we have our own toilets that will make lgb bullying better because it will be the only way to avoid them because they mostly bully us in the toilets and in break times segregating heterosexual learners from lgb learners through the provision of special facilities for lgb learners is believed to be one of the bullying management methods since according to lm3 when they use their own toilets there will be no conveyance of biased comments since they will avoid physical contact with heterosexuals the provision of special facilities for lgb learners is perceived as a longterm solution however its implementation may take years especially in public schools since school stakeholders must first file requests with the government and explain the undesirable effects of not having these facilities the provision of these facilities will not only be a management strategy for lgbbased bullying but also a welcome note and sign of acknowledgement for all lgb learners followup lgbbased bullying cases courage for school stakeholders to intervene and act towards disciplining learners that engage in lgbbased bullying will be advantageous for lgb learners as they will be almost free from victimization based on their gender identity thats the reason cymru suggested consistent and effective responses to lgbbased bullying cases which will assure lgb learners that their cases are taken seriously lf2 articulated that lf2 the school needs to take lgb bullying seriously by following up on the cases and not letting learners just go without punishment so that they will know that bullying is wrong for everyone lf2 observed that the school does not consider lgbbased bullying a crucial phenomenon that requires the schools attention hence she suggested that this type of bullying must be thoroughly addressed and punishable this will serve as a lesson for all heterosexual learners who intend to bully lgb learners whatever bullying method is used it is unacceptable based on this analysis there is undying trust and belief that teachers can play a crucial role in freeing learners minds from misconceptions and biases towards lgb learners this can be achieved by practicing their power and adhering to government laws that enforce them to protect and advocate for learners when necessary similarly to this finding the department of basic education recommends immediate intervention an investigation of the nature of the incident and disciplining those involved conclusion and recommendations the study explored the limitations of schools in managing lgbbased bullying and investigated methods for combating lgbbased school bullying in secondary schools using the principles of interpretivism paradigm the study concluded that inadequate teacher support and protection lgb not being recognized consistency with religion indistinct and no lgbbased bullying reports and usage of the same facilities as heterosexual learners are limitations that hinder schools from combating lgbbased school bullying on the other hand it was concluded that methods such as avoiding gender disclosure creating awareness about gender diversity providing bathrooms for lgb learners and following up on lgbbased bullying cases are strategies to combat lgbbased school bullying this study has the following recommendations • encouraging frequent and transparent catalogues about gender diversity to familiarize school stakeholders with the existence of lgb learners • demotivate learners from engaging in lgbbased school bullying by clearly elucidating the consequences they may encounter should they be resilient • foster teachers to intervene in lgb bullying cases regardless of gender identification • lastly encourage lgb learners to distinctly report lgbbased bullying reports to enable teachers and other school stakeholders to intervene and resolve their encounters the researchers suggest further studies that will focus on exploring teachers attitudes towards lgb learners which may reveal the root of lgb learners dearth of recognition and advocacy in their schools study limitations the sensitive nature of this study made it difficult for some participants to participate in it the researchers aimed to have at least 10 participants unfortunately some refused to share their opinions with us especially teachers funding this study received no specific financial support institutional review board statement the ethical committee of the walter sisulu university south africa has granted approval for this study with the protocol number beec 20922 transparency the authors confirm that the manuscript is an honest accurate and transparent account of the study that no vital features of the study have been omitted and that any discrepancies from the study as planned have been explained this study followed all ethical practices during writing competing interests the authors declare that they have no competing interests article history

purpose despite lgb recognition recent literature and news reports have evidenced the existence of lgbbased school bullying among schoolgoing adolescents through this learners experience calamities such as anxiety insecurity poor academic performance and even suicide for this reason this study investigates the limitations of schools in combating lgbbased school bullying and determines methods to combat lgbbased school bullying designmethodologyapproach this qualitative study was lensed through social stigma theory sst and the antibias education approach abea adopting a constructivist paradigm and a case study design to elicit descriptive data from the participants indepth interviews were conducted with 9 purposefully sampled participants including 4 senior phase teachers grades 8 9 2 lesbian females and 3 gay senior phase learners researchers utilized braun and clarkes six steps of thematic analysis to make sense of the data findings this study revealed a number of barriers that prevent schools from addressing bullying that is based on lgb among students in the senior phase these include uneducated and unsupportive professors the lack of recognition of lgb adherence to religion vague and nonexistent claims of bullying based on lgb and the use of the same facilities as students who are heterosexual this study also revealed that avoiding gender disclosure creating awareness about gender diversity providing bathrooms for lgb learners and following up on lgbbased bullying cases are methods that can be practiced to combat lgbbased school bullyingthis study concludes by recommending frequent dialogues about lgb among learners and teachers to familiarize themselves with its existence research implications the study identified the need for schools to combat lgbbased school bullyingthe study recommends open dialogues on gender diversity discourages lgbbased bullying empowers teachers to intervene and promotes confidence in lgbbased learners contribution to literature this research contributes to the body of knowledge by identifying and addressing the unique challenges associated with lgbbased school bullying

introduction the emergence of the covid19 pandemic in early 2020 has unleashed havoc of its kind on the entire world affecting almost all aspects of human lives the higher education system was no different primarily it caused delays and postponement of many physical events and activities which resulted in a rapid shift of physical teaching to the digital one leading to the emergence of new normality in the higher education system this emergence of covid19 has brought new opportunities in research collaboration education learning and institutional governance the higher educational institutes were made to rethink and redesign their overall structure for the modern and dynamic execution of the knowledge dissemination process with the implementation of immediate changes such institutes require contingency initiatives and riskmitigation strategies to continue growing innovatively even though this pandemic has forced the higher education institutes to reform the role of the innovative learning environment through digitalization and to educate formulate and induce those innovative skills in the students which can bring international students to the next level of learning besides the prevailing pandemic has adversely affected the students personalities because of their physical and technological exposure to the educational institute and its sociocultural learning and adaptions moreover the given study highlights the hidden aspects associated with international students personality development constraints it also opens the additional avenues for the higher education systems to rethink and reconsider the personality development aspects of the students which are the crucial aspects in their career planning and also in the formation of university image and ranking recently there has been a rising interest in international education as many students travel abroad to pursue higher education in developed nations several reasons attract students toward international higher education including international education as an essential source of their competitive personality grooming they were followed by providing improved chances of skills with the help of technologybased educational facilities along with all the positives higher education confronts several challenges in its journey toward adopting emerging learning models and meeting dynamic needs including issues related to educational technology and cultural and sociopolitical adoption specifically in the postcovid era it is essential to be mindful that advancedlevel teaching and learning cannot be translated into a reality without the influx of technology specifically it is essential to nurture the skills demanded by the job market in the 21st century it is obvious that the people travel to different countries and are more interested in learning the other countries cultural norms the government is taking different initiatives to ensure that the students are provided with every kind of facility in their international highranked institutes they must not be discriminated against because of their varied cultural affiliation similarly it is also the responsibility of the people of the host country to be more tolerant toward international students and let them embed themselves into the host nations culture furthermore aboramadan suggests that it is also the responsibility of the international students to promptly integrate with the international culture and opt for strategies to develop their academic profile effectively likewise career planning is supposed to be one of the primary motives of every international student which is why they prefer developing their academic profiles for a better career the urge for a brilliant professional career forces most aspirants to travel abroad for quality education similarly through innovative quality academic learning international students reasonably develop their personalities for a better professional career it is believed that those students who get an education in the international institutes of a high standard have more robust and influential personalities than those who do not have the opportunity to learn in the international institutes in developed countries cultural difference is one of the main problems for the international students it is essential to understand that the students with high cultural adoptive profiles sail through all the technological and socioeconomicpolitical hiccups however the students with a dominant mother culture personality face different problems in the way of their cultural adoption furthermore it has been observed that there is a definite shift in international academic institute structure which has given rise to the unique innovative educational possibilities to diversify teaching and learning procedures as such international learning environments have emerged at a rapid pace they have been termed the innovative learning environments which hold the potential to engage motivate and attract a more significant number of international academic aspirants it is one of the reasons why the desire to be part of institutes with innovative learning environments is quite prevalent among students interested in pursuing higher education moreover according to ige et al innovative learning behavior is one of the key traits that help people develop their profile by identifying new ways of learning students with innovative learning behavior are more substantial and effectively learn things however to reach its full potential it is essential to realize that digital evolution across international higher education has made all stakeholders undergo identifiable changes because of this innovative learning shift it requires a sufficient adaptation on behalf of students teachers and the international institute at large consequently to test the phenomena at hand this study uses the prism of higher education theory therefore this study aims to understand the role of an innovative learning environment career planning and sociocultural adaptation and difficulties as determinants of higher education institution choice decisions by international students in the postpandemic era in pursuit of testing the abovestated relationships it is imperative to understand that the cultural and social botherations caused by the host countries are some of the primary roadblocks to the success of the international academic institutes these indicators hinder international students from seeking admission to such institutes therefore this study is designed to understand to what extent of innovative learning environments career planning and personality development opportunities lead international students to get an education in the international institutes in the postpandemic era significantly the theoretical framework of this study has been extracted from recent studies with inconclusive findings notably past studies lack understanding of innovative learning environment career planning and sociocultural adaptation difficulties as determinants of higher education institution choice decisions by international students in the postpandemic era therefore the framework of this study is designed to provide meaningful information related to the motivation career planning and cultural adaptation difficulties in the context of the higher education of the international students in developed and advanced countries to the researcher no particular study was conducted to address the relationship between career planning personality development cultural adoption and higher education in international institutes however the theoretical implications of this study would address the gap in the literature and emphasize the role of other variables that bother international academic aspirants and institutes interested in having such students on board similarly the practical implications of this study would be helpful for the stakeholders to consider different variables used in the study for managing and improving the behavior and thinking of the international students to integrate with the culture of the host countrys people furthermore this study provides significant future directions that are important for future researchers not to repeat the same work but go with an alternative strategy literature review and hypothesis development in this study the research model is designed on the interpretation of the theory of higher education the theory of higher education highlights that the students are more concerned and affected by their thought patterns and beliefs which they establish over time therefore this theory emphasizes higher education managements importance in considering these values and providing a sustainable working environment for the students to learn furthermore the interpretive lens demonstrates that by providing a conducive environment for academic growth college students will be in a better position to perform in a productive manner however during the literature review it was identified that multiple other factors contribute to the sustainable development of higher education for college students this study has considered multiple other variables such as innovative learning environment personality development career planning and cultural adoption to understand motivation career planning and sociocultural adaptation difficulties as determinants of higher education institution choice decisions by international students in the postpandemic era also based on these additions to the body of knowledge stakeholders across the higher education system would be in a better position to emphasize factors that are more critical for students interested in pursuing international higher education in the postpandemic era relationship between career planning cultural adoption and personality development it is essential to understand that carrier planning is one of the prime objectives of international students when they are willing to get admission to international institutes for their higher education it is also observed that the students of thirdworld countries are more interested in getting admission across developed nations to groom their personalities however according to martíngarcía et al it is not easy to get admission to an international institute because most institutes are backed by several cultural political and social norms and rules and regulations studies have revealed that international students face cultural crises during their academic stay at international educational institutes international students will likely experience difficulties adapting to their new context it is hard for the international students to survive in the international institute because in such kinds of institutes different cultural and social dimensions challenge the ethical norms and it is not easy to integrate with the student of other cultures as such integration might demand multilevel accommodation therefore it would be fitting to expect that international students would have to go through a challenging lifechanging encounter conversely in america according to the study by thaothampitak and wongsuwatt the students of different countries are getting an education in the higher institutes and it is believed that american institutions are suitable for personality development and career development besides it is also essential to consider that international students in american institutes are not treated well because of sociocultural evil that disturbs the educational process across institutes similarly in canada students from different countries are getting an education however the cultural variation and different social backgrounds are hurdles in developing their personalities with no counter strategies available for the issue at hand likewise it is critical to understand that it is not easy for people to accept others from different cultural backgrounds while on the contrary such international institutes have a reasonable extent of cultural diversity among students moreover people from different cultures pursue their academic endeavors together so it is also the responsibility of the institutes management to apply policies to avoid cultural clashes innovative learning environment career planning cultural adoption personality development higher education institution choice by international students figure 1 research model in the international institutions of korea it is reported that the domestic students are more reluctant toward the international students and most are biased they do not treat the international students according to their culture and ethical values it has also been observed that institutes across korea arrange cultural classes for students who apply from the third world and asian countries to be specific which is adding to the reluctance of international students to consider korea for their international academic endeavors furthermore international students willing to be admitted to the international institutes are always interested in the host countrys culture the students believe that the cultural class of the first country would not allow these people to get an education in the right way and would not help them develop their personalities effectively in this regard the responsibility of the educational institute is to determine the different kinds of problems that are hurdles in the way of admission of the international students to provide the solution for them that would be refractive for their learning most of the time international students face a different kind of crises in international education due to such a crisis their personality development declines becoming one of the prime reasons behind negative word of mouth importantly in the era of the pandemic it is noted that students studying in international institutes have faced different kinds of cultural problems in the american universities the chinese student was blamed for the covid19 virus which supposedly happened because of a political narrative set by one nation against the other on the contrary it is also essential to understand that the people who represent the different cultures must believe that they should treat others ethically importantly it is the governments responsibility to provide ethical education to the people and develop students effectively for their better personalities and understanding therefore it is crucial to understand that those international institutes that provide students with proper training and career planning and counseling will be in a better position to make them adopt the host culture h1 there is a relationship between career planning and cultural adoption h2 there is a relationship between career planning and personality development h3 there is a relationship between career planning and higher education relationship between innovative learning behavior personality development and higher education people from multiple cultural backgrounds live together in international academic institutes representing their cultures and seeking education besides it is a trend that international students are getting admission into higher education because they believe that getting higher education from a reputable international institute would develop their personality and career through innovative learning practices further people from different cultural backgrounds seek education from international institutes and become more concerned about the host countrys culture and political system contributing a lot to their personality development and learning in this regard it is not only the responsibility of the people of the host country to value and respect the international students but also the responsibility of the people who are getting admission to the international institutes to value the innovative learning practices culture and the socialeconomic system of the host country while failure to adjust to the technologybased creative atmosphere can be subjected to the apparent disconnect between students culture host institutes culture and their leadership therefore it is believed that the host nations mutual trust and mutual respect and academic and national cultural values of each other help develop better harmony among locals and international students importantly with the help of globalization and different drivers of globalism it has become easier for the people to understand the culture of the people as trade and technology have ensured easy cultural diffusion it has helped locals realize the importance of accepting the guest students cultural differences and adjusting themselves accordingly in addition innovative learning behavior is crucial for an average student to adjust to the international education scenario as it helps them accept the emerging innovative academic and cultural dimensions which make them acceptably alter their personalities likewise to make this procedural and psychological adjustment by students easier critical analysis on how such an influx of innovative learning models will benefit students academic outcomes is unavoidable similarly unquestioned implementation of educational innovations might hinder innovative learning procedural adoption in addition in their study have discussed the impact of an innovative learning environment on students behavioral outcomes they have referred to an educational environment as a blended learning environment with a sufficient level of digitalized learning facilities it was also found that there has been an improvement in students learning and behavioral outcomes once they get a chance to adapt and adjust in such a blended learning environment that is why the students in international institutes are more developed in their studies than those who get an education from a domestic institute in america and the united kingdom the educational institutes are providing the opportunity for the international student to get the higher education from the facilitated and wellestablished institutes the research and development have been established effectively and creatively contributing to the students personality this way the trend of getting an international higher education has increased over the past three decades the students are more interested in getting an education in the international institutes because they are wellinformed about the clear distinction between the students of the national and international institutes notably the students are always willing to develop their personality because they believe personality is constantly changing concepts with the help of more innovative learning behavior it would be appropriate for the students to learn things critically still a good contradiction exists on how a technologybased innovative learning environment can help enhance student learning and engagement therefore there is a need for a wellthought influx of innovative learning tools especially the speedy digitalization of the education system during the covid19 pandemic it has made it imperative for the international students to stay ahead in terms of being flexible to cultural technological and social variations they will face therefore it is hypothesized as follows h4 there is a relationship between an innovative learning environment and personality development h5 there is a relationship between an innovative learning environment and higher education h6 there is a relationship between personality development and higher education personality development cultural adoption and higher education personality is another critical component of human behavior and action it is a fact that every individual has a different set of personality traits and he is entirely different from the other human being personality is one of the subjective approaches to human behavior that helps to grow and provides more of a gift for improving the behavior in the career development of any individual the role of personality is critical because it matters a lot when one is the applicant for getting any job in this way the students are more conscious of developing their personality and attitude to the advanced level for better jobs in the industrial sector significantly bhatti et al noticed that the thirdworld countries are not appropriately working to improve the students personalities to the required extent in this regard the students of the thirdworld countries are more interested in traveling abroad and getting an education from an international standard academic institute to develop their personality appropriately in the past the tradition of traveling for international education was not common because different cultural and social barriers inhibited the people from getting an education from the international institute for higher education however with the development of globalism and global institutes it has become more accessible for people to get admission to international institutes for education in this way the students from different thirdworld countries and the asian countries travel to the developed and advanced countries to get an education and develop their personalities according to the modern standard it is critical to understand that if the students are allowed admission to the international institutes their personalities will be shaped according to the international employer requirements it indicates that personality development is one of the critical criteria for shortlisting the academic institute held by students interested in applying to international higher education institutes therefore the international institutes that provide students with facilities to groom their personality as demanded by reputed employers will indeed be preferred by potential students for their higher education the reputed organization will credit the intellectual personalities because of their personal and professional interactions knowing that other people attract people with good personalities and positive attitudes is critical because they are more positive and do not react to their perceived values and norms however on the contrary people with low personalities and the capability to work with high standards are not selfmotivated they are limited to their personality as they are not getting the opportunity for the best education in this way the students from pakistan india and china travel to the international institutes and highclass universities in america and the united kingdom to seek education and enhance their skills related to research and development this research and developments are not only necessary for the students for the development of their personality but also it is critical for the people of different countries because with the help of these personality characteristics people are more advanced to get the maximum benefit from the society and the educational institutes importantly it is the responsibility of the stakeholder to consider personality as a unique and distinctive human characteristic and provide the opportunity to boost it to the students and other people of the society if the opportunity was provided to the people to enhance their personality skills it would be beneficial for them to get the right skills and develop more strategies for maximum benefit it also indicates that in developing ones personality the student willingly agrees to adapt to the culture which is not the primary culture students work to adapt academic professional and socially benchmarked cultures to achieve the desired performance outcomes therefore according to pan et al it is also the responsibility of the international institutes management and board of directors to integrate personality with human life and provide opportunities to the international student to develop their personality to the appropriate level it is also noted that if the opportunities related to personality development are provided to the students in the international institutes of higher education the development of human skills would be enhanced and people would become more competent in their respective fields likewise the students from japan are more concerned about their personality development when they are getting an education in the educational institutes of western countries similarly the english students in america and the united kingdom are working to develop their personalities and critical skills with the help of higher education because they have the opportunity to get an education in the wellreputed and wellestablished institutes in the world in the same manner the students from every country must be provided with the opportunity for personality development by the management of the educational institute to grow productively to the advanced level for a more efficient result therefore it is proposed as follows h7 there is a relationship between personality development and cultural adoption h8 there is a relationship between cultural adoption and higher education methodology prepare questionnaire this study is based on the quantitative data the target respondents collected through the surveybased method it is noted that the surveybased data collection method is the appropriate method as it is timesaving and costsaving in this regard the structured questionnaire was prepared on a fivepoint likert scale to collect the data to determine the relationship between different variables presented in the studys theoretical framework notably the scale items in this questionnaire were taken from the creditable earlier studies the scale items for personality development were taken from the study of penketh et al similarly the scale item of innovative learning environment was taken from the study of rosedi et al moreover the scale items for cultural adoption were adopted from hadziabdic et als study the scale items for higher education were adopted from scotland and the scale items for career planning were taken from the study of presti et al in addition these scale items were reviewed by expert researchers to check their significance and worth for the study data collection process the questionnaire of this study was developed carefully and ensured that the integrated scale items were essential and reliable for collecting the data from the respondents the respondents of this study were the students of different countries that are getting admissions and getting an education in international institutes across china moreover the data were collected from students of international institutes and 600 questionnaires were distributed to the respondents in china in this way the studys introduction also provided a better understanding of the subject similarly the paid envelopes were also provided to them for the return of the questionnaires the respondents were welcome to ask any question and in this regard they were provided with the researchers email to get an answer related to the questionnaires however the incorrect questionnaires were not considered for the study finally 260 questionnaires were considered for the study to analyze the data for the studys hypotheses findings this study section has the confirmatory factor analysis results which are presented in table 1 confirmatory factor analysis is conducted to determine the values of factor loadings for the scale items of variables used in the study significantly the values of factor loadings for all scale items were not less than 040 as recommended by hair et al furthermore the scale items used to measure the data are presented in this study section these scale items were carefully considered to determine the relationship between the hypotheses developed based on the theoretical framework of this study measurement model in this study section amos software was used to determine the reliability and validity of the scale items used the results reveal a clear correlation reliability and validity furthermore the composite reliability values were not less than 070 as recommended by henseler et al also the average variance extracted value was not less than 060 in this study as recommended by henseler and fassott according to the results there is apparent reliability and validity between the scale items used for each study variable in addition the measurement model fit was determined by analyzing and evaluating the root mean square of approximation absolute fit measures standardized root mean square residual comparative fit index normed fit index and adjusted goodness of fit importantly all the values were appropriate for the recommended threshold for it discriminant validity the discriminant validity was checked using heterotraitmonotrait method to understand the distinction used for each construct of every variable significantly the results reveal that all the values of discriminant validity were not less than 090 which hair et al recommended for modern studies therefore according to the results the constructs used for each study variable have apparent discriminant validity structural model in this section of the study the results of the hypotheses tests are presented in table 4 h1 was tested to check its significance and according to the results career planning has a significant effect on cultural adoption and h1 is accepted h2 was tested to check its significance and according to the results career planning has a significant effect on personality development and h2 is accepted h3 was tested to check its significance and according to the results career planning significantly affects higher education and h3 is accepted h4 was tested to check its significance and according to the results an innovative learning environment significantly affects personality development and h4 is accepted h5 was tested to check its significance and according to the results an innovative learning environment significantly affects higher education and h5 is accepted h6 was tested to check its significance and according to the results personality development has a significant effect on higher education and h6 is accepted h7 was tested to check its significance and according to the results personality development has a significant effect on cultural adoption and h7 is accepted lastly h8 was tested to check its significance and according to the results cultural adoption significantly affects higher education and h8 is accepted discussion table 5 shows the standardized path coefficient with h12345678 the findings of h1 h2 and h3 demonstrate a significant relationship between career planning cultural adoption personality development and higher education it is essential to understand that international students travel to firstworld countries to get higher education because they want to develop their careers successfully indeed according to scotland it is suitable for students who are willing to develop their personality and career by getting an education from a worldclass university however different barriers such as cultural adoption and social barriers must be eliminated in this way the opportunities should be provided to the students willing to get an education from the international institutes it is the responsibility of the government and the peacemaker nongovernment organizations to intervene and modify the cultural awareness of the students and provide them with information to tolerate the culture of the host country moreover it is also understood that for the development of culture and enhancement of regulations related to the culture more information must be provided to the people to develop them in a productive way for tolerating the culture and the people associated with it the chinese students who are getting an education in the universities in the united states are more aware of the cultural clashes but they tolerate kindness for their more significant benefit similarly cultural awareness of this kind must be provided to the student of the other countries to ensure that they are not rejected however they must consider and value the culture of the other community in this way creating unity in the cultural understanding would be an excellent opportunity for developing a mutual relationship between the community for progress and productivity the results of h4 and h5 demonstrate a significant relationship between an innovative learning environment personality development and higher education however it is noted that the innovative learning environment is critical for international students learning when they are getting an education in worldclass universities the students of japan who are getting an education in australia and the united kingdom believe that if they are provided with a sustainable and comfortable environment of learning with the security of innovative learning behavior then it would be more effective for them to develop their ability constructively the international institutes are responsible for providing opportunities to international students to enhance garcía et al 2019 besides it is reasonable to understand that the purpose of every student is to get an education from foreign institutes for the development of the personality because this development in personality provides the opportunity for better understanding significantly the appropriate actions must be taken to create an innovative learning environment with the help of effective and innovative teaching methods to improve the students performance to the advanced level notably more innovation in the learning must be provided to the students as a result it solves the problem in this manner the higher institutes must be responsible for developing innovative learning strategies and improving the students performance the results of h6 demonstrate a significant relationship between personality development and higher education indeed the critical motive of any student is to get higher education for the personality development because until and unless any institution is not providing the opportunity for the personality development of the student then it would not be reliable for the student to get admission in that institution besides the international institutes hosting international students are more flexible in providing the opportunity for personality development to the students because by providing these opportunities the institutes are attracting the students the institutes contributing to the students personality are more considerable by the international students for the higher education the results of h7 demonstrate a significant relationship between personality development and cultural adoption furthermore the results of h8 demonstrate a significant relationship between cultural adoption and higher education in this regard it is noted that the students willing to get admission to the international institute for higher education are more concerned about their personality development and profile status moreover some students believe that the host countrys culture would be challenging for them in their higher education as the people of different cultures are not ready to tolerate the values of the people of the other culture importantly it is the responsibility of the government and international university management to provide suitable facilities to the students for the development of their personality and socioculture adaptation exposure similarly the understanding of the culture and emotional intelligence must be provided to the society so the people should not be face to face for the concerned about their cultural values in addition it is noted that in the era of globalism everyone lives in one integrated culture but the traditional concept of cultures is not eliminated therefore the management must provide reasonable facilities for cultural tolerance to boost the personality of the international students conclusion this study concludes that there is a significant role of personality development career planning innovative learning environment and cultural adoption provided by the higher educational institute in attracting more international students to take admissions the study indicates that international higher education institutes need to be mindful of the emerging students requirements and their rising concerns in the postcovid19 era indeed international students are getting an education in america and canada because they believe their profile would be developed if they get an education from highclass institutes they would learn critical abilities to understand the problem and cope with the problems in an effective way therefore the implications of the study would be significant for the stakeholders to provide the best and most innovative learning environment by eliminating all of the barriers in the way of international students who are getting admission to the worldclass universities of the top world countries importantly this study demonstrates that the gap in the literature was identified that had been addressed by developing the research framework that would be useful for future studies to understand the relationship between different variables that are taken to develop the hypotheses of the study in addition the study provides significant future directions that are important to consider for future researchers interested in pursuing research in the given domain in the postcovid times moreover this study highlights that the responsibility of the international students is to integrate with the host countrys culture and develop their personality in the innovative learning environment for career planning by getting a higher education implications theoretical implications this study is designed to provide significant theoretical implications related to the admission and education of international students in the wellreputed international institutes of developed countries it is a fact that every student wants to develop his personality and career by getting an education from credible international institutes because the educational institutes contribute a lot to the development of a file of the students in this regard it is crucial to understand that there are different problems related to the culture and tradition of the international students that limit them from participating in activities to getting an education from the international institutes however very few studies were conducted to determine the relationship between different cultural factors in getting admission to international institutions in the postpandemic era in this way the study highlights that the students who are willing to get an education from the international institutes must consider the vital role of personality development and career planning because the educational institutes matter a lot while getting a job in the industry similarly the study demonstrates an essential role of cultural adoption in international education because it was not considered by any earliest studies to influence the students personality in the international institutions for higher education importantly this study highlights that the innovative learning environment is also critical for the students to be understood for getting an education in the international institutes in this manner the study provides the relationship between different variables that are taken in the research framework of the study that would be useful for future researchers to determine the relationship between variables related to the higher education of the students in the international institute practical and managerial implications this study also provides significant practical implications that are important to consider for the stakeholders providing international higher education to the students traveling from different countries to pursue their educational degrees it is essential to understand that the international students are traveling to the developed countries for an education because they believe that getting an education from the developed countries would be beneficial for them to develop their personality and skills for working and getting a job in the reputable departments however it is reasonable to note that there are different kinds of challenges posed by increasing competition and the covid19 pandemic that international students face in the international scenario because they belong to different cultures in this way it is the governments responsibility and the management of the higher institute to regulate human behavior and provide awareness related to the importance of patience required by international students notably the students are traveling to the developed countries to get an education and want to settle there and get professional life in the developed countries in this way it is the responsibility of the host countrys government to integrate the international students with the local students effectively to provide the best facilities for learning from each other moreover it is the governments responsibility to ensure that the students are not discriminated against based on culture and must be given equal opportunities to get better results for their living standards in addition it is the students responsibility to value the beliefs and norms of the opponent culture because if there is no emotional intelligence to determine the cultural changes it would be difficult for the international students to survive and pursue their education at international universities limitations and future directions this study aimed to understand motivation career planning and sociocultural adaptation difficulties as determinants of higher education institution choice decisions by international students in the postpandemic era like any other study the given one is also faced with certain limitations which can be the source of future direction for other research initially due to time constraints the study deals with a crosssectional research design however the phenomena can be studied better if data could be collected from students who aspire to get admission to international academic institutes and when they end up with their degree programs therefore the longitudinal research design is suggested for future studies in the given work area similarly the data were collected only from international topranked institutes from china so there can be an issue of generalizability therefore it is suggested that future studies could look into the phenomena from a comparative viewpoint the literature review observed that multiple other factors contribute to the motivation and career planning for higher education in international institutes first future studies must consider the important role of visa policy in getting admission to international institutes second future studies must focus on ethical values role in international students problems lastly future studies should focus on government policies role in taking admission into international institutes specifically in the postpandemic era data availability statement the original contributions presented in this study are included in the articlesupplementary material further inquiries can be directed to the corresponding author ethics statement the studies involving human participants were reviewed and approved by the shanghai polytechnic university china the patientsparticipants provided their written informed consent to participate in this study this study was conducted following the declaration of helsinki conflict of interest the author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

the world is facing an unprecedented health crisis with the spread of covid19 across different corners of the globe this pandemic has raised more significant concerns about international students learning environment personality development and career planning particularly in highranked institutes in china now the question concerning this dilemma is would the covid19 pandemic negatively affect students education and the country culture where they are bound to seek information and the subject education therefore this study examines the impact of innovative learning environment career planning and sociocultural adaptationrelated difficulties faced by international students as determinants of higher education institution choice decisions made by international students in the postpandemic era this quantitative study examined international students in highranked universities across china the data from 260 students were collected through a structured questionnaire and analyzed using the amos technique moreover it has been observed that the current global health crisis has intensified social inequalities across different international higher education systems countries fail to maintain the scale of the innovative international learning environment the results further indicated that international students are more considerate of innovative learning environments cultural adoption career planning and personality development specifically after the outbreak of the covid19 pandemic which has drastically affected the global higher education system unusually more than half of the participants wanted to maintain the option of overall distance education after the pandemic however apart from this argument it is appropriate to demand significant changes in postpandemic education adapted to the postdigital era and to satisfy the concerns and expectations of the students

introduction menopause is a biopsychosocial phenomenon starting at the median age of 51 marking the end of reproductive life for women it coincides with midtolate career stage a time associated with technically competent leadership this study focuses on cognitive menopause symptoms defined as declining attention verbal learning verbal memory working memory caused by chemical changes to the brain during early menopause depending on severity of symptoms women may have difficulty in managing job demands potentially leading to voluntary or forced exits from employment as highlighted in some recent uk employment 1020856jnicec5108 journal of the national institute for career education and counselling tribunals the women and equalities committee survey menopause in the workplace found cognitive symptoms were experienced by 73 of women and the second most difficult symptom to manage therefore understanding the lived experiences of women transitioning through menopause is important to create a genderinclusive and intergenerational workforce the literature review conducted in 2022 found some women are subjected to workplace gendered ageism including sexist comments on appearance creating pressure to appear more youthful working menopausal women are surrounded by negative messages resulting in some women hiding their menopausal identity for fear of being overlooked for opportunities hall and mirvis describe the meanings women attach to identity whilst experiencing menopause at work as contextual and influenced by genderbased norms expressed by coworkers leading to potentially adverse performance interpretations therefore any negative perceptions of cognitive ability may weaken leader emergence for fear of negative performance management or redundancy overall the review found meanings women give to menopause in the workplace is an interpretive complex process based on selfconcept and the work environment extant research has predominately been conducted through a positivist paradigm seeking to quantify menopausal symptoms however positivism does not give meanings to feelings perceptions and attitudes uncertainty exists around how professional women in leadership positions make sense and attach meaning to cognitive symptoms associated with menopause weicks theory of sensemaking offers a conceptual framework to explain how women make sense and attach meaning to their menopause transition in the workplace weicks model can be used to identity how professional womens lived experiences of menopause are influenced by their interactions with others through language and cues drawing on louiss model for sensemaking in transitions it is possible given the shock that may occur during menopause transition women have no established network around them to test perceptions and end up using stereotypes existing in society potentially this puts their professional identity into question resulting in adverse interpretations of their capability to work therefore if menopause triggers a change in a womans sense of self it could influence her professional identity methodology given the interest in sensemaking an ipa framework was used to explore participants lived experiences this study contributed to the understanding of this phenomena by asking how do women experiencing cognitive symptoms associated with menopause make sense of their experiences in the workplace helen root journal of the national institute for career education and counselling table 1 an interpretive phenomenological analysis this study was granted ethical approval from birkbeck university in 2022 in accordance with smith and nizza five participants were recruited using snowball sampling via a professional womens network findings and discussion how participants experienced and made sense of cognitive menopause symptoms in the workplace emerged as five interrelated themes providing an opportunity to understand the impact of menopause on careers menopause was an emotive word holding a negative meaning for participants to give meaning to their menopause transitions participants often relied on how they were before the symptoms started to make sense of the change in cognitive functioning this had the added impact of highlighting the suddenness of change to their working lives which came as a shock in common with other ipa studies examining transitions participants expressed difficulties in integrating symptoms with their selfconcept as not feeling myself symptoms were described as not normal making work experiences more challenging validating louis sensemaking theory findings are discussed with reference to existing literature and illustrated with germane quotations in italics from individual participants five group experiential themes subthemes a sense of loss and fear a sense of loss and fear the language of burden around menopause is deeply embedded this was echoed in this study of seemingly successful and confident professionals who upon menopause transition became fearful of losing credibility describing experiences using language of anguish such as terror and panic people look to me for direction for answers for advice for guidance i felt totally spaced out…which was really frightening it just makes you feel vulnerable…it gives you that feeling of quite isolated fearful i thought im not going to be able to do my job…i was terrified at the point of it happening helen root journal of the national institute for career education and counselling evidence was found suggesting systemic embedded negative stereotypes around menopause the embodiment of which created concerns about being labelled or capability being questioned you dont want to walk around with a big m on your forehead and labelled as a female going through menopause…others will see me as less capable i dont want to identify as menopausal as i dont think it identifies me participants experienced liminality during this time of adjustment struggling let go of their premenopausal self and embrace their new menopause self vulnerable it confidence and control participants felt menopause was a taboo subject its easier to say its my age forgive me than to say its my menopause forgive me they concealed and controlled their cognitive symptoms attempting to conform to workplace norms fearful of giving anyone ammunition for women where they have reached that level where they are expected to be dynamic to be attentive to be switched on…a price comes with that you dont want to give anybody ammunition to say shes not performing quite right their sensemaking indicated conflict between symptoms experienced and their work persona of intelligent and articulate further challenging selfconcept fear of stigmatisation culminated in participants becoming withdrawn questioning their value and organisational fit as a senior leader within the organisation people expect you to be sharpto be switched on that selfconfidence that selfbelief youve built up from years of experience performing at a certain level when that isnt there that fundamentally calls into question…am i in the right place am i in the right role participants displayed strong role commitment yet when their confidence diminished became disengaged and started to withdraw commitment to the organisation building on the study by jack et al all participants expressed negative menopausal stereotypes which were incongruous with the ideal worker characteristics they held such as being switched on and sharp sensemaking is a social process in organisations where ideal worker schemas are typically forceful and decisive women experiencing cognitive symptoms may feel their identity no longer fits that schema and choose to withdraw professional identity professional and nonwork identities are connected dimensions of employability therefore if cognitive menopause symptoms trigger a change in an individuals sense of self it could influence their professional identity this study builds on steffans research exploring how menopausal women construct work identity participants put great value on consistency of performance and intellectual capacity which was tied to their image of a successful midlife career unpredictable symptoms created a fear of reputational damage ultimately challenging their selfconcept you dont want anyone feeling sorry for you or feeling pitiful you dont want to be pitied… i dont want to feel like i am coming across as a menopausal mess because im very conscious how to portray myself in a professional setting concerns about others perceptions together with their own thoughts of being a professional mess cumulated in a sense of negative selfidentity they might treat you differently they might think differently of you especially males… you have to look a certain way like you in control like you know what youre doing winterich and umberson found how workplace colleagues define menopause is socioculturally specific shaping how women put meaning to menopause impacting their engagement and career choices i want to be respected so the thought of people losing respect for you because youre not as sharp or as switched on as youve been previously or your star has dimmed… that would have made me feel deeply deeply unhappy deeply unhappy negative socially constructed discourses of menopause seep into workplaces not only through the wider socioeconomic context but also through the psychosocial characteristic of organisational environments where gender inequality is built into employment structures partly through workplace interactions parallels can be made with maternity leave returners who think others will view them differently helen disclosure the sensemaking process was seemingly environmentally contingent as participants acknowledged the competitiveness in pressured vicious and hostile organisational environments direct reporting lines impeded disclosure decisions with particular concern that revealing symptoms might lead to loss of reputation or stigmatisation managers were depicted as awkward indicating disclosure decisionmaking was contextual and relational dependent on how they felt others would judge them perceived unsupportive male dominated environments created disclosure barriers i report to a male theres absolutely no way on this earth i would have a conversation with him he would look at me and run away its a bit dogeatdog… hes a classic male driver just bang bang bang wants to control everything…no time to hang around…bam bam bam on to the next thing some organisations had launched menopause policies yet there was little faith in policies per se being a mechanism to improve the work environment participants felt that changing working patterns might reveal their midlife status and lead to negative career consequences to work flexible hours in senior roles the reason becomes very blatant this study adds to the fawcett survey which found disclosure was lowest for women in senior leadership roles where workplace menopause dialogue existed language and symbols became integral to participants sensemaking participants felt patronised by younger women it was like oh bless you the oneil bilimoria three phase model adds to this understanding by finding womens sense of self being driven by relationships however fear of disclosure went beyond environmental perception mostly there was a sense nothing could be done to support them thus reinforcing feelings of isolation helen root journal of the national institute for career education and counselling impact at work and on career participants described considerable challenges maintaining performance levels whilst experiencing symptoms that were often described as being incompatible with the organisations leadership schema participants used assertive language killer ammunition attack signalling embodiment of the hypermasculine norms of the organisation all participants had high work autonomy yet feared cognitive changes being identified as a performance issue participants focused on working longer hours keeping up with job demands to minimise perceived underperformance and protect their reputation yet there was little sense of worklife conflict in narratives i would try and read the material in advance to try and get the words and their phraseology into my mind behind the scenes i was endlessly checking thingsnever confident what something was good enough which isnt really me working longer days…taking more time in the evenings to prepare things than i would have done this concurs with ideal worker theory where women privilege work over homelife to fit in participants often felt disarmed by intellectual fogginess this sometimes lead to a reticence when taking on new projects almost a weariness thats going to be difficult a kind of fogginess intellectual fogginess needing to be able to do that quickly because youre forming judgements…not being as snappy it was almost a weariness whereas normally it would be great get in as professional women their selfconcept of intellectuals became threatened as words escaped them leading to negative selfperception highstake psychosocial factors including client meetings and presentations were coupled with feelings of incompetence creating inconsistent selfnarratives i would regularly forget keywords in presentations often even the subject of the presentation the word would escape me i started to lose confidence…it kept happening the words would escape me topics i delivered regularly would dilute just disappear…just swimming before my eyes…i seem to have lost some of my antennae associations with incompetence in the workplace signify a noninclusive environment ultimately harming womens careers however while not disclosing the cause masking symptoms for fear of repercussions might have stopped managers offering support whilst the extent symptoms impacted participants careers is not certain it is worth noting all experienced a career transition to some degree during the first year of menopause this study concurs with the sullivan et al review of supers career stage model which recognises that a personal difficulty leading to loss of helen root journal of the national institute for career education and counselling confidence could account for changing career direction feelings of helplessness and decisions to resign is it time for me to move on should i stand back and sit in the wings whereas before i would have been super focused and excited…suddenly i feel risk averse before i would have pushed myself forward…now im grappling do i stay in my comfortable role factors driving career transitions come from multiple directions are socially constructed and alter over time therefore menopause may have been a catalyst for change for participants highlighting the importance of social construction in careers at a stage when women are often moving into senior positions attempts to conceal symptoms through withdrawing from opportunities could become a barrier to progression leading to indirect costs for women by not applying for a promotion or reducing hours only one participant disclosed her menopause status to her manager and was later made redundant whilst she did not feel the two events were connected at the time her sensemaking was ongoing as she reflected she was replaced by younger fresher meat…i do wonder if that could just be coincidental implications for organisations whilst formal menopause communications are useful to set the tone within organisations building on the hardy et al study womens openness about support needed is unlikely to be tied to an organisations menopause awareness rhetoric but influenced by the systemic culture making menopause a major focus of attention might conversely result in disempowerment through marginalisation thus rendering workplace interventions ineffective given the relational nature of how women manage careers this study suggests encouraging informal mentoring to support psychosocial needs could lead to greater career satisfaction organisations have an opportunity to train managers on how to have supportive career discussions to promote selfinsight throughout the employee life cycle through developing an understanding of womens changing needs it is possible to foster a culture of inclusion in particular understanding the change in cognitive functioning that some women experience as an early part of menopause may facilitate open ended career path planning ahead of symptoms occurring possibly increasing employee engagement thus the normalisation of menopause conversations in the workplace in conjunction with educating managers on the internalised fears many women experience in order to create empathy and reduce barriers to disclosure may support the retention of midlife talent helen root journal of the national institute for career education and counselling implications for career practitioners the findings have implications for career professionals when considering the intersection of age and gender in the workplace women with successful careers based on intellect may find their selfesteem and confidence impacted when their professional identity is threatened using tools such as a family genogram to analyse social influences as well as scheins model of organisational culture to explore workplace environments may support sensemaking around internalised menopause stigma unpredictable cognitive menopause symptoms can be connected to decreased selfefficacy and confidence therefore using career construction theory to bring understanding of different life roles may enable clients to build confidence and understand their menopausal self career practitioners may consider using nicolsons transition model to understand how symptoms impact confidence and professional identity throughout the menopause transition this studys findings support wright who found women with cognitive symptoms may experience performance issues where there is an expectation they will have immediate recall of data considering menopause often coincides with women taking on more responsibility as they transition into more senior roles identifying effective coping strategies is important eg job crafting to ensure midlife women thrive at work attempts to conceal symptoms by withdrawing from opportunities could have unintended consequences and become a barrier to achieving career goals limitations and future research whilst the researcher did not explore evidence of contextual factors occurring in participants lives menopause intersects with other life stage events potentially accounting for the participants sensemaking the experiential themes identified raise an opportunity for further research on different employment groups and ethnicities to further understand the impact of cognitive menopause symptoms on careers conclusion change in cognitive functioning such as memory loss during menopause is under researched yet important to understand to reduce stigma surrounding menopause as part of creating an inclusive multigenerational labour market by adhering to ipa ideographical principles the design of this study offers a deep understanding of how professional women experience and make sense of cognitive symptoms associated with menopause their sensemaking centred around a desire to maintain reputation and professional identity associated with intellectual capacity a sense of loss pervaded the participants language and went to the heart of sensemaking who am i helen root

more women than ever before are working during the menopause transition yet studying menopause from a career perspective is in its infancy this study explored how women reporting cognitive menopause symptoms make sense of their experiences in the workplace by linking participants narratives to the social construction of menopause interpretive phenomenological analysis ipa was used to reveal how selfconcept can be called into question thus impacting professional identity and career decisions

introduction maternal and child health is considered to be one of the key development indicators of any country 1 over several decades improvements in maternal deaths around childbirth have been quite moderate in lowand middleincome countries leading to the mch strategy as a global campaign to improve maternal health 2 the reduction of maternal and child mortality as well as morbidity remained at the center of successive family welfare programs implemented in india through the government of india various state governments and partners including international organizations and civil society platforms however india still bears an unacceptable burden of maternal and infant mortality 34 evidence shows that institutional delivery reduces the risk of neonatal mortality by 29 percent in lmics it also reduces stillbirth and perinatal mortality as well as maternal mortality 5 6 7 8 9 therefore including the international organization the national and state government of india promoting various scheme and programs to encourage women for institutional delivery to ensure safe birth 10 similarly efforts have been made in india to encourage families to change their healthseeking behaviors so that the majority of underprivileged families can be mobilized for institutional delivery in public health institutions the demand side financing scheme janani suraksha yojana was launched in 2005 by the national rural health mission of india which also included cash incentives for community health workers accredited social health activist in addition in order to strengthen the supply side janani sishu suraksha karyakram was designed as an entitlement scheme for pregnant women and newborns in 2011 11 the world health organization initiative to improve the standard of care given to pregnant women during childbirth is as critical as providing clinical care to achieve the desired humancentred outcomes 12 access to health care facilities may not however guarantee good quality of care 13 across the world disrespectful and unworthy care is prevalent in many facility settings especially for underprivileged populations which violates their rights to create a significant obstacle to seeking healthcare and discourage them to favor institutional delivery 13 however the literature revealed that there is little evidence in india regarding respectful maternity care therefore the purpose of this study was to explore the experiences of ashas on rmc in odisha india rationale disrespect and abuse is a concept closely related to obstetric violence also respectful maternity care is not only a crucial component of quality of care it is a human right there have been many anecdotal reports which depicts pregnant women seeking maternal health services receive discrimination abandonment disrespect and abuse in a health care facility in the indian context there is an urgent need to execute specific research which will explore and highlight the community peoples knowledge and perception regrading disrespect and abuse not only at the facility level but also at the community level asha is the grassroot level worker which connects community as well as the health system asha could be a helpinghand in spreading awareness among the community related to disrespect and abuse which enrich the concept of respectful maternity care among the childbearing mothers in a community hence it is important to know the perception of asha towards respectful care in the facilities and her role in providing knowledge about respectful maternity care in the lens of human rights methods design and settings a qualitative exploratory study was conducted in odisha india three districts were chosen from the 30 districts of the state with one district from each of the three revenue zones of the state total of 24 indepth interviews were conducted among ashas eight from each district all of these participants were actively involved in the provision of mch services motivating and accompanying women for institutional delivery inclusion and exclusion criteria participants were recruited by authors who belonged to the study settings providers were on average 30 years old ranging from 2338 years and everyone had working experience for more than three years all participants belonged to rural areas those who are not willing to participate were excluded from the study ethical consideration the names of the districts were not maintained in order to protect confidentiality a brief overview of the study the intent and their position over the research study was provided to the participants prior to participation and their written consent was obtained the interview was conducted at the home of the participants according to their convenience data collection and analysis the data were collected using semistructured facetoface interviews between march to may 2019 the interview guide was developed in the local language in this case odia the interview guide contained questions about the participants understanding of rmc and their perspectives as well participants were asked about their involvement as a birth companion the facilitys situation and the health care providers behavior in addition they were questioned about their opinion on addressing disrespect and violence at the facility level all the idis were recorded digitally the interview lasted between 30 and 65 minutes with an average length of 45 minutes the interviews recorded were transcribed and translated into english the data were analyzed using content analysis methods 14 interview guide the interview guide was developed in english and later translated into odiya by the researcher the interview guide was at first piloted and pretested for comprehensibility with a sample of five ashas at khurdha the interview guide contained questions on participants perceptions and current opportunities and practices on respectful maternity care to address our first research aim participants were asked about their perception towards respectful maternity care how they assess childbearing mothers needs and expectations prior to the delivery in a hospital and their job responsibilities towards a delivery mother they were also asked directly about their health promotion activities in terms of respectful maternity care at the village level in addition our second research aim was to explore ashas respectful maternity care practice opportunities specifically in the view of promoting institutional delivery and their role in delivering respectful care the researcher also asked for their suggestions or recommendations regarding disrespect and abuse or practicing respectful care at the individual level results two main themes emerged community health workers experiences and perception towards disrespectful care and factors contributing to irrational care the findings are presented under each major themecategory with quotes from the participants theme 1 community health workers experiences and perception towards disrespectful care category 1 disrespect towards the childbearing women a number of experiences have been perceived by ashas regarding the behavior of healthcare providers although some said about the warm and gentle actions of doctors and nurses others shared their negative encounters the most common expression of the study participants was in reference to medical negligence misbehavior and bribery in addition inadequate contact to support mothers who have discomfort during work has been rooted in maternity care practices the senior gynecologist is really nice he is very polite and he treats us and pregnant women as members of his family however the nurse expects money from the family of delivery women in addition discrimination in maternal health services was expressed by ashas which identified social determinants such as economic status and caste as factors affecting mothers accessibility and experience in health services for example a poor mother from a lower social caste was more likely to be discriminated against and exploited when receiving maternal health care in public health facilities there are twothree nurses who only tend to work with cases of higher castes the staff nurse is very reluctant to deal with cases coming from the scheduled tribe community we have no issues with mothers who have a good financial background mistreatment often happens with poor ladiesthey have been unable to provide bribe participants also established the notion of the insensitive and coercive essence of maternal care given at health facilities the abuses have been encountered both verbally and physically often both during the intrapartum period the mothers were scolded eveteased and slapped another dimension of disrespect witnessed by ashas was during the episiotomy process in a few health facilities episiotomy is performed by service providers without the consent of the mother or accompanying person if questions raised by the mother or the accompanying person the health service providers threatened to refer them to another hospital or insist on visiting private hospitals after delivery rama shared her terrible experience of being scolded during delivery you didnt have any pain during sexual intercourse and now youre behaving like dying out of labor pain category 2 disrespect with accompanying persons lack of information related to dignified care the bureaucratic nature of the health care system was the key reason why ashas were scolded by healthcare providers few ashas said they had to establish a good relationship with their anms and other health professionals to prevent mistreatment for example most of the time they had to do the job of an attendant such as buying coffee or tea sometimes after birth the mother was left without a cloth i wrapped her up when i was allowed to enter the room we were asked to clean the floor and the bed if we refused my patients would be referred to a private nursing home where high outofpocket expenses the understanding of the ashas was that the presence of the relatives ensured a loving care of the childbearing mother as they could stay close to the mother and the newborn during and after birth although few ashas have been reported most healthcare providers have not allowed anyone inside the labour room often if the relatives inquired about the women most of the time they were verbally abused the lack of information related to women during a crucial time was also a form of disrespect usually experienced by relatives in health facilities one asha reported that the husband of a childbearing woman faced disrespect and chose not to use the services in the future just close your mouth and stay out there dont question us again and again if you inquire another time just take your wife to another hospital category 3 birth preparedness and complication readiness and case priority when asked to identify the participants as to their responsibility and obligation towards a childbearing woman few participants reported that birth preparedness and complication readiness often contributes to mistreatment by health care providers the two important components of the bpcr are the identification of the birth companion and the organization of the mode of transport few ashas reported on the various challenges they faced while taking a childbearing woman to the facility specifically in terms of transportation in the event of an emergency sometimes the ambulance could not reach a time that restricts mothers not only from providing maternal health services but also ended up facing disrespectful behavior on the part of health providers although few ashas acknowledged their mistake in this situation few blamed the management of the health care system some participants have clarified the adverse situation they had to face from both the community and the health system which sometimes resulted in an uncomfortable state listen to was just the term no one really tried to grasp it as a result they felt devoid in resourcelimited facilities eight women had to be taken care of simultaneously most of the time by one health care provider and at that point emergency and lifesaving treatment had to be given priority over comfort to a woman few participants also made it clear that caste socioeconomic status and multiparity could lead to discrimination and abusive behavior on the part of healthcare providers the staff usually focus on the only highrisk cases if health providers treat everyone equally and provide equal services then no one will feel superior and inferior theme 2 factors contributing to irrational care category 1 institutional factors according to the participants many of the facilities have been underequipped which has always compromised patient safety and quality of care the scarcity of human resources and workloads eventually led to abusive behavior and to the mistreatment of patients in some cases doctors suggest referrals to other private health facilities from which commissions are received most of the cases were referred to the nearest private hospital the doctor does this knowingly in order to get extra income from there lack of transparency was also a factor leading to disrespect and violence at the facility level ashas clarified that no one at the facility level would like to take responsibility for offering any potential solution to the actions of the providers they also indicated that if anyone could track and supervise them and inform them about the attitudes they exhibit to the patients i couldnt understand whom to approach about the problem at the hospital nobody is going to listen category 2 noncompliance with guidelines and ineffective enforcement mechanisms while numerous policies have been introduced in india which depict health rights the definition and theory have remained abstract and their implementation has been neglected in public health facilities in addition participants had no clear knowledge of health policies and regulations suggested developing possible policies strengthening the care delivery system or strictly monitoring existing regulations so that mothers would be able to receive respectful care during their maternity period taking feedback from and accompanying pregnant women could be an effective strategy for improving the delivery of quality maternal care the respondents suggested for few rules and regulations at the health facilities which should be legitimized and followed strictly by every single resource person the implementation of a grievance redressal mechanism would be an appropriate solution to improve the quality of care in the form of respectful and dignified care the respondents suggested a few rules and regulations for health facilities that should be legitimized and strictly followed by every single resource person implementation of the grievance redress mechanism would be an appropriate solution to improve the quality of care in the form of respectful and dignified care feedback must be received from the mother or family members on their experience of service then only the doctors and nurses will be afraid of being abused category 3 the hierarchical structure of the health system it has been understood that breaches of the concept of respectful and dignified care have always been the product of professional hierarchical systems power relationships education and cultural attitudes responses of the participants showed that the overpowering perception of health care providers often transforms to shame and contempt because of the hierarchical nature of health care providers education and status play an important role they are the doctors and the nurses how much we are going to try and convince and make patients and families understand they are going to say we are just a nurse when the patients arrive they must listen to the doctor discussion community health workers explained that the type of abusive behavior of the childbearing women was significantly different verbal abuse was one of the most common and often used by healthcare providers toward community health workers the consequences of such abusive behavior hinder the effective performance of their role in the facility although many community health workers did not have sound knowledge of rmc the study highlighted major gaps in the behavior and attitude of health care providers at the facility level the use of institutional health services for delivery reduced the risk of complications between the mother and the newborn baby various studies have shown that institutional delivery reduces the risk of maternal and newborn mortality and reduces stillbirth 7 a comparative analysis performed by chinkhumbaetal revealed that perinatal mortality was 21 percent higher for home delivery compared to facility delivery 15 a substantial decrease in maternal fetal and neonatal mortality was associated not only with institutional delivery but also with the involvement of professional workers 16 similarly the study found that compared to women with intrapartum complications at home the incidence of perinatal mortality among women with intrapartum complications was 43 per cent higher for women who performed at a public health facility 17 another study also explained that women living in areas near facilities offering comprehensive emergency obstetric care emergency neonatal care or highquality routine care or facilities with satisfactory skills found a lower risk of intrapartum mortality 18 the government has implemented a variety of schemes to promote institutional delivery in public health facilities the drivers of this shift from home to institutional delivery include the social pressure of the accredited social health activist to deliver in a health facility and individual perception of the importance of safe and easy delivery most likely an expression of the new social norm in addition the incentive was a significant factor in many womens decisions to be taken at a health facility 19 usually women are likely to go to health facilities due to knowledge of increased provision and birthpreparedness education prior delivery of health facilities and improved quality and usability of facilities in recent years 20 women preferred delivery to healthcare facilities to better manage complications 21 furthermore the various maternal schemes implemented to increase institutional delivery have the potential to reduce maternal and neonatal morbidity and mortality along with ensuring maternal health equity in india 22 various factors are associated in the search for maternal health services from a healthcare facility the jsy cash incentive scheme played a smaller role as an enabling factor due to higher opportunity costs in the use of healthcare facilities compared to home delivery 23 other emerging factors that deter the process of seeking maternity services are the mistreatment and abusive behavior of healthcare providers which has been identified not only in indian public health facilities but also worldwide 24 25 26 27 28 especially when planning and implementing maternal healthcare a rightbased approach must be developed and implemented who describes such an approach as one in which human rights norms and values are integrated into policy planning execution supervision and assessment such values and ideals include equality respecting vulnerable population needs fairness to health services and protection from discrimination this study will contribute to the existing knowledge regarding the qualityofservice delivery along with the abusive treatment among childbearing women policymakers should consider these findings while planning maternal healthrelated policies limitations a major limitation of this study is its reliance on health workers selfreports another limitation of the study relates to the generalizability of findings as these may be limited to the experience of health workers in odisha for the women who deliver at public health facilities conclusion despite the lack of knowledge and training related to rmc participants claimed the disrespectful behavior of healthcare providers towards the childbearing women and the accompanying person the findings of this research study have important implications for the promotion of maternal health and wellbeing indicating the need for significantly increased exposure to this issue mistreatment and abusive behaviour as important as the quality of health services or geographical constraints are essential dissuasive for obtaining care the violation of womens health again threatens current attempts to improve the quality of birth attendance respectful and dignified care along with positive attitudes among healthcare providers will contribute to improved maternal and neonatal health outcomes funding no funding sources conflict of interest none declared ethical approval the study was approved by the institutional ethics committee

background every woman deserves respectful maternity care throughout her journey to motherhood however disrespectful maternity care is prevalent in various settings it has an effect on the utilization of services it can be more explored from the witness of maternity the aim of this study was to explore the experience of accredited social health activists on respectful maternity care in odisha india methods a qualitative exploratory study was conducted among 24 ashas with more than two years of experience to gain a deeper understanding of the phenomenon this study was conducted in three distinct odisha districts india results two main themes emerged community health workers experiences and perception towards disrespectful care and factors contributing to irrational care participants explained that verbal abuse was the most common use of health care providers the consequences of such abusive behavior hinder the effective and efficient performance of their role especially when it comes to their role in the facility the study highlighted major gaps in the behavior and attitudes of healthcare providers at the facility level conclusions despite the lack of knowledge and training related to rmc ashas acknowledged the abusive and disrespectful behavior of health care providers not only towards the childbearing women but also towards the accompanying person ie asha or a member of the family such mistreatment often acts as a barrier to the use of public health services such as the institutional delivery of childbearing mothers a need for orientation and training on rcm among healthcare professionals along with appropriate monitoring of implementation

introduction recently numerous studies have significantly enhanced the chances of theorizing about brazilian social thought showcasing the breadth of topics and approaches from the perspective of the establishment of this field of study the organization and actions of intellectuals interpretative research lines the relationship between intellectuals culture and politics the intellectual repertoires available the collective actions of intellectuals and their interactions with social movements and ideas and their contextualization these perspectives have paved the way for investigations into the connections between social and sociological theory and brazilian social thought extending the possibility of sociological theorization beyond the confines of the north atlantic peripheral scientific contexts and interconnected sociologies have emerged as crucial elements in supporting alternative explanations of modernity by transcending their national contexts these perspectives contribute to the construction of contemporary sociological theory on global themes such as modernism modernization and different manifestations of modernity in a certain way these peripheral modern experiments challenge the eurocentrism inherent in sociological explanations and propose new approaches to understanding the production dissemination and assimilation of ideas and cultural products furthermore they allow for a reformulation of social theory regarding the motivations behind social actions and thus a reevaluation of the meanings and significance attributed to social actors throughout the historical development of these regions the development of national and regional sociologies particularly in peripheral contexts has brought attention to these specificities as unique characteristics of peripheral modern experimentation contrasting and comparing the trajectories and historical developments of peripheral areas with central regions has played a crucial role in interpreting these places1 in the case of brazil the flourishing of essayism in the 1920 and 1930s was instrumental in characterizing the process of national modernization it stands as one of the most prolific expressions of local modernism this particular interpretation of brazil reveals the essential factors that contributed to the formation of an imagined community the bureaucratization of public administration the establishment of solidarities and social dominance and the shaping of hierarchical subjectivities these elements were pivotal in mobilizing the social actors who played a fundamental role in brazils historical process providing a foundation for understanding the rationale and meanings behind their actions as well as the spaces in which these actions unfolded through its exploration of the relationship between space and social action the essayistic interpretation of brazil has constructed a rich diagnosis of the trajectories of brazilian modernity in the first part of this article we delve into the concept of the modern chronotope and its intricate relationship between space and time drawing upon mikhail bakhtins insights we aim to establish the foundational elements of the chronotope which encompass temporal and spatial markers and would summarize the actions of characters pointing out howp figuration is conceptualized within social theory this exploration encompasses both the construction of a figuration space and the creation of an imaginative cartography furthermore we have delved into the interplay and contrasts arising from studies on space within brazilian social thought our aim is to uncover the processes through which space was constructed perceived imagined andor experienced and to establish connections between these spatial imaginaries and contemporary social theory we place particular emphasis on exploring the physical and symbolic dimensions of these imaginative constructions of space lastly in the concluding sections of the article we examine the substance of brazilian essayism during the 1920 and 1930s our focus is on elucidating the operative mechanisms that connect figuration as an explanatory factor for social actions of actors with the imaginative cartography we particularly highlight the contrasting elements within the peripheral trajectories of modernity and their spatial imaginings sociological theory and imaginative cartography trajectories of modernity the utilization of the concept of multiple modernities and its critique of the theory of modernization has prompted a reconsideration of the historical processes that have led different regions to modernity as noted by eisenstadt the notion of homogeneity should be discarded since actual developments in modernizing societies have contradicted the homogenizing assumptions of the western program of modernity instead multiple patterns of societal organization emerged which are undeniably modern but distinct from the western model such as european modernity in this particular instance 2 the notion of multiple modernities posits that the most effective approach to comprehending the contemporary world and explaining the history of modernity would be to perceive it as a continuous process of formation and reformation of various cultural frameworks national or regional cases with their distinctive characteristics can be seen as part of a broader global modernity or worldsystem as proposed by wallerstein they would be characterized by a unified timespace framework in which a division of labor facilitates the material reproduction of the world its spatial scope determined by its materialeconomic foundation encompasses political entities and supports diverse cultural systems as process by the capitalist worldeconomy the division of labor and unequal distribution of surplus would give rise to central and peripheral activities based on the capacity of capital and state alliances to absorb surplus within various commercial chains utilizing economic and noneconomic means expanding on our argument if we were to critique the homogenization and westerncentric view of modernity we would have to consider how these national and regional examples made us to think the heterogeneities that emerge from the unique developments of each sociology within the context of nationstate formation market economy and the formation of social classes furthermore it would prompt us to examine how these national and regional cases relate to the broader modern worldsystem in which they exist the analytical reconfiguration of trajectories towards modernity has challenged the eurocentrism inherent in classical and contemporary sociological perspectives thereby questioning the universal validity of categories traditionally regarded as unambiguous markers of modernity this reconfiguration also scrutinizes the replication or imitation of modern patterns from central societies within different spacetime contexts shedding light on power asymmetries that underpin normative and prescriptive projections of these central societies onto peripheral spacetime contexts ultimately these alternative perspectives offer alternatives to the hegemonic notion of modernity and propose nonmodular trajectories within it therefore we can acknowledge the analytical existence of multiple trajectories within the modern chronotope whether viewed through the lens of multiple modernities the worldsystem global modernity or hegemonic modernity this interpretive and constructive exercise aligns with the proliferation of theories concerning the social and political aspects of brazilian thought which stem from these nonhegemonic paths of modernity moreover it leads to the establishment of two fundamental elements in sociological theory space and time these elements form the basis of the analytical category known as the chronotope initially we refer to bakhtins definition which characterizes the chronotope as the essential interplay between time and spatial relationships artistically assimilated within literature according to the russian author the key concept of chronotope lies in the unification of time and space with its literary function being the organization of narrative events through the condensation and materialization of time markerssuch as human lifespan historical time and social timewithin specific spatial contexts when examined through the lenses of historiography and social theory the perspective of chronotope enables a meaningful debate if the time markers were encapsulated by the actions of plot characters their figuration and the formation of figurative space referred to as imaginative cartography in other words as we bridge the gap between literary criticism and the formation of sociological theory our aim is to emphasize time markers that allow for the systematization of nonhegemonic trajectories of modernity present within brazilian social and political thought these factors present a dual challenge to the chronotope figuration and imaginative cartography it is worth noting that in his exploration of the concept of formation present in brazilian essayism bernardo ricupero draws upon bakhtins ideas even with a quick look to develop his arguments centered around the syntagma of ideas out of place as proposed by roberto schwarz ricupero rejects the notion that the concept of chronotope simply implies a standardizing aspect or recurring theme in every work or author within a particular context weaving and contrastivity imaginative cartography in the brazilian social thought numerous studies have drawn attention to the theme of territory and space within the sociological imagination of brazils scholars oliveira emphasizes the significance of territorial conquest in shaping national identity while discussing the evolving meanings associated with the term sertão in brazilian social thought this exploration extends to the creation of the myth of hinterland and the notion of borders stemming from the movements of the bandeiras leading to an analysis of the bandeirantes and their mythical function in organizing the symbolic world and constructing an interpretation of the country candice souza draws attention to the constructed versions and visions of brazils rural areas through an examination of various interpretations of brazil that contribute to a reflection on national singularity within the spatial dimension the author explores the geographical imaginary depicted in discourses surrounding the nationbuilding process and the formation of brazilian identity these native representations of nationality gave rise to a geographic nation a discursive invention wherein nationality is equated with spatial terms the countrys fragmented unity territorial discontinuity spatial imbalance heterogeneity and the contrasting notions of hinterland and coast become recurring themes in the renowned narratives of euclides da cunha cassiano ricardo oliveira vianna nelson werneck sodré and nestor duarte similarly lima delved into the power and significance of geographical metaphors in shaping representations of a national identity for a country perpetually embroiled in spatial conflicts by uncovering the portrayals of an identity that is consistently portrayed as incomplete or in need of reconstitution lima proceeds to analyze the mindset of modernizing intellectuals who grapple with the irreducible distances between the numerous countries within brazil she highlights the enduring divide and contrasting characteristics of the hinterland and coast metaphorically fashioned by the countrys interpreters robert wegner on the other hand explores the connection between tradition and modernity through an analysis of sérgio buarque de holandas work particularly focusing on the theme of borders and the expansion of the brazilian west from são paulo by examining the concept of borders and the relationship between iberian tradition and modernization holandas works from the 1940 and 1950s discuss the characteristics of modernity in a brazilian context and reassess the dual polarities present in his interpretations of the 1930s he envisions potential combinations between traditionalism and modernization civility and cordiality idleness and work as well as americanism and iberian influences the recurrent nature of this theme prompts an analysis aimed at establishing markers for a reconstitution of the subject within brazilian social thought specifically within peripheral social theory joão marcelo maias work is relevant in this context according to him there is a correlation between space and sociability in the interpretation of brazil which supports a dual dimension firstly there is the production and analysis of space as an independent variable in explaining habits and customs encompassing physical space as the backdrop of civilization secondly there is a conception that associates space with images and allegories closely tied to forms of sociability and civilizing organization lastly werneck vianna delves into the territorialism of the iberian elites in the development of brazil specifically in the formation of interests that would clash with the pace of the passive brazilian revolution this revolution characterized by its transformative nature serves as the driving force behind the actions of these characters and their aspirations over time intertwining elements of tradition and rupture it is within this framework that the political elites of the nationstate prioritize political reason above other rationalities resulting in the preservation and expansion of territory and the exertion of control over the population based on the insights and perspectives provided by scholars of brazilian social thought the theme of space can be understood through two complementary aspects firstly there is an ordering of physical environments and social categorizations presenting it as the stage where the civilizing process unfolds secondly these physical environments serve as a foundation for the creation of images and symbols that imbue social experiences with meaning it is through this fundamental duality that the construction of an imaginative cartography of brazilian social thought takes shape considering both the physical and symbolic dimensions within the framework of the constitutive imaginary of interpretation in line with this perspective it becomes necessary to delve into the complex conceptualizations and interrelationships between space and territory as milton santos suggests … as a starting point we propose that space be defined as an inseparable combination of systems of objects and systems of actions in its entirety this definition encompasses the process through which the natural space is appropriated through human intervention influenced by the dynamic interplay between actions and the environment this interplay encompasses material and immaterial aspects encompassing economic social cultural and practical needs space not only holds symbolic significance but also serves functional purposes understanding space goes beyond the mere recognition that territories consist of objects from different periods it also involves recognizing that territories are socially constructed and imbued with diverse meanings as santos argues territories have layers of historical significance with their past manifested in the forms and functions of objects and the natural environment moreover territories are shaped by various cultural layers reflecting the meanings and values attributed by society to different aspects and portions of the territory this complexity is evident in the interpretation of landscapes a rural landscape for example can evoke a sense of bucolic connection with nature while simultaneously being seen as archaic or associated with backwardness and ignorance conversely urban environments are often characterized by dynamism and temporal acceleration having said that the construction of an imaginative cartography extends beyond the physical substance of territory or landscape it encompasses how this substance is interpreted and given meaning by different individuals this process involves contrasting and evaluating different places resulting in spatial differentiations in both form and substance moreover the understanding of space is characterized by its referentiality and the contrasting relationships it establishes with other territories or landscapes the construction of these distinctive images of the territory relies on the power to represent and rank places based on various interests aspirations and acta scientiarum human and social sciences v 45 e68368 2023 sentiments that are shaped by the complex web of social relationships and power dynamics inherent in the interpretation in this sense the imaginative cartography functions as a network interweaving social relationships and power dynamics if space exhibits such characteristics in the construction of this imaginative cartography then we must further explore the role of figuration in the process of structuring social groups different forms of sociability and the motivations and meanings underlying social actions that would fill the ground with density established by the imaginative essaysm and social figurations a social action theory from the perspective of social theory the concept of figuration encompasses the intricate network of interdependent relationships among individuals which manifest in various ways and at different levels the collective actions of interdependent individuals give rise to a structure characterized by a multitude of emergent properties these properties include power dynamics tensions class and stratification systems forms of solidarity and social hierarchies according to norbert elias figuration represents a profound interconnection between subjectivity and social and historical structures he argues that individual actions cannot be understood in isolation from the social structures that enable or hinder them figurations would be forms of relationships that emerge and evolve over time their alterations and transformations end up shaping both social organization and subjectivities in concerning corruptions the concept of figuration goes beyond mere technical or narratological description although it can be seen as an elaborate effect of characterization a figuration is an interdependent network that is both structuring and structured by the interactions and conflicts arising from power dynamics among groups or individuals fulfilling different roles furthermore the conception of figuration highlights the agency of individuals in shaping historiography as certain groups exert influence within this interdependent network figurations seen as meaningful social relationships become more intricate when they intersect with time and space space assumes a crucial role as the backdrop for social actions in the way how time is socially generated while time encapsulates the collective experiences of social actors ultimately it is the understanding of space as a relational arrangement of beings and objects in the ways in which space and time are experienced returning to the concept of chronotope influenced by bakhtin space is envisioned through the lens of imaginative cartography while social action finds expression through figuration broadly speaking figuration and imaginative cartography involve a process of semiotization where a language is constructed to convey meanings and generate pragmatic effects in the analysis of brazilian essayism according to afrânio coutinho the essay is embraced within brazilian culture not so much as an attempt but rather as a mode of interpretive study it becomes the paradigmatic form for historiographical philosophical political and sociological interpretations during the first half of the 20 th century therefore the act of writing transcends the realm of fictionality typically associated with literature in brazil the essay is a genre that defies disciplinary boundaries in a sense building upon coutinhos ideas as presented in literatura e sociedade antonio candido has approached brazilian essayism by emphasizing its connection to the tradition of thought and the intersection of fictionality found in literary works with a scientific foundation the allure of literature would exert a strong influence on the sociological inclination giving rise to a hybrid genre of essay that merges history with economics philosophy or art this distinctive form of investigation and exploration of brazil is uniquely brazilian and it has produced notable works such as sílvio romeros história da literatura brasileira euclides da cunhas os sertões oliveira viannas populações meridionais do brasil gilberto freyres writings and sérgio buarque de holandas raízes do brasil it is fair to say that this line of essaywhich skillfully combines imagination and observation science and artrepresents the most characteristic and original aspect of brazilian thought regrettably candido did not delve into a more systematic reflection on the genre that he himself considered to be the most characteristic and original aspect of brazilian thought nevertheless he viewed the essay as a distinctively modernist manifestation as it interpreted brazil through a synthesis that allowed for the discovery of authors associated with what is known as the premodernist period the presence of the essay as a defining feature of those years is indisputable however the choice of this type of writing represented an expansion of what had been done in the 19 th century blending a sociological tendency with the essay form according to coutinho the essence of the essay lies less in attempting something and more in the notion of study where writers are primarily engaged in exploring the factual aspects rather than indulging in fictional realms in his words … they are not truly essayists but rather philosophers historians sociologists political thinkers another issue is that the argumentation should address the intricacies that this literary support would encompass in condensing a tradition that has been reinvented over the course of two centuries while in the formation of the state the essay encompassed elements of political philosophy that encompassed sociology towards the end of the 19 th century as candido argues the sociological tendency became more implicit taking these considerations into account it is necessary to assess the notions of space and time in the essayistic interpretation of brazil with the goal of framing the imaginative cartography and the figuration of the modern chronotope through social and sociological theory regarding the topic of space and its role in shaping his interpretation of brazil duarte stated in this analysis let us emphasize from the outset that one of the most determining physical factors in shaping the form style and orientation of brazilian social organization is not solely the climate its biochemistry flora or fauna it is in fact the territorial expanse available to and required by the people to meet economic needs and pursue the aims driven by economic instincts or ought to be driven every form of production in brazil has had and continues to have a largescale approach above all it is a production of space in fact authors such as oliveira vianna paulo prado gilberto freyre caio prado junior sérgio buarque de holanda nestor duarte and afonso arinos de melo franco highlight the elements of rural life in brazil characterized by its unique features their isolation the absence of an internal market between different segments the centrifugal force of an agroexporting economy the relatively weak urban centers and their players the challenges of colonization and land occupation the lack of roads and communication infrastructure and the limited presence of the state in establishing internal public regulations each rural nucleus or each complex between the casa grande and the senzala would be a social microcosm a small collective organism with full capabilities for isolated and autonomous living these phenomena with their cultural and sociodemographic roots would allow essayism through its conceptual tools to interpret the modus operandi of certain oligarchic structures of domination that are incompatible with the establishment of a liberal democracy yet highly effective in acquiring organizing and exercising power in a hierarchical manner the prominence of certain individuals and their figurationsocial action within a network of interdependencewould form the basis of the interplay between politics and society this type of clanbased solidarity linked to historical heritage did not seem destined to disappear as a mere consequence of development or modernization in the political sphere it would be like a cultural constant a kind of amalgamation of the national collective psychology the existence of this pattern of domination is intertwined with the absence of a spontaneous articulation of interests between social groups and the apparatus of the state which in turn would be obliged to interact with these social groups through vertical structures of power with the rural clan chief landowner landlord or patriarch at the top depending on the designation given to this character in each work marking this civilizing process it would become evident for sociological essayism of the 1920 and 1930s that political power and social power would organize themselves pyramidally in such a way that each rural chief would connect to another to form a structure of domination articulated through reciprocal exchanges as seen in analyses of issues such as political patronage based on gratitude andor friendship matters related to an ethic of cordiality and the specification of pivotal points of patriarchy as foundations for the failure of liberal ideals and institutions one conclusion would be that in this type of sociopolitical construction there would not have developed a national or public interest transcending immediate and particular interests in this political activity instead there would be a purely partisan and exclusive conception exercised and consumed strictly within the small circle of the group the clan the faction the local directory the family in summary based on the latifundium and rural life the type of solidarity that formed and the stability that revolved around family groups which allowed for the formation of a web of stable permanent and traditional social relations with the patriarchal figure of the pater familias as the source of authority led to acta scientiarum human and social sciences v 45 e68368 2023 patrimonialism in the handling of the public sphere the subjugation of private interests over the public interest and the establishment of a social ethic based on sentiment the large rural property and consequently the notion of agrarian exclusivity and the simplifying function of latifundia became crucial in this explanatory model of the conditions in which solidarity and interests were formed in the peculiar brazilian case with the differences acknowledged these interpreters of brazil realized that this simplifying function would hinder trade and the emergence of a commercial bourgeoisie or an industrial class which would be concentrated on the coast or in small towns inland but without any political power thus between the class of free workers and the landowning aristocracy solid bonds would not be formed accentuated by the absence of a middle class of the european type it is during the 1920 and 1930s that the brazilian essayism experienced a significant increase in the proliferation of its arguments particularly in relation to its connections with modernism and the political sphere these essays of general interpretation are closely tied to the emergence of brazilian sociology and have since become classics in the field of interpreting brazil due to their genre the essay they have become an integral part of the tradition of sociological discourse known as essayism critiques and analyses of brazilian essayism as a whole offer us valuable insights into how this form of writing was conceived and examined within the brazilian context thus we undertake a threefold exploration with the aim of constructing an interpretation of brazilian essayism firstly we delve into interpretations of brazilian social thought through the lens of space connecting it to the quest for defining the significance of the imaginative cartography crafted through the fusion of social theory and brazilian social thought itself secondly we examine the social theory of meanings and the potential of figuration as an interpretive framework for brazilian social thought lastly we investigate the convergence of imaginative cartography and figuration in shaping the modern chronotope and its relevance to interpreting brazilian social thought with a specific focus on the essayism of the 1920 and 1930s by reexamining some of the most prestigious essays originally published between the early 1930s and the mid1940s we probe into their interpretative affinities around two correlated questions on the one hand the conceptions of time that implicitly or explicitly underlie their views on the intricacies of brazilian social life and on the other hand how such notions predetermine their ideas about the asymmetric place and the particular condition of this society in the modern world we conclude by examining the correspondences and symmetries between these authors representations of brazil showing that they tend to allude to a temporality that is only partially in synchrony with social and political visions of modernity while revisiting some of the most acclaimed oeuvres of the socalled brazilian social thought we examine the feeling of temporal mismatch that underlies a wide variety of portraits of social life in brazil we contend that notwithstanding the variegated analytical perspectives inherent to this intellectual constellation most of these oeuvres are inclined to ascribe to brazil a peculiar temporal configuration only partially synchronized with the homogeneous and linearprogressive time envisaged in modernity that said we also interested in investigating a set of critical propositions to the sociological imagination in order to assess an additional hypothesis namely these very same visions of brazilian society seem to insinuate an alternative theoretical frame of reference sensitive to the unbalances asymmetries and contradictions that crisscross modernitys temporality the hypothesis of brazilian singularity is the single most powerful idea in brazilian social thought as no other it has succeeded in circumscribing and shaping the agenda of research and reflection concerning the countrys social experience conjured up a entirely unique compared to others brazilian society is elevated to an analytical category and in the same measure a privileged object of investigation worthy of specific explanatory and interpretive efforts excesses and absences the brazilian modernity diagnosis together but not as a unified whole and beyond the intellectual context from which these diagnoses emerged the distinctive feature of brazilian essayism in operationalizing concepts such as patriarchy familism patrimonialism personalism agnatism clientelism and the myriad of privatist obstacles enshrined in its ideals is the decisive role in the constitution of public life in the tradition of brazilian political and social thought the emergence of this theme is recurrent there are positions that glimpsed this interpretive path in the 19 th century but essayism provides it with new concepts and assertions in these terms the recurrent appearance of such a conceived public life can be understood either as manifestations of outdated and definitively surpassed readings of reality or as a legacy of interpretations with varying degrees of plausibility instead of assuming a characterization of public life as settled or surpassed in historical or analytical terms it seems more productive to problematize its role as an explanatory device for the ambiguous configuration of the brazilian public sphere the recurrence of this theme appears through the literature and the object of study in a dual aspect on one hand in the realm of ideas it entailed a nuanced examination to reconstruct the specificity of the approach and understanding of the public sphere by the essayism of the 1920s and 1930s namely its emergence crystallization reproduction and analytical method on the other hand the centrality of this theme can be explored as a phenomenon in which fundamental dilemmas of the configuration of the brazilian public sphere and its private counterpart become apparent highlighting historical difficulties brought about by the emergence of the modern state in peripheral environments analysts of hegemonic modernity may not have realized that the process of modernization leading to modernity could not assume a westernization of modernism that starts from the center and extends to the periphery european modernity was unable to uniformly transcend its values and aesthetic standards to the rest of the world without upheavals as the process of modernization differed across various areas of the world for eurocentric socialsociological theory what characterizes modernity is the partitioning of reason that is its differentiation into institutionally autonomous spheres historically the differentiation of the political system occurred when political authority crystallized around legal positions that control the means of force within the framework of societies organized around the state markets emerged and acquired their own logic these systems are formally organized domains of modern social action with their historical beginnings in the political revolutions of the 18 th century and their subsequent cultural and philosophical manifestations thus modernity emerged as a project on european soil with the establishment of the organizing principle of modern subjectivity and the separation of spheres of value selfreferential in its historical consciousness it had to derive its own normativity from within itself in the case of brazilian essayism more or less explicitly present in the interpretations proposed by the authors above mentioned we find the idea that in their contemporary brazil the state economy and civil society were never fully able to differentiate themselves and become dynamic based on their own logics and codes the public domain would be abducted and subjugated to the logic and purposes of family realms personal and private codes with restrictive sociability that is why impersonal and rationalized rules were often relegated to a secondary position in this society the degree and extent of social differentiation secularization and the separation between the public and the private observed in central modern societies were never achieved 3this matrix of brazilian social and political thought expresses an alternative path to modern development through its dichotomies both in the composition of an imaginative cartography and in the figurations of social action such peripheral intellectual experience would carry a contradiction as the foundation of its modernity particularly in how it approached space and its characters within the modern chronotope in other words while seeking to explain this difficult synthesis the authors would understand brazilian modernity in terms of contemporaneity and historicity and from the perspective of a kind of alternative modernity or as a nonmodel path of modernity the countryside would have its own sociology its main characters with their subjectivity and agency in the world the latifundium would serve as a backdrop for the realization of interests and virtues for the landowner the slave the henchman the common free man and the slow passage of time would shape social life and establish certain types of solidarity and interests the city would be the site of social interrelations and the locus of fastpaced time initiative the lust for modern living with its liberal characters and sociability often subsumed under the rural world and unable to find fertile ground for its advancement acta scientiarum human and social sciences v 45 e68368 2023 the understanding of the city and the rural world would involve analyzing all the elements that compose their framework land water climate people civilization culture architecture labor ideas symbols the countryside and the city would not only be materiality they would possess a symbolic and subjective dimension that would also shape their spatial forms the significance of space whether urban or rural would give individuals and communities unity and identity with their surroundings in a sort of signifying structuring of space each place would shape an imaginative cartography that attributes certain ways of living thinking and experiencing the world to a specific timespace certain social types a particular solidarity and a certain constitution of interests and virtues in its sociability all aimed at revealing an alternative to hegemonic modernity with its excesses and absences in a dialogic manner conclusion in this article we examine brazilian essayism from the 1920 and 1930s as an interpretation of brazil that considers the meanings of brazilian collective action and the resulting political culture in the formation of its nationstate the explanatory role of this strand of brazilian social thought reflects the possibilities and constraints that arise outside the traditional and modular explanations of hegemonic sociology with these characteristics the characters in historiography gain intelligibility and plausibility within the framework of social theory that guides these interpretations that seek to employ history as an analytical method for understanding society and the state this approach postulates that the foundations and concepts of sociology are best suited to uncover the origins and uniqueness of the country and its history thus establishing a strategy that constitutes a theory of interpretation undoubtedly the leadership arising from rurality and its manifestation in solidarity authority and the composition of interests would constitute specific social types most importantly it is the actions of these characters these social types within brazilian history in their public realm and in the formation of the state that matter when isolated from this broader analysis of their social and political agency and constitution the different characters lose their depth around the imaginative cartography encompassing the countryside and the city the coastline and the hinterland the center and the periphery their interweaving of themes such as solidarity authority freedom and equality their figuration through composite characters driven by specific interests and virtues demonstrate that the overall concern of essayism surpassed the criteria of a strictly culturalist interpretation of the country the central and mobilizing concepts such as patriarchy patrimonialism familism among others served to elucidate the configurations of the relationships between the state and society these were relationships that could be intertwined in the process of forming the political community in the bureaucratization of public power in the formation of social solidarities connected to such types of authority in the constitution of subjectivities lastly it is important to point out that the development of distinct national or regional sociologies especially in peripheral contexts has emphasized the differences in historical trajectories as a singularity of peripheral modern experimentation anchored in the delay or inadequacy between theorization developed in hegemonic contexts and its production circulation and acclimatization in peripheral contexts this perspective can be understood from the centerperiphery framework of the worldsystem multiple modernities or global modernity simultaneously it becomes essential to investigate the relationships between socialsociological theory and brazilian social thought which gives rise to the demand for sociological theorization from the margins to provide alternative explanations on global topics such as modernism modernization and different configurations of modernity this approach allows for the reformulation of sociological theory and the realignment of the meanings and significance attributed to social actors throughout the historical development of these areas

the paper aims to analyze the brazilian essayism through the category of modern chronotope and reflect upon the theoretical junction between imaginative cartography and figuration as interpretative axes of essayism and brazilian social thought as an example of peripheral intellectual experience highlighting the multiple paths and interpretations of modernity

introduction over the past 30 years a consensus has emerged about the need to protect what is left of the planets biodiversity this globally shared social acceptance opens a multifaceted debate on the best ways to achieve this goal taking a foucauldian perspective we understand the emergence of biodiversity conservation as the social construction of an object of knowledge and therefore a space of power relations throughout this historical process different models of practices and discourses have become preponderant the first global model for conservation based on the implementation of restrictive and large protected areas came to be known as fortressconservation this model was severely criticized due to the research communications special issue on diverse conservations in our perspective this polarization does not account for the complexity of conservation disputes in a context where social inclusion is becoming increasingly mainstream we argue that the construction of viable solutions for conservation could benefit from material attempts at dialogue among diverse groups of people working towards a more sustainable future nonetheless many conservation policies continue to generate situations experienced by local populations as injustices we understand environmental justice as key for the longterm involvement of those who have been sharing those environments for centuries thus we seek to contribute to a convivial approach to biodiversity conservation that sees the dialogue among different perspectives and radical equity as fundamental tenets for discourse and action to protect ecosystems in this paper we focus on the discursive disputes around biodiversity conservation in a specific territory relating directly to environmental narratives of those who live in and seek to protect the brazilian atlantic rainforest we apply a qualitative analysis to compare solutions to the shared problem of biodiversity degradation of the atlantic forest proposed by two different groups of people the solutions developed by tupinambá indigenous people and the institutionalized western sciencebased environmentalism developed by state agencies and nongovernmental organizations who work with conservation projects in southern bahia we avoid universalizing solutions trying instead to compare the concrete solutions presented by each narrative we understand that although indigenousand other traditionalknowledges have their construction grounded in concrete life experience and not in generalization they should not be seen as less valid than sciencebased perspectives nonetheless in conservation planning and implementation so called evidencebased perspectives tend to have more legitimacy despite the continued efforts toward showing the social and cultural injustices it produces the solutions provided by more powerful actors in conservation namely conservation biologists and ecologists that act in academia ngos and state agencies fail to account for the overlying power relations and causes of conflicts around conservation including the detachment to local perspectives and excessive bureaucratization with our case study we wish to contribute to the ongoing advocacy for more effective pluralism in conservation the methodology based on the analysis of environmental narratives makes it possible to compare and equalize the solutions proposed by representatives of commonly empowered decisionmakers in environmental issues and representatives of commonly marginalized discourses through the equal juxtaposition of narratives that usually are perceived in a strict hierarchy we wish to shed light on concrete challenges for mitigating the recurrent conflicts around conservation planning and implementation we also illuminate the actual possibilities of building alliances between different perspectives we conclude by advocating for pluralism in conservation through direct engagement with the proposed solutions offered by ontheground agents of indigenous life and struggle the territorial contours the geographic scope of this research is composed by the tupinambá de olivença indigenous land una biological reserve and una wildlife refuge located in southern bahia in northeastern brazil an area once completely covered by the atlantic forest biome the brazilian atlantic forest hosts one of the worlds most diverse and threatened tropical forest biota of the world only around 26 of its original cover remains with severe defaunation the south of bahia is the second largest remaining fragment of the biome in northeastern brazil though it is threatened by intense processes of deforestation related to plantations mining and tourism enterprises before colonization the lowlands of the atlantic coast were occupied by indigenous peoples mainly from the tupi linguistic community through the colonial period the lands that today form the tupinambá de olivença indigenous land were occupied by a jesuitcontrolled indigenous village during the nineteenth century cocoa gradually became the main monoculture for export in the region and the brazilian state officially declared the extinction of the indigenous populations authorizing the alienation of their lands around the 1980s cocoa production was deeply impacted both by the spread of pests and overseas competition the crisis in cocoa intensified research communications special issue on diverse conservations deforestation and impoverishment most of the cocoa in the region was planted in a system called cabruca which consists of a plantation that maintains part of the original atlantic forest to take advantage of shade given the low profitability several landowners predominantly from white and settler communities resorted to timber to pay off debts at this moment a conservationist movement emerged in the cocoa cost aiming to contain the accelerated process of deforestation in 1994 the institute for socioenvironmental studies of the south of bahia was created and quickly became the largest ngo with an emphasis on biodiversity at a local scale this ngo was a main actor in a process of enlargement of the local protected areas network during the 2000s the biological reserve that had been implemented in the early 1980s was enlarged in 2007 giving it 1871506 hectares this process was accompanied by the creation of a new pa the wildlife refuge with 2326209 hectares functioning as a buffer zone for the biological reserve and overlapping with some portions of the indigenous land concurrently in the late 90s and early 2000s a renewed tupinambá indigenous movement rose reframing their cultural past and present the tupinambá enacted certain political strategies among them the retomadas the reappropriation of something that was usurped from the indigenous peoples in the past the retomadas are mainly expressed in the effective occupation of lands and are used as a way to pressure the brazilian state to ratify indigenous titles to indigenous lands however this politicalcultural strategy goes beyond the sphere of negotiating rights constituting a dimension of autonomy for indigenous movements and the construction of new landscapes in this sense they have an ontological dimension since they provoke reorganizations of material and immaterial territories the indigenous land is therefore the result of an intense politicalcultural process performed by the tupinambá through which they actively take back their land and history in 2009 the first official map was published by the brazilian state in which the indigenous land consisted of 47376 hectares this demarcation however has never been ratified by the ministry of justice and thus remains more legally vulnerable than the protected areas since those processes occurred concomitantly efforts were made to assure the smallest overlap possible according to diverse expectations nonetheless as we shall demonstrate the implementation of the protected area led to conflicts due to reinforced environmental monitoring experienced as injustices by indigenous peoples therefore despite the attempt at finding middle ground the paths for conservation remained disputed and uncertain since legitimacy for choosing the best paths for biodiversity conservation remained unequal this makes it important to look at the different proposed solutions for biodiversity conservation and recognize to what extent they have the power to research communications special issue on diverse conservations effectively become a central guidance for conservation methods our analysis is based on the comparison of the environmental narratives of two groups indigenous and institutionalized scientific environmentalism different actors have different access to the discursive power to define what should be understood as environmental degradation as well as its causes and solutions in order to approach these power relations we analyze environmental narratives understood here as stories bounded by the narrators particular experiences observations and attachments to place the narrative concept was used as a tool to compare competing knowledge systems bounded to place including those based in western cosmologies the selection of materials that could compose such narratives was guided by the aim to access views over an urgent problem shared by both perspectives namely the need to protect what is left of the atlantic forest the main sources of access to the tupinambá narrative were 20 interviews conducted with tupinambá people in 7 villages inside indigenous territory and participant observation during fieldwork conducted in 20162017 when conflicts between the indigenous population and local state agencies were unfolding due to environmental fines received by the tupinambá the tupinambá interviewed by the researcher were defined by the coproduction relation between the researcher and two indigenous leaders this choice took into consideration gender age and territory range but had the indigenous people and leaders of communities that were in direct involvement with the disputes around conservation issues as its main criteria on the other hand the set of discursive materials that comprise the institutionalized western sciencebased environmentalism narrative is linked to the performance of iesb and its partner institutions due to its prominent role in southern bahia and influence in decisionmaking in this case we drew upon 8 scientific papers 15 project reports and 10 interviews with members of iesb and the local agents of the national brazilian agency for biodiversity conservation therefore the second narrative is composed from peoples personal experiences and perceptions as well as the available documents and projects developed by governmental and nongovernmental established institutions that work directly with conservation implementation in the region analysis of the data was conducted through the identification of repeating categories on the materials that composed each narrative related to the causes and solutions for biodiversity degradation the most recurrent topics became unifying themes that composed each narrative each of these unifying themes was systematized in a table per documentinterview per narrative and all data was then condensed to the three causes and solutions most present in each narrative therefore drawing from the field work and collected materials we have identified the general contours of two different perspectives on the same issue making it possible to compare contrasting perspectives on biodiversity conservation in the results section we point out three main causes for the shared problem and its related solutions according to each narrative our main objective is to bring into dialogue points of view about the best paths for forest management that have considerable differences in terms of language and social legitimacy to move closer to plurality in conservation results institutionalized environmentalism narrative traditional strategies for biodiversity conservation have emphasized the creation of intact protected areas free from human presence while these areas have enormous potential for conservation longterm conservation of biodiversity requires the development of an approach that includes the management of buffer zones and biological corridors the main argument that stands out in the institutionalized environmentalism narrative is the defense of the bioregional paradigm for biodiversity conservation the restriction of conservation planning to protected areas is considered one of the main causes of the degradation and the solution would thus be planning on a wider landscape scale categories such as corridor and network of protected areas are recognized as the basis for biodiversity conservationespecially in the context of the atlantic forest conservation efforts should be geared towards maximizing habitat connectivity ecosystems and ecological processes facilitating genetic flow and increasing the chances of species survival for these research communications special issue on diverse conservations precepts to be followed scientifically grounded planning is crucial geographical information systems are recognized as a good basis for decisionmaking because of their ability to provide rapid information on landscape dynamics by identifying priority areas the environmentalist narrative proposes a series of solutions that are intrinsically related to each other as part of a coherent discourse solution 1 actions in human occupied areas and social participation the adoption of a more comprehensive scale for biodiversity requires activities for conservation outside protected areas necessarily including human populations in the equation the solution proposed seeks to keep the protected areas as intact as possible and at the same time to work with local communities that inhabit their surroundings thus the inclusion of so called social dimensions is a founding element of the narrative but this inclusion appears in specific terms the most relevant publication on the theme produced by iesb aims at analyzing the opportunities to reconcile economic and conservation use of areas the proposition is to generate mechanisms to compensate landowners for environmental services provided stating that areas with less potential of profitability and greater potential of environmental services should be privileged another form of argument is the need to create participatory spheres for the implementation of biodiversity projects such as decision committees and advisory councils in several of the activities carried out by iesb and partners in the region participatory workshops were implemented although the profile of the members of these participatory meetings is quite specific state agents ngos and researchers environmental education is another cited path to solve biodiversity degradation which is presented as complementary to participatory processes this instrument is seen as a way to change peoples behavior by bringing them environmental awareness about the value of inhabiting the surroundings of a biological reserve solution 2 the cabruca identity in southern bahia the proposal to carry out biodiversity conservation management on a broader scale is linked to the need to confront the cocoa crisis through a new development model this narrative argues that in the face of the lack of financial return of the cacao plantations the pressure on timber resources increases mainly in the areas of cabruca agriculture landowners as a form of economic complementation may prefer to create pastures in areas once covered by forest or cabruca the expansion of pastures is seen by environmentalists as the central cause of degradation to the institutionalized environmentalism narrative the solution is to encourage organic cocoa plantation to promote the maintenance of cabruca areas and to stimulate alternative productive activities for local agriculture in order to justify this point of view research projects were carried out to demonstrate the occurrence of several species of plants and animals in cabruca areas and its connective capacity between forest fragments it is also worth mentioning that the valorization of cabruca is linked to ideas of a regional identity the environmentalist narrative points to the social and historical value of cocoa culture affirming the importance of the personality of the region as a path to an integrated sustainable socioeconomic development solution 3 expansion of the network of protected areas according to this narrative biodiversity conservation especially in the atlantic forest necessarily depends on the expansion of the protected areas network advocacy for strengthening monitoring of existing conservation units and creating new ones is recurrent the creation of private reserves is also encouraged although it is seen only as a complementary solution in fact all solutions are only seen as effective if they are combined with large restrictive protected areas thus forming the basis of the conservation landscape system land regularization through compensation payments and the relocation of human inhabitants within parks and alike is prioritized here on the other hand these areas are intensely populated by a myriad of nonhuman living beings the choice of priority areas for biodiversity conservation is largely anchored in the behavioral patterns of animal species in all institutional documents endemism and the risk of extinction of certain species are recognized the framing of the problem in the institutionalized environmentalism narrative is strongly influenced by threats to certain species which are often defined research communications special issue on diverse conservations through global indicators such as important birdlife areas and key biodiversity areas lack of knowledge about the different species is widely seen as a cause for the problem according to the analyzed documents the lack of data on the occurrence of threatened species makes it harder to push for more restrictive environmental protection policies indigenous narrative conservation tupinambá leader in interview 2017 when field research was conducted the indigenous narrative was marked by feelings of injustice in relation to fines for environmental crimes in the areas of overlap and buffer zones of the protected areas environmental monitoring is intense and in recent years several indigenous people have been accused of suppressing vegetation in areas considered regenerating forest in accordance with the atlantic forest law unsurprisingly the indigenous narrative evidences indignation in relation to punishment for an act that they do not consider to be in any way criminal the practice of crop rotation is common among the tupinambá de olivença and has been used historically in the view of the tupinambá agriculture for family sustenance should never be considered deforestation the tupinambá understand deforestation as the withdrawal of what they call thick wood or hardwood from areas of dense forest or native forest on the other hand what is perceived by the environmental agency as regenerating forest falls within indigenous categories such as arrancador and capoeira arrancador is recent vegetation that grows in lands with little rest time and is generally described growing up to three feet from the ground capoeira is vegetation somewhat higher than the arrancador endowed with fine woods or white woods which can be felled with machete and ax the common point of view of all tupinambá is that other types of land use should be forbidden in areas described as dense forest since this would mean deforestation therefore most indigenous formulations on the best ways to conserve nature are connected to land use according to certain restrictions autonomously decided by them in the tupinambá view there is a clear distinction between a use that would cause environmental destruction and one that would take into account the times of nature taking less than the land can produce again over time solution 1 recognition of indigenous land claims in the indigenous narrative the main vectors of environmental degradation are large enterprises with high impact capacity if their land claims could be fulfilled they believe they would have the power to halt those activities in their territory and therefore become contribute to growing examples of effective conservation on indigenous lands in brazil the subject of such activities are variously named by the tupinambá the outsiders the miners the powerful the nonindians or the fazendeiros the impunity of these other groups in relation to activities of high social and environmental impact within the indigenous land aggravates indigenous feelings of injustice about the fines the care for nature an indigenous concept that relates to their ability to take care of the times of nature constitutes for the tupinambá an element of alterity in relation to the nonindigenous people living in their territory especially in relation to the fazendeiros in the indigenous narrative the fazendeiros have no relation to the land because they do not depend on the water that flows through it and on the quality of the environment when raising their children and grandchildren therefore they devastate with impunity among the highly impactful activities the most frequently mentioned by the tupinambá is sand mining the sandbanks are seen as disastrous and were named as a main cause to biodiversity degradation by all tupinambá interviewees sand extraction for the construction industry generates enormous craters that in addition to the deforestation cause springs to dry up this directly affects indigenous families and often involves the removal of natural fields containing the piaçava tree a source of income and an important element of tupinambá cultural life another highimpact activity is the largescale monocultural planting of coconuts and palm hearts the tupinambá de olivença also vehemently condemned timber logging and the active presence of agents of real estate speculation in the indigenous narrative the ideal environmental solution that would ameliorate all the research communications special issue on diverse conservations framed causes would be confirmation of indigenous land titles which would allow indigenous peoples to deepen their ties to their territory encouraging preservation for their descendants solution 2 retomadas the tupinambá develop within the areas that come to their management through the practice of retomadas transformations in the landscape to protect nature the diversity of actions that are carried out in the retomadas by the tupinambá to preserve include efforts to maintain the forest in the spring area restoration in pasture degraded areas closure of charcoal stores production of several crops in the same space so that the different species help each other extraction of raw materials such as piaçava straw imbira shells and aroeira seeds used for crafts andor sale respecting their times of regeneration among others the retomadas are seen by the tupinambá especially their leaders as seedboxes for actions that point in the direction of preservation the tupinambá widely recognize the possibility opened by the retomadas for more autonomous management of their collective labor and also control over their territory this ability to organize the work is aligned with the possibility of collectively deciding on the management of the territory making choices in terms of the varied uses of the different areas based on their own criteria solution 3 income alternatives and educational seminars the tupinambá accept to some extent monitoring activities as a solution for environmental degradation as long as they penalize practices that they consider to be causes of deforestation indigenous peoples also point out that the prohibitions if indeed necessary could be enforced by them one of the main concrete proposals in terms of conservationrelated public policies reiterated by a significant number of indigenous leaders is the hiring of indigenous brigade fighters to contain fires and indigenous rangers to curb deforestation the monitoring would however be carried out in accordance with indigenous criteria in addition the possibility of conducting educational seminars is present in the indigenous formulation of solutions to the biodiversity degradation problem the main objective of such seminars would be to open a space for dialogue where joint alternative land management strategies could be developed in accordance with collectively established environmental limits hunting is a good example of how the limits are established for instance crabs must be larger than a fist to be collected and pregnant females of all mammals cannot be disturbed it is important to emphasize that in the view of the tupinambá monitoring would only have some effect if accompanied by alternatives to generate sustenance for indigenous families in a context of limited financial resources and in some cases extreme poverty authoritarian bans do not reach their conservation objectives discussion when we analyze the solutions proposed by each narrative we can see resonances and divergences first both narratives present themselves as counterdiscourses since they challenge dominant perspectives by advocating for the conservation of forest areas the mainstream perspective on the development of the region advocates for the implementation of plantations large tourism enterprises and resource extraction both stress the importance of engagement participation and environmental education in addition both narratives consider the economic aspect and the need to generate income alternatives that are sustainable albeit in different forms those similarities can open paths for joint efforts and could be used as middle ground to develop alliances for instance by including the indigenous populations as main beneficiaries of sustainable alternatives however the narratives diverge in relation to the degree of use and integral protection in different areas the indigenous statements present some criteria to choose areas for use that would not necessarily be recognized as sustainable by the institutionalized environmentalism as stated previously for the tupinambá hunting may or may not be a cause of degradation depending on who does it and how it is done they recognize a difference between indigenous hunting that respects limits regarding the time and species that can or cannot be a target and predatory hunting the irresponsible attack of any of the wild animals by outsiders in the institutionalized environmentalism narrative hunting is necessarily a cause of biodiversity degradation in all forms and it is as a threat perpetrated by the populations surrounding the protected areas since the human actions are recognized in a generic way without a specification of the groups responsible for degradation the tupinambá on the other hand recognize that the big and powerful not themselves research communications special issue on diverse conservations are responsible for the activities that really destroy the environment and therefore should be contained by law and enforcement a dichotomous view of the disputes over biodiversity conservation does not account for the complexity of relations in this case and other territories where conservation is at stake on the one hand the a priori perception that environmentalist and indigenous narratives would be mutually exclusive since the former would tend to overlook environmental justice can become an obstacle for alliances between environmental actions and indigenous perceptions on forest management on the other hand a vision that sought to recognize an automatic alliance between the indigenous movement and a socioenvironmental movement would be equally difficult unlike the institutionalized environmentalist narrative the indigenous narrative illuminates how processes occur and how they could be better but does not articulate a fixed set of principles about how things should be done any coalitions among these perspectives need to take into account this epistemological difference several factors give the different groups a greater or lesser capacity to publicly legitimize their perceived solutions for the problem in the case in question through political organization the tupinambá reach greater capacity to convince other actors and to manage their territories however their access to resources for biodiversity conservation is low when compared to institutionalized environmentalism since most decisions of high impact related to biodiversity conservation in the region were taken in arenas from which they were excluded the tupinambá are not an isolated case conservation policies even when they seek to address the ethical issue of marginalizing local populations often reinforce exclusion dues to the ontological dimensions that define the different interventions in this scenario injustice is aggravated by the power differentials relating to juridical and political authority between the protected areas and the indigenous land the brazilian bureaucracy created a complex expensive and hard demarcation process for indigenous lands which creates a sort of obstacle race permeated by several politicization processes the protected areas implementation on the other hand although complex is rather faster making it easier for environmental institutions to make their solutions prevail conclusion the need to address social justice and participation is becoming mainstream and yet the overlying power relations still play a role in the actual legitimacy of diverse proposed solutions for concrete environmental problems the upfront identification of the solutions for the atlantic forest proposed by both sides shows that they are equally coherent and that there is room for bridges between the perspectives the abovementioned differences in social legitimacy and territorial effectiveness however show the stronger weight of the institutionalized environmentalism in actual decisionmaking this case illustrates the importance of recognizing nondominant imaginaries for the future we hope that this can inform contestation of knowledge production and decision making current times of accelerated deforestation urge for the formation of all possible alliances and an in depth understanding of knowledgepower relations in each context is crucial to make a fertile ground for that we argue that our method of making the divergent perspectives as equal as possible can contribute to tackling those power relations this is a key step to move beyond the perceptions of inconsistency typically recognized by institutionalized environmentalisms on indigenous and other traditional ecological knowledges pluralism is needed to contemplate not just the different proposed actions impacting the prosperity of all living beings but also to recognize the diverse values that guide relations to nature and their implications on the recognition of the main causes behind biodiversity degradation in the first place just conservation is more effective in long term but can only be pursued through historical reparations that should encompass both dynamics of land dispossession and colonial knowledge structures acknowledgments thank you to all people involved in this research especially the communities of the mamão serra do padeiro itapuã tupã and tucum of the tupinambá indigenous land for their trust thank you also to all members of instituto de estudos socioambientais do sul da bahia and the instituto chico mendes para conservação da biodiversidade for the support time and access to documents and reports this work was fully funded by the national council for scientific and technological development and the article research communications special issue on diverse conservations

injustices its implementation created adams and hutton 2007 restrictive pas often do not encompass social and cultural heterogeneities creating negative impacts on otherwise sustainable livelihoods the consolidation of this critique led to the mainstreaming of more inclusive models of conservation such as participatory conservation and communitybased conservation that became the global paradigm in the late 1990s thereafter the debate on biodiversity conservation took a polarized form stressing the role of local populations in conservation one side advocates for the restriction of access and circulation and the other recommends community involvement as a solution to conflict holmes 2009

introduction the letters and reports sent to the neoassyrian kings esarhaddon and ashurbanipal by practitioners of the scribal arts of celestial divination exorcism pharmacology extispicy and lamentation represent our earliest evidence of the application of divination as well as our only avar as the middle assyrian period and scholarly texts copied from babylon and nippur are widely attested in temple archives and private collections from aššur and kalhu for centuries before sargons conquest of babylonia from 710707 bce 9 others have suggested that political instability led to an increased demand for supernatural protection on the part of assyrian kings during the seventh century bce 10 recently eleanor robson has linked official support for scholars to official veneration of the scribal god nabû which received extensive state support from the reign of sargon ii onwards robson argues that ashurbanipal was the last assyrian king to maintain an extensive scholarly retinue and that state support for scholars declined steadily as a result of a general economic decline in the aftermath of the war between ashurbanipal and šamaššumuukin from 652646 11 entangled with this question is the extent to which assyrian kings followed the recommendations of their scholars when making practical decisions about how to run the empire it is difficult for modern minds to imagine that neoassyrian rulers maintained a functional empire for the better part of three centuries while regularly making important political decisions on the alignment of planets or protrusions from the liver of a sacrificial sheep and many scholars have argued that scholars served a propagandistic purpose by reassuring the populace that the king enjoyed the favor of the gods 12 similarly eckart frahm has argued that by presenting the king with many possible interpretations scholars ensured that whatever decision he made was arguably correct according to the omens 13 others have suggested that scholars under esarhaddon crossed over to become policymakers with significant influence on political decisions 14 the view that esarhaddon was a uniquely paranoid and superstitious individual who was manipulated by his scholars has a long history although others have noted that he took measures to avoid being overtly manipulated or have emphasized the dependence of scholars on the king 15 this study will apply new methodologies to answer these questions by employing social network analysis to analyze esarhaddon and ashurbanipals correspondence with their scholars it will argue that an inner circle of nine prominenet scholars gained significant power during the final years of esarhaddons reign through controlling access 13 eckart frahm royal hermeneutics observations on the commentaries from ashurbanipals libraries at nineveh iraq 66 4550 see also jeffrey l cooley celestial divination in esarhaddons aššur a inscription journal of the american oriental society 135 13147 14 radner royal decisionmaking 27274 giovanni b lanfranchi scholars and scholarly tradition in neoassyrian times a case study state archives of assyria bulletin 3 99114 cynthia jean divination and oracles at the neoassyrian palace the importance of signs in royal ideology in divination and interpretation of signs in the ancient world ed amar annus 26775 15 for those scholars who entertained the idea that esarhaddon was a uniquely paranoid monarch see at olmstead history of assyria 347 wolfram von soden herrscher im alten orient 12526 oppenheim divination and celestial observation 12021 simo parpola assyrian royal inscriptions and neoassyrian letters in assyrian royal inscriptions new horizons in literary ideological and historical analysis ed frederick mario fales 11742 here 123 lorenzo verderame has noted steps esarhaddon took to avoid being manipulated such as asking multiple scholars to separately give their interpretations of the same event see verderame a glimpse into the activities of experts at the assyrian royal court in from source to history studies on ancient near eastern worlds and beyond dedicated to giovanni battista lanfranchi on the occasion of his 65th birthday on june 23 2014 ed salvatore gaspa alessandro greco daniele morandi bonacossi simonetta ponchia and robert rollinger 71328 verderame astronomy divination and politics in the neoassyrian empire in handbook of archaeoastronomy and ethnoastronomy ed c l n ruggles 184753 erle leichty esarhaddon king of assyria in civilizations of the ancient near east ed jack m sasson vol 2 94958 here 957 suggested that esarhaddon was no more paranoid than any other assyrian king more recently brown mesopotamian planetary astronomy 4447 and josette elayi esarhaddon king of assyria 4344 have emphasized scholars dependence on the king rather than the reverse avar to the king through frequent substitute king rituals and warnings about auspicious days after esarhaddons death in 669 bce the scholars of the inner circle were quickly excluded from positions of power by ashurbanipal this strongly suggests that the decline of court scholars in the latter half of the seventh century should be understood primarily as a political phenomenon through which scholars who wielded power through their claim to exclusive access to an esoteric body of knowledge came to be viewed as a political threat which must be curtailed methodology previous studies of the role played by scholars in the assyrian court have rightly emphasized the personal relationships between the king and scholars over attempting to identify their formal position within the imperial administration 16 this framework can be rightly extended to understanding the entire neoassyrian administration letters sent to the king by provincial governors and palace and temple officials are just as concerned with royal favor rewards and punishments as those of their scholarly counterparts 17 studies of modern organizations have shown that organizations rarely operate according to their formal hierarchy orders given by leaders brown mesopotamian planetary astronomy 4248 pečírková divination and politics in the late assyrian empire 15868 eleanor robson empirical scholarship in the neoassyrian court in the empirical dimension of ancient near eastern studiesdie empirische dimension altorientalischer forschungen ed gebhard j selz 60329 here 60708 melanie m groß at the heart of an empire the royal household in the neoassyrian period 30002 the major exception is parpola the assyrian cabinet in vom alten orient zum alten testament festschrift für wolfram freiherrn von soden zum 85 geburstag am 19 juni 1993 ed manfried dietrich and oswald loretz 379401 who situated scholars within a proposed cabinet of eight officials which reflected a divine council of gods parpolas model is too rigid and includes offices which were prominent at different points in neoassyrian history are often ignored by subordinates few members read their organizations formal regulations and most employees find out about policy changes through their peers rather than through formal channels understanding power within an organization therefore requires studying informal ties rather than formal organizational structure 18 this applies to the ancient world as well as modern corporations the correspondence of assyrian kings reveals many cases where officials who held formally important titles wielded little actual influence and conversely where persons who held less prestigious offices were in fact extremely influential due to having a high trust relationship with the king 19 social network analysis is an especially useful tool for quantifying informal relationships within organizations social networks simplify relationships into a system of nodes and connecting edges which can then be mathematically analyzed in a communications network nodes represent either individuals or other actors within the network edges represent communications sent between the nodes edges can connect nodes in one direction or in both directions a path is a connection between three or more nodes which does not include any node or edge more than once edges can also be weighted for this avar study the weight of the edges corresponds with the number of communications sent between two nodes 20 this study uses two measures to analyze the networks betweenness centrality and bonacich centrality betweenness centrality attempts to identify which nodes serve as bridges between different parts of a network by calculating how often each node sits on a possible path between two other nodes nodes with a higher number of possible paths which run through them will have higher scores 21 betweenness centrality therefore measures which nodes have the most control over the movement of information within the network however betweenness centrality does not consider the weight of ties so a node which communicates once with two separate nodes will have the same betweenness centrality as one which regularly serves as a conduit between two other nodes research by karen cook et al has shown that betweenness centrality often failed to predict influence in networks where centrality was a zerosum game in which gains made by one actor came at the expense of another 22 in order to address these weaknesses philip bonacich developed a measure called betacentrality this measure calculates centrality by taking into account the centrality scores of other nodes when computing each nodes centrality score every nodes centrality affects the score of other actors within a certain radius the formula for bonacich centrality contains an attenuation factor β which can be set to any number between 1 and 1 by the analyst the absolute value of β determines the radius within which the centrality scores of other nodes affect a certain nodes score setting β as a positive number analyzes a network as positively connected so that nodes gain power from being connected to influential nodes setting β as a negative number analyzes the network as negatively connected 23 absolute values of β which are closer to zero heavily weigh the immediate connections of each actor while an absolute value of 1 takes into account scores across the entire network 24 because different values of β can produce extremely variable results in low density negatively connected networks bonacich suggests either selecting a value for β based on an estimate of the degree of separation which affects an individuals status or setting an extreme absolute value for β 25 as the goal of this paper is to identify shifting power relationships between the king scholars and other officials this analysis treats power and influence as a finite resource superiors can only give a finite amount of attention to subordinates and so they distribute this attention unequally increased attention given by the king to one subordinate takes attention away from other subordinates while studies of communications networks typically analyze their subjects as positively connected networks in this study communications are not being analyzed in order to gauge their efficiency but as a proxy for power and influence 26 this study therefore treats the neoassyrian empire as a negatively connected avar network i have therefore set the value of β to 1 weighting the entire network when calculating the scores of each node any change in the kings favor towards one official can therefore elevate or demote others the data i constructed the data sets 27 for this study manually compiling networks of all extant communications which can be dated to the reigns of esarhaddon and ashurbanipal to better understand changes in the networks over time i also constructed four smaller networks consisting of letters which can be dated to the years 680675 and 674669 during esarhaddons reign and the years 669664 and 652646 under ashurbanipal only a handful of letters from the neoassyrian period contain dates and even fewer mention the king by name letters must therefore be dated through a combination of prosopography stylistic considerations orthography paleography archaeological context and historical events mentioned in the texts 28 letters from scholars which contain detailed reports of astronomical phenomena and can often be dated to the precise day the letter was written 29 this data set makes use of the extensive work on dating letters which has been carried out as part of the state archives of assyria project this allows us to assign 848 letters to the reign of esarhaddon from his coronation on 18 or 28 adar 681 bce to his death on 10 marchesvan 669 bce 30 as the precise dates for the end of ashurbanipals reign are not known all letters from his accession in 669 until the fall of the empire 27 the data can be accessed through 28 parpola assyrian royal inscriptions and neoassyrian letters 12628 29 parpola letters from assyrian scholarsvol 2 the cautious scholar should note when dating texts that saa 10 uses julian calendar years for astronomical calculations while saa 8 uses astronomical years as astronomical years contain a year 0 for mathematical purposes astronomical years bc are numbered one year lower than the equivalent julian years have been analyzed as a single network containing 630 letters an additional 530 letters largely very brief or fragmentary examples could date from the reigns of either esarhaddon or ashurbanipal and have therefore been excluded from this study because one of the goals of this study is to analyze the status of scholars relative to other officials in the empire all letters dating from the relevant time frame were included in the relevant networks not only those sent to or from scholars i was able to considerably expand the initial data set through including what i call developed messages two forms of developed messages can be recognized the first are written or verbal communications which have been lost but are mentioned in surviving correspondence this could include cases where a letterwriter mentions that they are replying to a previous message where a letter summarizes other messages sent and received by the writer or other references to previous letters and communications communications the writer promised to send at a later date and unsubstantiated allegations about communications sent or received by third parties were not included as developed messages the second form of developed message comes from coauthored letters which are especially common among the letters from scholars and posed a special challenge for compiling this data set letters from coauthors were counted as a separate communication from each coauthor to the recipient as the senders of the letter presumably communicated with each other about its contents a bidirectional connection was added between each coauthor messages sent to multiple recipients were counted as separate messages from the sender to each recipient but no connections were made between the recipients as they may have read the message individually without consulting one another the inclusion of developed messages expanded esarhaddons network to include 289 nodes which sent a avar total of 1231 messages the network of ashurbanipal and later kings consists of 259 nodes which sent a total of 843 messages table 1 avar the same principle of disambiguating personal names discussed above namely that splitting individuals is less likely to distort the final conclusions than merging them fragmentary letters for which the sender and recipient are both unknown were not considered for the analysis 136 letters dated from the reign of esarhaddon and 134 from the reign of ashurbanipal were therefore not included in the networks six letters from the reign of ashurbanipal and two letters from the reign of esarhaddon identify themselves as being written either by all the people of a city or by the ruling class of that city33 there are also ten letters sent by kings which are addressed to an entire city or cities 34 these letters have been accounted for by adding a single node for each city which sent or received them letters where governors identify themselves by name but append a demonym or city name to their greeting formulae have been counted only as messages to or from that individual governor as this is likely a rhetorical strategy rather than indication that the letter had a larger number of authors has the scholarly correspondence of earlier assyrian kings not yet been found any modern scholar considering whether the scholarly correspondence of esarhaddon and ashurbanipal is typical or exceptional is immediately confronted with the massive disparity in the number of letters from scholars which can be dated to their reigns versus the reigns of their predecessors out of 848 letters dating from the reign of esarhaddon 436 are to or from scholars among the 630 letters from ashurbanipal or later kings 106 are to or from scholars compare this to the 1151 letters dating from the reign of sargon ii of which only two were written by scholars only one letter from a scholar is present among the 69 which can be dated to the reign of sennacherib while no letters from scholars are to be found among the 188 that date from the reign of tiglathpileser iii r 745727 bce 36 the subset of letters which can be dated more precisely than to the reign of a king tend to cluster around certain date ranges the majority of esarhaddons datable correspondence comes from 674 bce or later while only sixty letters can be dated to 675 or earlier thirtyone letters from scholars can be dated to 675 or earlier compared to 213 which can be dated to 674 or later 37 fiftyseven letters from the reign of ashurbanipal can be dated to before 664 of which fifty were sent to or from scholars only twentythree letters avar from scholars can be dated to ashurbanipals reign after 664 38 there is also a substantial cluster of 151 letters from the years 652646 but only fifteen of these letters were sent to or from scholars 39 one must proceed cautiously with such statistics letters from scholars can be more precisely dated than letters from other officials which means that they are overrepresented in subsets of letters which can be dated to within a sixyear period if we divide the 412 letters from nonscholars to esarhaddon by the twelve years of his reign we return an average of 343 letters per year or 206 letters for the period 674669 this suggests the true figure for the proportion of letters to and from scholars in the final six years of esarhaddons reign is around 50 the same as the earlier half of his reign and for his reign as a whole likewise scholars seem have consistently written to the king in akkadian the dearth of letters from officials outside of babylonia or the assyrian heartland during the reigns of esarhaddon and ashurbanipal suggests that much of this correspondence must have been carried out in aramaic written on perishable materials rather than on durable clay tablets it is here that a close study of the archaeological context of the nineveh letters would be of great assistance yet here we face the difficulties caused by half a century of destructive excavations by the british museum at kuyunjik excavators usually did not record any find spots for any of the tablets recovered which means that the only way to recover any information about find locations is by matching museum registration numbers which indicate a year of accession with rooms of the southwest palace or other areas known to have been excavated during a specific season 42 while each expedition collected surface finds all over the tell and catalogued texts found by the watchmen hired to guard the site between dig seasons the majority of the texts which were added to the museums collection in a certain year can be assumed to have come from the areas which were excavated that previous season collating this data shows there were five major locations where large numbers of letters were found if we accept that the letters were recovered from secondary depositions into which the surplus royal archives were discarded the fact that esarhaddonashurbanipal letters show that scholarly correspondence made up a fairly consistent 4555 of letters across all find spots while hardly any scholars letters appear among the recovered correspondence of sargon ii strongly suggests that the earlier king did not correspond regularly with scholars in the same manner as esarhaddon and ashurbanipal this is not to say that scholars were not present in assyria during sargon iis reign only that they did not enjoy the same access to the king as they did during the the reign of these later kings the temple appears to have been the primary employer of scholars throughout the middle and early neoassyrian periods as it was in all periods in babylonia 50 even as scholars took on an important role in crafting sargon iis royal propaganda sargon appears to have kept them at arms length and did not allow them access to the inner circles of power in both centrality measures because they either only wrote to the king or rarely or never received replies social network analysis allows us to refine parpolas list to define the inner circle more rigorously zscores were computed for each node in the network first the mean score and standard deviation were calculated for each centrality measure esarhaddon and the nodes representing unidentified correspondents were excluded from these calculations zscores were calculated by subtracting the mean score from each nodes score and dividing the result by the standard deviation the resulting zscore for each node gives their centrality score in terms of number of standard deviations from the mean scholars whose score lies greater than one standard deviation above the mean were included in the inner circle this allows us to define the inner circle down to ten prominent scholars nine of whom have a zscore greater than one in bonacich centrality and six of whom have a zscore greater than one in betweenness centrality the chief scribe issaršumuereš the exorcists adadšumuuṣur and mardukšakinšumi and the scholar and envoy marissar rank highly in both categories the astrologers balasî and nabûahheeriba the exorcists nabûnaṣir and uradgula and the physician uradnanaya score highly in bonacich centrality only while the chief scribe nabûzerulišir has a high score in betweenness centrality alone nabûzeruliširs low bonacich score may be due to an early death as he does not appear in any sources after 673 and likely died that year only a handful of other officials have centrality scores comparable to the members of the inner circle those other officials with zscores at least a standard deviation above the mean in either centrality measure include the crown princes ashurbanipal and šamaššumuukin esarhaddons mother naqia his son šamašmetuuballiṭ and a handful of palace temple and provincial officials with only a handful of exceptions scholars in the inner circle are the only ones who recommend the enthronement of a substitute king the only ones who write letters addressing the king as the farmer during a substitute king ritual and the only ones who advise the king on auspicious and inauspicious days for receiving visitors or performing activities 56 many of them were blood relatives nabûzeru56 for letters concerning the enthronement of a substitute king see saa 10 1 3 189 209 219221 314 377 saa 10 25 221 240 saa 10 1 12 25 saa 10 350352 saa 10 25 saa 10 13 the only persons outside the inner circle to recommend enthronement are uradea and nabûšumuiddina in saa 10 134 where they appear as two of five coauthors alongside three members of the inner circle and munnabitu in saa 8 316 r 13 but note that this letter was sent in 677 bc early in esarhaddons reign and this scholar is not attested after 674 it is possible that munnabitu was an important scholar earlier in esarhaddons reign when there are fewer surviving letters for letters sent to the farmer see saa 10 2 saa 10 26 saa 10 209212 221 saa 10 1 saa 10 212 saa 10 325 in addition to the coauthored avar lišir and adadšumuuṣur were sons of nabûzuqupkenu a prominent scribe under sargon ii and a descendant of the scribe gabbuilaniereš issaršumuereš was the son of nabûzerulišir while uradgula was the son of adadšumuuṣur 57 nabûzerulišir and issaršumuereš also appear as esarhaddons scholars in the synchronistic king list a late seventh century list of assyrian and babylonian kings which also records their most prominent scholars 58 however scholars from the inner circle only make up onefifth of the fifty scholars attested in esarhaddons correspondence the rest form a longtail distribution of scholars with low centrality scores nearly threefourths of the scholars in the outgroup did not correspond with anyone other than the king and the median number of letters this group sent was two while all the members of the inner circle except for marissar appear to have been based in nineveh scholars in the outer circle identify themselves as hailing from aššur arbela harran borsippa dilbat cutha and uruk 59 it is not known if these scholars were writing from their hometowns or if they relocated to nineveh to seek royal employment in either case scholars from the outgroup were on the outside looking in sending saa 10 1 two additional letters to the farmer from outside the inner circle are known saa 10 128 and saa 13 75 for letters advising esarhaddon on auspicious days see saa 10 19011r 4 192 r 19 20312r 11 207517 221 r 512 3143´11´ saa 10 233 r 612 25315r 12 254 r 213 26010r 6 saa 10 58r 6 6 r 1119 7614 13615 148r 10 185r 9 194´r 8 saa 10 70614 737r 17 746r 3 saa 10 526r 12 44714 5310r 7 saa 10 325 r 3´7´ the lone exception saa 16 6259 was sent by the socalled anonymous informer their observations to the king while receiving infrequent replies and occasional acknowledgment of their services what did scholars in the outgroup write to the king about a survey of astronomical omen reports shows that scholars in the outgroup were much more likely to report positive omens and less likely to report negative ones omens were classified as positive if they decreed something good for the land or for subartu or akkad the latter two terms were equated with assyria and babylon by scholars and as esarhaddon held both crowns simultaneously omens concerning both regions were of equal relevance 60 omens were also classified as positive if the scholar explicitly stated they should be interpreted as positive scholars of the inner circle reported close to equal numbers of positive and negative omens scholars in the outavar group however reported almost three times as many positive omens as negative omens if one counts reports which contain a mixture of good and bad omens as a half negative and half positive then scholars in the outgroup reported positive omens in 69 of their reports compared to 36 for reports from scholars in the inner circle this is all the more surprising given that the probability of a lunar eclipse omen portending negatively for assyria was somewhere between 5060 depending on the interpretive method used 61 in short it appears that only scholars from the inner circle had the standing to deliver bad news to the king scholars of lesser status sought to move into the inner circle by sending good news of the gods continued approval of the king avar november 3 677 actually triggered an enthronement 64 although at least sixteen scholars are attested as writing to esarhaddon during this period not a single response of the king is recorded nor do the scholars ever coauthor letters while one report sent by the scholar munnabitu recommended enthroning a substitute king his advice is contradicted by a report from another scholar and there is no evidence that an enthronement actually took place 65 our first firm evidence of a substitute king being enthroned comes from letters sent by scholars from the inner circle in response to an eclipse on september 3 674 which discuss the unfortunate substitutes time on the throne and his burial 66 the presence of a substitute for each of the four eclipses which occurred thereafter is attested by numerous letters which discuss esarhaddon in hiding as well as the execution and burial of the substitutes 67 if each instance required the king to remain secluded for the full one hundred days normally required this would mean that esarhaddon spent more than onefifth of his final five years as king in hiding while a substitute sat on the throne in either assyria or babylon the king and uradnanaya forbidding the crown princes from going outside during the ritual 69 attestations of the substitute king ritual are rare outside of esarhaddons reign the ritual is attested as being performed twice late in the reign of adadnirari iii sometime between 786 and 783 bce but is not explicitly attested anywhere else in assyria prior to the reign of esarhaddon 70 the rhetorical phrase i would go as a substitute for the king in letter greeting formulae from babylonia was common from the old babylonian period onwards so its continued use in letters from the reign of sargon ii does not imply that the ritual was currently being practiced 71 it seems likely that the inner circle of scholars revived a ritual which had long since fallen out of use in order to control access to the king likewise auspicious days are first referenced in the royal inscriptions of sargon ii describing the founding of duršarrukin but there is no evidence for kings prior to esarhaddons reign following a regimen of auspicious days which determined their movements and when they would receive visitors avar multiple experts 73 the picture of scholars during esarhaddons reign is therefore one in which a small group of scholars occupied positions of great power and influence while a much larger group attempted to curry favor in hopes of someday being invited to join this inner circle when did this situation come into being while letters from scholars make up about half of the letters which can be dated from earlier in esarhaddons reign nabûahheeriba is the only scholar from the inner circle who appears in the earlier correspondence 74 there are no letters describing the reign of a substitute king nor are there any letters informing the king about auspicious days all of these appear in the correspondence from 674 bce onwards we can only speculate as to what internal or external pressures caused esarhaddon to turn towards scholars during the latter half of his reign esarhaddons attitude towards scholars combined utter confidence in their methods with a measured trust of the persons employing them early in his reign the scholar belušezib warned him in a letter that during the reign of his father the interpreters of astronomical omens and extispicy experts had conspired together to conceal negative omens from the king 75 esarhaddons own scholars sometimes pleaded that they had not hidden any omens from the king defending themselves against a concern esarhaddon must have sometimes expressed 76 his suspicions were not unfounded as has been shown above his more junior scholars showed a clear preference for 73 for coauthored letters from the inner circle see saa 10 3 saa 10 209 256 259 saa 10 24 saa 10 205 saa 10 1 saa 10 212 saa 10 4041 4344 47 50 53 saa 10 25 saa 10 297 74 saa 8 39 75 saa 10 109 r 110 dated by the discussion of the events surrounding sennacheribs assassination in ln 7´21´ and r 1415 reporting positive omens over negative ones while esarhaddon was probably literate he was unlikely to have mastered the obscure signs and knowledge of the sumerian language needed to read scholarly texts as evidenced by the glosses which his scholars sometimes added to their reports for the kings benefit 77 although esarhaddon sometimes attempted to obtain independent interpretations from his scholars and prevent them from conspiring together to agree on an interpretation he was ultimately at his scholars mercy when it came to understanding the complex astronomical texts from which they drew their interpretations 78 as balasî wrote in one letter to the king after esarhaddon attempted to read the standard birth omen series for himself šumma izbu is difficult to interpret…truly one who has not had the meaning pointed out to him cannot hope to understand it79 scholars and social networks under ashurbanipal the network of ashurbanipal and later kings contains 259 nodes and 412 edges containing 843 separate communications eleven actors in the network can be identified as temple personnel eleven as palace personnel six as members of the royal family eight as tribal leaders the network includes twentynine communications from the reign of sînšarruiškun two from the reign of aššuruballiṭ ii thirtysix which could date from late in ashurbanipals reign or in the reign of a later king and five dating to one of the kings following ashurbanipal but which could not be dated more precisely the network includes many private archives dating from the final fifty years of the empire which form their own networks distinct from the main network and cause some of their members to score very highly in the bonacich centrality measure letters from the western half of the empire are completely absent from ashurbanipals correspondence except for correspondence with foreign kings in urartu elam and dilmun all letters originate either from the assyrian heartland or from babylonia despite even narrower geographic limitations on the corpus letters to and from scholars make up a much lower percentage of ashurbanipals correspondence than they did under esarhaddon nearly all the scholarly correspondence from ashurbanipals reign dates from the 674664 bce cluster of letters which represents continuity from esarhaddons correspondence there are only twentythree letters from scholars which date from later than 664 and none which can be dated to the reigns of the kings who came after ashurbanipal 80 the latest known letter sent by a scholar was sent sometime shortly after 648 bce81 whereas esarhaddons network features a clear inner circle of scholars who have centrality scores much higher than the majority of scholars as well as other officials there are only three scholars in ashurbanipals network who have a betweenness centrality score higher than zero only one scholar akkullanu has a zscore more than one standard deviation above the mean in betweenness centrality and no scholar has a bonacich centrality score above this mark four scholars akkullanu babušumuiddina and former inner circle members nabûahheeriba and issaršumuereš achieve a bonacich score more than one standard deviation below the average avar only sixteen of the fifty scholars who appears by name in esarhaddons correspondence also appear in ashurbanipals letters this is not merely a product of normal turnover those sixteen scholars make up the majority of scholars attested by name from the reign of ashurbanipal the missing scholars from esarhaddons correspondence were mostly not replaced only five scholars appear by name in ashurbanipals letters who were not also attested in esarhaddons correspondence and all of them have very low centrality scores of the ten scholars in esarhaddons inner circle nabûzerulišir was probably deceased by the time ashurbanipal took the throne in 669 bce as he is not attested in any documents after 673 82 the physician uradea the exorcists nabûnaṣir and mardukšakinšumi and the scholar marissar also do not appear in ashurbanipals correspondence to compare centrality scores in networks of different sizes scores must first be normalized by dividing each score by the maximum possible score for that network comparing normalized scores from the reigns of esarhaddon and ashurbanipal shows that nearly every scholar with a bonacich or betweenness score higher than zero experienced a decline in centrality scores of 75 or more the one exception is akkullanu a scholar of little importance during esarhaddons reign who rose to become the only scholar of any appreciable centrality during the reign of ashurbanipal this decline is especially striking among the five remaining members of the inner circle who all exhibit sharp declines in centrality measures relative to both to the positions which they held under esarhaddon and to other persons in ashurbanipals network for reasons outlined above comparisons across the 6year subset networks must be done with caution due to both the small sample size and the fact that letters from scholars are more likely to be dated with precision the smaller sample sizes and the removal of most of the nonscholarly correspondence from the networks spanning 674664 combine to have a major distorting effect on complex centrality measures such as the bonacich measure nevertheless while scholars account for the vast majority of the letters which can be dated to ashurbanipals early years from 669664 few of them connect to anyone besides the king in sharp contrast to the final years of esarhaddon only one coauthored letter is evident and of the thirteen scholars in this network only akkullanu connects with anyone other than the king or a coauthor 83 with the exception of balasî who coauthored a letter to ashurbanial with the astrologer bamaya none of the scholars of the inner circle communicate with anyone other than the king avar connected to other actors changes from esarhaddon to ashurbanipal under esarhaddon adadšumuuṣur sent messages to twelve other actors while receiving messages from eleven his nephew issaršumuereš sent messages to twelve and received messages from thirteen under ashurbanipal issaršumuereš sent messages to two actors and received messages only from the king while adadšumuuṣur corresponded with the king only other persons no longer saw these scholars as persons of influence through whom they could connect to the king scholars from the inner circle also no longer coauthored letters in the same way they did under esarhaddon only one scholar managed to increase his centrality score under ashurbanipal the scholar akkullanu who had been of little consequence under esarhaddon managed to maintain an unusually long career under ashurbanipal corresponding with the king into the 650s 85 however akkullanu scores very low in the bonacich centrality measure suggesting his status was highly dependent on the king overall the picture which social network analysis reveals is that under ashurbanipal the status of scholars in the inner circle declined to a level similar to that of scholars in the outgroup under esarhaddon while scholars from the outgroup largely ceased to write to the king altogether presumably after hearing of the decline in status of the inner circle many of them lost hope that the new king would reward them and so returned to the temples to continue their work there a few new scholars appear in ashurbanipals later letters but most scholars ceased to write to the king and were not replaced avar a qirsu was a portable tent shrine used to perform aspects of various rituals including the substitute king ritual 89 the secrecy surrounding these reports could only have increased the control which the scholars of the inner circle maintained over esarhaddon while the eclipse of 667 did not call for the enthronement of a substitute ashurbanipal clearly had no intention of continuing his fathers practice of receiving reports in secret the tensions between ashurbanipal and his scholars became more apparent a year later when a partial lunar eclipse occurred in conjunction with jupiter on april 10 666 bce this portended evil for subartu and that an important person would die in the place of the king 90 ashurbanipal responded to his scholars recommendations by doing nothing for several months even though the sartinnu died within a month of the eclipse 91 eightysix days into the onehundredday period specified by lunar eclipse omens akkullanu finally sent a sharplyworded letter asking why is nothing being done month after month it is a crime something will come of it 92 akkullanu recommended that ashurbanipal confine himself to the palace while the ritual giving a persons substitute to ereškigal was performed 93 ashurbanipal instead enthroned an inanimate statue as a substitute in akkad but did not reply to akkullanus letter or inform him of this decision until after the ritual had been completed 94 akkullanu was furious writing a lengthy letter castigating the king for enthroning a substitute in akkad where it would protect šamaššumuukin rather than himself he couched his criticism as protecting the kings best interests saying if i had not talked to the king my lord today in the morning would the king not say to his servant you were a servant of my father why did you not advise and explain to me 95 he further suggested the king may have been poorly advised by other scholars 96 yet ashurbanipal had studied the omen corpora himself when crown prince and may have known that eclipses in the month of nisan were usually taken to pertain to akkad as were eclipses which occurred in the evening the eclipse of april 10 moved from left to right across the lower part of the moon exiting in the quadrant which some interpretive schemes associated with akkad 97 it is entirely possible that ashurbanipal pursued his own interpretation of the omen and chose a course of action at odds with the recommendations of his scholars one which did not require him to isolate himself ashurbanipals choice to use an inanimate statue rather than a live human as a substitute king represented a departure from normal practice under esarhaddon although it was not unprecedented in assyrian rituals 98 in fact despite the occurrence avar of several solar eclipses as well as a great number of lunar eclipses during his reign some of which portended evil for subartu only two substitutions rituals are attested as being carried out under ashurbanipal there is no evidence that ashurbanipal ever carried out a substitute king ritual using a live human being 99 the only other text possibly referencing a substitution ritual from his reign is an anonymous ritual instruction addressed to the farmer which describes a helical rising of mars in aries that could only have occurred on april 18 689 or may 4 657 bce 100 parpola preferred the latter date as a solar eclipse had occurred only nineteen days prior but another solar eclipse had occurred ninetyeight days prior to the april 689 rising and it is possible that the rituals were intended to close out the kings term as a substitute in any case the type of substitute is not mentioned and it is possible that this ritual was also carried out using an inanimate image ashurbanipal also does not seem to have consulted his scholars about evil or auspicious days as this topic is conspicuously absent from his correspondence compared to the letters between scholars and esarhaddon it would be inaccurate to say that ashurbanipal completely disregarded his scholars expertise he occasionally wrote to them inquiring about observations of expected lunar eclipses earthquakes or purification rituals 101 but by disregarding their advice on substitute kings and auspicious days he ensured that scholars no longer had the ability to control his movements or dictate who was allowed to be admitted into his presence nowhere was the decline in status of scholars in the inner circle felt more acutely than in the gabbuilaniereš family even before he became king ashurbanipal had refused to hire nabûzeruliširs son šumaya even even as the younger scholar was struggling to pay off his fathers accumulated debts avar that he had either died or sold off his personal library which by this date was incorporated into ashurbanipals library at nineveh 115 a lone scholar stands out amidst the declining centrality of scholars in ashurbanipals social network akkullanu is the only scholar whose betweenness centrality rises one standard deviation above the mean during esarhaddons reign he had been a scholar of no particular importance who sent reports of mostly negative omens to the king under ashurbanipal he became the kings preferred scholar regularly fielding inquiries about rituals temple administration and copying texts for ashurbanipals royal library 116 his later omen reports to ashurbanipal suggest that he changed his approach during the conflict with the cimmerians in 657 bce akkullanu authored a long omen interpretation which went to great lengths to spin negative omens into assurances of assyrian victory even quoting a nowlost middle babylonian literary letter to argue that a recent drought represented a positive omen as it would encourage assyrias soldiers to fight harder in order to secure food for themselves 117 in another report he predicted that a solar eclipse would augur poorly for the king of elam 118 yet akkullanu had a base of support outside of the palace he was a priest in the temple of aššur and many of his connections in ashurbanipals network were to priests or other temple personnel with whom he interacted during the course of his duties 119 he was avar administrative texts which are common from the final three and a half decades of the empire is a powerful argument for their decline only three scholars appear in legal texts dating from after 648 bce uradnabû the doctor appears as a witness to a real estate sale from 630 bce while an exorcist named … nadinapli and an extisipicy expert named belnaṣir appear as witnesses to a sale document from 621 126 of the three belnaṣir is described as working for the crown prince while … nadinapli is in the employ of aššuršumuibni a person about whom nothing else is known none are described as working for the king conclusions scholarship as a political phenomenon in her recent book ancient knowledge networks eleanor robson argued that the decline of court scholars in assyria came about as the result of an economic crisis in the aftermath of the 652646 bce war with šamaššumuukin and elam which left the assyrian kings unable to afford to pay large numbers of scholars 127 however the decline in centrality of scholars from esarhaddon to ashurbanipal which is evident in both the aggregate networks and between the 674669 and 669664 networks suggests that the decline in their status was immediate and took place as soon as ashurbanipal took the throne this is supported by numerous letters which suggest that scholars especially those from the gabbuilaniereš family and others who had been part of esarhaddons inner circle were no longer accorded the status they had previously held ashurbanipal did not immediately do away with the scholars some of whom continued to serve in their positions until at least 650 bce but he reduced their numbers excluded them from the inner circles of power and did not allow them to control access to his person or 126 saa 14 35 r 15 saa 14 166 r 46 127 robson ancient knowledge networks 8286 restrict his movements with substitute king rituals or a regimen of auspicious days these decisions would have reduced their influence by removing the tools which the inner circle of scholars had used to control the previous king it would be wrong to conclude that ashurbanipal a king otherwise famous for his scholarly learning who began to assemble a personal library of scholarly texts while still a crown prince disbelieved in the basic premises of divination and the cuneiform omen tradition rather his problem was one of power and control the decline and fall of the assyrian court scholar should be understood as an essentially political phenomenon under esarhaddon a small group of scholars had risen to become some of the most powerful men in the empire who used their scholarly knowledge to achieve a certain level of control over the king himself ashurbanipal found this situation intolerable and saw the scholars as a political group whose power needed to be curtailed ashurbanipal had been trained in cuneiform scholarship by balasî a member of his fathers inner circle 128 he collected a large number of omen texts himself including the series barûtu and enūma anu enlil commonly cited by scholars 129 some of these texts formerly belonged to members of the gabbuilaniereš family 130 in contrast to his father whose basic literacy skills were not sufficient for interpreting scholarly when his scholars are stumped while the more explicitly hostile verse account mocks nabonidus for his pretentions of competence at interpreting astronomical and liver omens 136 both texts may represent disapproving memories among scholars of a king who overrode their expertise and did not allow them to overly influence his decisionmaking 137 under achaemenid rule scholars worked exclusively for the temple where they sometimes performed rituals to avert evil from the king without the kings knowledge however there is no evidence that persian kings took notice of these performances scholars turned toward providing private horoscopes rather than advising kings 138 in the latter half of the first millennium bce the temples of southern mesopotamia served as arks preserving the traditions of cuneiform knowledge in a world which had moved on but the court scholars had long since been marginalized from political power from the beginning of the reign of ashurbanipal 131 in doing so he empowered himself to critically assess his scholars recommendations and make his own decisions about the proper course of action in response to omens 132 in doing so he undermined the source of their power that is their ability to provide exclusive access to an esoteric body of knowledge having been ejected from the inner circles of power cuneiform scholars retreated into the temple they would remain there until the end of cuneiform writing there is little evidence for a close relationship between neobabylonian kings and their scholars nebuchadnezzar ii asked the eanna temple in uruk to send lamentation priests for a ritual implying that these scholars were primarily employed by the temple 133 royal inscriptions from throughout the neobabylonian period also describe scholars being consulted for rituals associated with temple or ziggurat construction 134 the royal inscriptions of nabonidus frequently reference omens and auspicious days for beginning the construction of temples often claiming to have performed extispicies himself in one case he simply claims to have dreamed the appropriate astronomical omens into existence

modern scholars have long been divided over whether the correspondence of ancient scholars with the assyrian kings esarhaddon and ashurbanipal represents an anomaly or a typical relationship between scholars and kings in the ancient near east this article uses social network analysis to examine the changing status of scholars in assyria it argues that the reign of esarhaddon saw the emergence of an inner circle of scholars who maintained power and influence through controlling access to the king and an outgroup with little influence who hoped to move into the inner circle by contrast under ashurbanipal all scholars experienced an immediate decline in centrality scores suggesting a sudden loss of status as the scholars were marginalized and slowly phased out even as ashurbanipal collected his own archive of cuneiform scholarship the decline of court scholars in assyria should therefore be understood primarily as a political phenomenon that is an attempt by ashurbanipal to reduce the influence of a group which he perceived as having become too powerful within the assyrian imperial administration

introduction in recent years people around the world are increasingly experiencing the effects of climate change in the form of extreme events such as devastating floods storms droughts and fires while the longstanding problems of global warming and glacier melting were probably perceived as far away because the latter occurred mainly in remote places on the planet or the former originated in the atmosphere the rapid acceleration of extreme events in industrialised countries has demonstrated the seriousness of the current environmental situation exacerbated by the global energy economic and food crisis and triggered by an unexpected conflict in europes neighbouring countries all these events may have served as triggers for climate activism and the collective mobilisation of citizens more than adults young people have raised the demand for more effective and urgent intervention by policy makers to protect the planet and have become protagonists of a global protest movement that has quickly captured the attention of public opinion this movement is called fridays for future after the day of the first global school strike in march 2019 which involved 16 million protesters worldwide some months later in september 2019 76 million participants took part in the third global fff day of protest for climate justice and the strikes continue each year leading de moor et al to call the fff movement the largest globally coordinated climate protest in world history youth are aware that they are the generation who will inhabit a planet that is already sick and whose situation is inevitably deteriorating they protest against the negative externalities of economic development and believe that they are the main victims of the rise in temperature water and air pollution caused by the unsustainable production of goods and consumerism responsible for the overconsumption and waste of natural resources they are ready to fight for their right to a healthier and sustainable future and to make their voices heard to raise public awareness of this issue they want to shake up those who still believe that environmental problems are far away from them are not really addressed by them and therefore do not feel the need to incorporate ecological practises into their lifestyles to investigate young peoples engagement with the dangerous effects of climate change a survey was conducted in february 2020 among 1138 high school students in southern italy who were interviewed via an online questionnaire the research question was based on investigating awareness of the main environmental issues their opinion on the environmental plans of local authorities and whether students were willing to make a paradigm shift based on concrete actions that can reduce or stop the waste of natural resources and the pollution of the planet based on these premises they committed to sharing the goals of the fff movement actively participating in the strikes and making a positive contribution through everyday environmental practises to perform the statistical analysis we used a treebased method since in our opinion it is easier to interpret for example using a classical model such as pom 1 3 perceived climate change risk and global green activism among… we get as many coefficients as there are categories for both the response variable and the predictors all of them minus 1 the latter applied to our data would return 57 regression coefficients for the additive model only in this case interpretation is difficult and we find that the classification tree for ordinal responses is much more interpretable when a data set contains many categorical variables with many categories in our analysis we applied an ordinal classification tree with the original impurity measure proposed by morrone et al the novelty of the ordinal tree methodology used in this paper allows for better discrimination of paths when the response variable is ordinal with a cutoff value that separates ordinal categories with a positive semantic meaning from those with a negative one the results of the study could be of interest to policy makers to understand how young people see their future from a sustainable perspective and to what extent they are ready to support the ecological transformation of public services provided to citizens at a time when european countries need to put into practice the strategic guidelines to achieve the sustainable development goals sdgs of the un agenda this study could be a contribution that gives some suggestions to public administrators and policy makers it is not trivial to mention that the italian government has put almost 250 billion euros in the reconstruction plan after covid19 the socalled national recovery plan to carry out projects and initiatives that will influence the destiny of the country not only towards repairing the damage caused by the covid19 pandemic but above all to leave a more sustainable country for the next generation among the six missions of the pnnr the green revolution ecological transition and sustainable mobility infrastructures occupy an important place great attention will be paid to supporting young people and the south of italy traditionally poorer than the north which will receive more than 50 of the infrastructure budget to reduce the mobility gap the paper is organized as follows sect 2 reviews the literature in sect 3 we illustrate the survey on the perception of environmental risks in young people and their means of reaction in sect 4 we describe and formalise the statistical methods used for the data analysis the main results are illustrated in sect 5 the paper ends by summing up the results and discussing our main remarks climate activism and mitigation strategies climate change activism has been discussed by scholars from different angles roserrenouf et al addressed the question of cognitive and affective underpinnings to understand the genesis of climate change activism kleres and wettergren seeking to understand how core emotions influence activists motivations and mobilisation strategies showed that fear plays a key role in raising awareness of the dangerousness of climate catastrophes and that hope drives collective movements sharing the theme theorised by nairn obrien et al explored youth activism on climate change by arguing about dutiful disruptive and dangerous dissent three different types of behaviours that can be adopted by young people and following corner et al they expressed concern that their personal engagement may decrease if young people perceive their selfefficacy as limited fisher and nasrin debated on a specific form of activism called civic engagement a form of activism aimed to pressure different kinds of actors who might address the issue of climate change by adopting different tactics in particular they argued a different level of commitment depending on actors citizens participating to influence communities politicians and businesses can directly engage in lifestyle change by modifying their individual behaviour and consumption patterns there are still a few studies that look at the direct effects of participation in green activism movements on changes in resource consumption according to fisher and nasrin it is also important to distinguish between direct and indirect pathways to achieve positive impacts on climate change by putting pressure on policy makers and companies to take emissionreducing measures the direct pathway can be chosen simply through the adoption of the abovementioned ecological behaviours by individuals the other way works at a higher level by asking government policies to take into account the suggestions of scientists and this is for example the strategy followed by international environmental nongovernmental organisations some scholars have discussed the special roles that the economic sector and businesses can play in this case peoples civic engagement has declined in the form of shareholder activism which focuses on dissatisfied investors who as shareholders have the power to put pressure on the company to move towards social responsibility and environmental corporate activities and performance companies give due consideration to the expectations of their shareholders to address these issues in their strategic social responsibility documents specifically related to the issue of the impact of peoples actions in addressing climate change a growing body of literature has addressed climate change mitigation strategies the pathways of which can be expressed through three main climate approaches the first approach addresses conventional climate mitigation efforts that use decarbonisation technologies capable of reducing co2 emissions namely renewables fuel switching efficiency improvements nuclear energy and carbon capture storage and use the second direction addresses a newer set of technologies and methods that can be implemented to capture co2 from the atmosphere referred to as negative emission technologies they are based for example on methods for removing pollutants storing bioenergy increasing the alkalinity of the oceans sequestering carbon in the soil facilitating deforestation and reforestation the last 1 3 perceived climate change risk and global green activism among… direction of mitigation strategies is perhaps the most specialised as it deals with extremely advanced technologies whose goal is to lower temperatures without altering greenhouse gas concentrations in the atmosphere however as lawrence et al affirmed the latter techniques are still theoretical in nature and cannot currently be included in policy frameworks in this framework which focuses on mitigation strategies that lie in the possibility of peoples intervention it is interesting to consider two levels of intervention the collective level as a city and the individual level as an individual citizenactivist they comprise more than half of the worlds population and are consequently responsible for threequarters of global energy consumption and greenhouse gases many urban climate policies have been adopted to address climate change the most important are improving energy efficiency reducing fossil energy consumption and finding appropriate lowcarbon development routes for sustainable development all public organisations especially local and regional authorities need to clearly communicate their plans for environmental protection to improve citizens commitment to collective and synergistic action from our point of view it is interesting to understand the extent to which young people are informed about the policies and actions of local authorities and whether they feel committed as part of the community or as individuals based on the aims of our study this difference is not trivial as they could belong to at least two main profiles of young citizens the first considers the community as a kind of shield in which other citizens work to achieve environmental goals the second firmly believes that his or her own actions have a strong positive impact and are a necessary seed for the spread of ecological behaviours for a more sustainable future of the planet the issue of young peoples climate activism has been increasingly discussed by scholars in recent years de moor et al defined two recent movements fff and extinction rebellion as new forms of climate activism because they had the power to inject new energy into global climate politics to study the phenomenon in depth they compared these movements with previous climate campaigns and found that the participants had some elements in common while the main difference was the use of a more politically neutral framing of climate change recent studies have focused on the fff movement and have made interesting contributions to knowledge about the phenomenon social base and strategic choices of european youth the communicative power of youth activism and crossing crises in particular della porta and portos addressed the background of protesters as a possible trigger for an active role noting that their social composition is heterogeneous as there is a crossclass coalition that forms the collective mobilisation against climate change in particular social background may influence their opinions as demonstrators from the upper class are more likely to believe that governments and corporations are capable of solving environmental problems than activists from the working and middle classes eide and kurnelius focused on the ability of fff activists to build an identity based on scientific evidence that strengthens their authority among climate policy actors they are defined as new ambassadors for climate action who use networked communication tools to link personal experiences and add value to climate science we believe that this could help encourage young people to engage in genuinely proenvironmental behaviour and it is in line with de moor et al who argued that many fff demonstrators who turned out to be students embodied the belief that the climate crisis can be solved by individuals taking responsibility and called on policymakers to address global warming on the basis of some kind of intergenerational justice taking into account the recent literature on the subject and with the aim of further contributing to the knowledge of the phenomenon the basic idea of this study is to understand to what extent the only desirable scenario for a sustainable future is that citizens together with businesses and policy makers are willing to adopt environmentally friendly practises even if they are more costly from a purely economic point of view or more demanding in terms of social behaviour this can be illustrated in particular by the aim of understanding whether young people are willing to participate in strikes represented here by the fff movement to defend the planet and adopt green practices as a way of life in this way we can identify and compare their claimed principles with actual daily engagement in such a globalised society young people are most concerned about climate change and know its consequences regardless of where they will occur on the planet because they are its future inhabitants a survey of young peoples perceptions of environmental risks and their climate activism to discover how young people perceive the main risks of climate change and whether they are taking action to address the vulnerable impacts in their future a survey was conducted in february 2020 among students and teachers in puglia a region in southern italy student participation consisted of completing an anonymous online questionnaire for which formal privacy consent was obtained the respondents belonged to apulian high schools participating in the national project for a scientific degree in statistics sponsored year after year by the ministry of education and research the schools participating in the pls program signed an agreement with the italian universities concerned with carrying out activities that promote the acquisition of scientific and statistical skills that are more in demand in the labour market in particular this work draws on the experience of the university of bari which is one of the 14 italian universities currently participating in the pls and has been doing so since the 20102011 academic year the pls targeted a large number of high school students participating in the 20192020 pls project for statistics the respondents were surveyed using an online questionnaire containing 32 questions divided into four sections i sociodemographic information 2 knowledge and awareness of environmental issues 3 perception of environmental risks due to climate change 4 environmental awareness and agreement with the principles of the fff 1 3 perceived climate change risk and global green activism among… movement the respondents were asked to express their responses by selecting a few options or more frequently by rating their responses on a fivepoint likert scale with 1 being the lowest 5 being the highest and 3 being neutral a total of 1793 questionnaires were collected but 395 records were deleted during the cleaning and preparation data phase because they were not completed or proved unreliable or the response variable was missing 260 questionnaires completed by adults were not considered for analysis because this group did not fulfil the aims of the study the final data frame contained 1138 records and a subgroup of variables of interest were selected from a larger number considering the responses that most closely matched the characteristics of the region of residences exposure to climate change impacts as shown in table a1 the students surveyed were almost evenly distributed by gender their mean age was 159 years in the year in which the survey was conducted they were representative in terms of age and gender as the proportion of female southern italian students to the total number of female southern italian students was 483 and the corresponding proportion of male southern italian students was 516 overall female and male southern italian students represented 261 and 262 of italian high school students respectively table a1 also shows the percentage distribution of the variables analysed in the decision tree from the data collected more than 896 of the respondents believe that fff can be effective in combating the destruction of the planet and has achieved important results such as a slight reduction in environmental problems a global resonance to environmental issues and a call to policy makers around the world to take concrete action for greater sustainability although the respondents showed a high level of commitment to and support for the principles of the fff movement only five out of 100 played an active role in environmental associations in addition the respondents believe they are well informed about environmental issues and are concerned about the various risks posed by climate change although they do not believe they live in a geographic area exposed to the most extreme phenomena they see their country as moderately to highly vulnerable to climate change and its associated risks especially extreme temperatures strong environmental awareness is demonstrated by the adoption of ecological behaviours such as recycling reducing waste and plastic consumption using organic products and using public transport bicycles and electric scooters students participating in fff strikes often show an even higher rate of adoption of these ecological best practices methodology in line with the aims of the study the preliminary exploratory analysis allowed us to identify the distributions of the variables of interest we hypothesized that young people who participate in the strikes of the fff movement because they see their future in danger consistently adopt ecological practices as a lifestyle to understand the factors that influence participation in fff movement strikes regressionlike techniques could be used but parametric methods do not always produce the expected results on the contrary data mining techniques based on recursion averaging and randomization are able to discover hidden paths and build better predictive models we have a set of 22 predictors that are ordinal and nominal variables and the response variable is measured on an ordinal scale to examine the factors that affect the climate activism we used a treebased method based on the classification and regression tree proposed by brieman but modified for ordinal response variables classification tree in brief a classification tree identifies the relationships between a response variable y and a set of predictor variables in particular a classification tree is a binary segmentation procedure of the data matrix to generate many more informative subpartitions in our opinion the use of a treebased method instead of a linear model is more effective because ordinary least squaresbased regressions return one type of best fit to the data namely a straightline combination of the independent variables in a higherdimensional space moreover the classification tree approach is chosen among the most commonly used supervised machine learning algorithms apt to cope with a categorical target as the flexibility and robustness it offers to analyse such kind of data a strong tolerance to missing responses and the absence of strict constraints in terms of distributional assumptions about the dataalong with the intrinsic capability of addressing in an easy way interaction nonlinear effects and causal prioritiescoupled with the possibility of attaining a high degree of interpretability of the classification rules makes it a very good candidate for an explorative approach to our data treebased methods are often used in data mining contexts with large datasets to study such as social science surveys for an extensive introduction to treebased methods we refer to breiman et al and hastie et al treebased methods for ordinal response variables to take into account the ordinal nature of the response variable piccarreta suggested adopting of a new impurity measure based on the dispersion for ordinal data defined by gini where f y p d 2 h1 ∑ f y 1 f y i1 1 3 perceived climate change risk and global green activism among… the proposal was originally implemented in an r package by archer and was then revised and technically corrected by galimberti et al in a new freely available r package named rpartscore nonetheless the formulation in eq 1 does not fit the case of an ordinal variable such as for example satisfaction because we believe that the scale used to measure it has an implicit crisp cut point which separates ratings or scores expressed by people judging themselves as satisfied from ratings or scores referred to those who are unsatisfied in our specific case the response variable spans over 5 ordered categories and in our opinion an interviewee can be considered an active participant in fff movement strikes if their score is higher than 3 therefore the threshold equal to 3 is considered the cutpoint that identifies an active participant in fff movement strikes in our opinion to explain with an example how to choose a suitable impurity measure for the case at hand let us consider the following table 1 summarizing five hypothetical frequency distributions of this response variable it is worth noting that neither calculating the normalised diversity index of gini for the five artificial distributions in table 1 d1 d2 d3 d4 and d5 nor adopting the ordinal gini formulation by piccarreta d1 d2 d3 d4 and d5 results reflected in a good choice both formulas fail to address the substantial difference that we would see reflected in the impurity function related to a peculiar case like d4 with respect to d2 or d3 therefore some of the authors proposed an ad hoc formulation of the impurity function based on weighting the differences among the ratingsscores on the two sides of the crisp threshold between an active participant in fff movement strikes and a nonactive participant so that the impurity measure used leads to nodes where the separation between active participants in fff movement strikes and not active ones is maximised when pursuing splits the formula for obtaining our modified gini impurity is as follows where the weights w i are defined as 1 if y i ≤ y and 1 otherwise and the sum is taken over the scores that have a non zero frequency only as can be easily obtained hi h norm × h ∑ i2 w i y i w y sign f y i ⋅ f y i1 table 1 artificial distributions used to evaluate the impurity function y i 1 2 3 4 5 d1 12 0 0 0 12 d2 12 12 0 0 0 d3 0 0 0 12 12 d4 0 0 12 12 0 d5 15 15 15 15 15 by means of the signum function being sign f y i ⋅ f y i1 1 if f y i ⋅ f y i1 0 and 0 if at least one of the involved frequencies is null and h norm is the usual normalized gini index h× � 1 ∑ h i1 f 2 y i � this choice enables discriminating the relevant cases as d4 as the following values can show by setting y 3 our index applied to the distributions shown in table 1 returns the values 3750 0625 0625 4375 and 10000 for d1 d2 d3 d4 and d5 respectively this aptly targets the objective of penalizing potential splits where the frequencies peak around the threshold y since these splits would produce children nodes in which active and nonactive participants are mixed together for more details about the proprieties of the corrected gini diversity index for ordinal categorical variables we refer to morrone et al the random forest method the random forest method is a widely used approach for classification and regression in brief rf is an iterative process that builds a set of classification or regression trees using bootstrap samples iteratively drawn from the original learning data set observations not used to construct a tree are termed outofbag observations for that tree to reduce the correlation between the trees in the forest each split in each tree was identified by using the best among a subset of predictors randomly chosen at that node rf was used to further harness the informative value in our data by strengthening the identification of influent variables via resampling instead of resorting to the ensemble method for prediction something we are not interested in at this stage we exploit rf as a tool to rank variables based on their ability to predict the response which is assessed by variable importance measures given an error measure m vim is defined as where ntree is the total number of trees in the forest mp tj denotes the error of the t tree when predicting all observations that are outofbag for tree t after randomly permuting the values of the jth predictor variable m tj indicates the abovementioned error of tree t before permuting the values of the jth predictor variable the rf method has the same advantages it is not parametric since no specific distribution of the response variable is assumed and does not require any specification of the type of relationship between the response variable and the predictors moreover it provides results for a more robust assessment of the importance of the variable compared to classical treebased methods we used rf only to conduct a variables importance study and not to obtain the minimum prediction error for a review of rf methodology we refer to breiman and boulesteix et al vim m j 1 ntree ntree ∑ t1 mp tj m tj 1 3 perceived climate change risk and global green activism among… data analysis and results the ordinal classification tree was used to examine the relationship between the decision to participate in the fff protest movement caused by the perception of being at risk from climate change and several variables such as perception of being exposed to the main consequences of climate change individual level of information ecological practises carried out on a daily basis to respond to environmental degradation and finally commitment to the principles and achievements of the green fff movement table 2 shows the 22 predictors that we believe influence young peoples decision to take action to improve the environmental situation at risk data analysis was conducted with our own software written in r language on a computer with an intel core i7 quadcore processor the dataset was randomly split into a learning set and a test set with dimensions of 800 and 338 statistical units respectively the decision tree was selected via cross validation and the test set was used to estimate the prediction error in the tree pruning procedure the minimum crossvalidation error does not correspond to the minimum test set error which would suggest a decision tree with 12 leaves we chose the most conservative decision tree which in any case confirms the interpretation of the phenomenon the selected decision tree has l 9 terminal nodes the crossvalidation prediction error is equal to 05930 and the corresponding prediction error computed on the test set is equal to 05917 the tree graph allowed us to produce a partition of the sample of individuals into groups following the interactions between the predictors and the dependent variable key information about each node is summarised in table 3 the perception of being exposed to extreme temperatures as one of the most frightening results of climate change is the first split and separates the left side of the tree with 511 of students who are from not at all to somewhat concerned about it from the right one where we find the students who considered themselves to be at a very high risk of experiencing extreme temperatures the tree in fig 2 shows the role of predictors in the decision to protest by participating in the fff movement and to obtain the composition of the corresponding subgroups of student respondents the tree has 9 terminal nodes and 8 splits corresponding to the following variables tmpext fffccc torn fffres levinf extph and stosu the information on the terminal nodes can be better assessed by examining the distribution of the variable fff protest participation in each of them moreover to obtain detailed information about the specific factors that trigger the fffprt response it is interesting to analyse the pathways to the terminal nodes the first split is defined by the level of concern about experiencing extreme temperatures so that on the left side are students who have a medium to low concern and on the right are those who are highly scared following the path in this branch we find respondents who believe that participation in the movement is important and that the positive contribution of the fff movement is to fight environmental degradation by raising peoples awareness a detailed analysis of terminal nodes number 4 and number 5 allows us to understand the combined effect of not being too scared about extreme temperatures exposition and to believe that fff movement is able to produce effective results in contrasting climate change on the right side of the tree are respondents who are generally very concerned about the risk of being exposed not only to extreme temperatures but also to other dangerous effects of climate change related to the physical and orographic characteristics of the area in which they live this concern is closely related to an equally strong commitment to the results achieved by the green movement protest in fact the modal values of the response variables in the final nodes range perceived climate change risk and global green activism among… between 4 and 5 indicating a high commitment to protest events in defence of the planet as shown by all the terminal nodes created by the split at internal node number 3 in particular splitting at internal node number 6 separates students who perceive extreme temperatures tornadoes and storm surges as serious threats and who view the fffs main outcome as a call for policymakers to take concrete action on sustainability from those who focus on the remaining options returning to the main path leading to the top of the tree other triggering factors seemed to additionally characterise the students interviewed they strongly believe in the effectiveness of protest actions and have a medium level of information but the split in node 24 highlights the respondents who consider themselves very well informed about environmental issues and see storm surges as the most likely feared impact of climate change occurring in their neighbourhood which is not considered to be affected by extreme phenomena anyway the pathway leading to nodes 48 99 196 and 197 describes students who believe that the fff is capable of drawing public attention to environmental problems and is thus an effective tool to reduce the destruction of the planet by raising peoples awareness this is consistent with the literature as recent research reports that emotions such as fear and anger can trigger positive action on climate change it is worth noting that the impact of potential risks emanating from the sea is felt more strongly than the others suggested which is not surprising given that students live in close proximity to the adriatic sea finally an overview of the distribution of the level of engagement in the fff protests in the 9 terminal nodes might help to better understand the paths just drawn the paths leading to these distributions are shown in detail in the last column of table 3 the methodology of decision trees for ordinal variables provides terminal nodes that have the most powerful interrelations with the selected predictors the paths to the terminal node are determined by the splitting criterion based on the impurity reduction approach of the cart algorithm it allows us to look at the variable importance measures that led to the final solution figure 4 shows the normalised importance plot for all predictor variables used in the tree it confirms that extreme weather events specifically storm surges tornadoes extreme temperatures droughts and floods have the same importance as the positive outcomes that can be achieved by people protesting to focus policy makers attention on sustainability it is clear that these predictors are more effective than the others which are at the bottom of the list and have decreasing importance probably because they are mandatory behaviours and because they are seen as incapable of stopping environmental degradation at this time it is known that variable selection bias can occur with cart method resulting in predictors with many cutoff points being selected without taking into account the information they provide to check for the presence of bias in our analysis the rf technique was used this technique was used to examine the importance of predictors in determining the levers that led the student respondents to protest and make their demands for a greener future in the interest of a global community a forest of 5000 trees was created to provide a robust ranking of predictors by importance as can be seen in fig 5 the most important variable reducing overall uncertainty coincides with the first split which relates to perceived levels of vulnerability to extreme temperatures due to climate change moreover the most important predictors are the same as those shown in fig 4 in relation to the tree albeit in different positions in the rank and this result confirms that the tree is robust overall it is interesting to confirm that among the ten main predictors in both analyses six of them namely stosu torn tmpext drexp floexp and firexp relate to the perception of vulnerability to natural disasters the frequency of which has increased in recent years due to climate change the results that the fff movement has achieved in raising awareness among public opinion and especially among policymakers about the dangerous consequences of the increasing destruction of the planet as well as the belief in the fig 5 predictors ordered according to their importance in rf effectiveness of fff in combating climate change play an important role in young peoples protests for a better future final remarks straining natural resources and the entire environmental system are increasing anthropogenic pressures on the earth and are expected to have catastrophic consequences for humans if they are not stopped among the various approaches proposed by researchers to address the problem and find the best solution bengquist et al focused on individuals changing their behaviour towards environmentally friendly behaviour to achieve a more sustainable future a proenvironmental behaviour can be defined as one which harms the environment as little as possible or even benefits the environment relatedly a growing body of literature provides evidence that current mitigation efforts and future emissions commitments are unable to meet the temperature targets set out in the paris agreement therefore new ways of reducing emissions must be adopted we share the theory of these scientists and hypothesise that in theory all measures taken by governments to protect the environment can benefit our planet in the long run but many recent climate disasters have shown us that we have little time and we have to stop climate change by taking vivid actions there is an urgent need for citizens and businesses to incorporate environmentally friendly practices into their lifestyles for the sake of a sustainable future many people are aware of the seriousness of the environmental problem but some probably still believe that it is happening in such a remote place that the negative consequences are not perceived as urgent since 2018 a global movement of students called fff has drawn the attention of politicians and public opinion to the seriousness of the environmental situation turning their fear of an uncertain future into a call for activism fff was able to mobilise many students who had experienced activism for the first time and felt the need to put pressure on politicians to listen to science the effectiveness of the fff is more likely due to the fact that it is a global mobilisation wave composed of young people who are best informed about disasters and ecological risks through social media and traditional media which contribute to increased concern many scholars believe that studies of young peoples engagement with climate change are a matter for closer investigation about climate activism and provide a better understanding of the younger generation this study aims to contribute in this direction by examining students perceptions of environmental issues and subsequent actions we assume that young people who are so concerned about their future should take action either by participating in school strikes or by acting ecologically 1 3 perceived climate change risk and global green activism among… in their everyday lives to reduce or even stop the causes of climate change to this end approximately 1100 high school students in a large city in southern italy were surveyed cart trees for ordinal data were used to analyse the relationship between participation in the fff movement and the willingness to adopt ecological practices as a lifestyle specifically we used the cart method modified by introducing a new impurity measure for a distributionfree treebased supervised classification method for ordinal response variables the proposed methodology is based on the assumption that the impurity measure must account for either the diversity or the order of the categories of the response variables the novelty of the ordinal tree methodology proposed in this paper is its greater ability to distinguish groups based on the semantic value of the response categories the classification system rewards individuals who give answers with the same semantics and distinguishes individuals with semantically opposite answers by using the central neutral answer as a cutoff the results obtained in previous research confirm the suitability of the proposed approach in this study both the response variable and the predictors are ordinal and their categories exhibit diversity that must be handled correctly because they correspond to ranks that have the same absolute distance from each other but opposite semantic meaning on the left and right sides of the cutoff through the responses collected we were able to understand the levers that lead young people to act within the framework of climate activism it has been shown that the levers that drive students to protest and make their demands for a greener future in the interest of a global community are initially based on their concern about the negative impacts of climate change and the awareness that the worsening situation will spiral out of control if we do not take immediate action the responders are well informed about what is happening to the planet and view the environment as a whole system whose events can negatively affect their future this awareness feeds into their environmentally friendly behaviours and lifestyles as they adopt key ecological practices namely recycling plastic glass paper and organic waste using organic products and biodegradable materials reducing waste and reducing plastic consumption the students interviewed believed that global green movements such as fff and climate activism in general could help effectively combat climate change by alerting policy makers to the urgency of environmental degradation appendix see table 4 consent to publication this manuscript has not been published anywhere and is not being considered for publication elsewhere open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 authors and affiliations angela maria duggento 1 • alfonso piscitelli 2 • nunziata ribecco 3 • germana scepi 4 alfonso piscitelli nunziata ribecco germana scepi

in recent years the increasing number of natural disasters has raised concerns about the sustainability of our planets future as young people comprise the generation that will suffer from the negative effects of climate change they have become involved in a new climate activism that is also gaining interest in the public debate thanks to the fridays for future fff movement this paper analyses the results of a survey of 1138 young people in a southern italian region to explore their perceptions of the extent of environmental problems and their participation in protests of green movements such as the fff the statistical analyses perform an ordinal classification tree using an original impurity measure considering both the ordinal nature of the response variable and the heterogeneity of its ordered categories the results show that respondents are concerned about the threat of climate change and participate in the fff to claim their right to a healthier planet and encourage people to adopt environmentally friendly practices in their lifestyles young people feel they are global citizens connected through the internet and social media and show greater sensitivity to the planets environmental problems so they are willing to take effective action to demand sustainable policies from decisionmakers when planning public policies that will affect future generations it is important for policymakers to know the demands and opinions of key stakeholders especially young people in order to plan the most appropriate measures such as climate change mitigation

introduction oesophageal cancer remains an important public health concern globally owing to its aggressive nature with an overall 5year relative survival rate around 20 1 worldwide oesophageal cancer is the sixth most common malignancy accounting for over 500000 cancer deaths each year 23 oesophageal squamouscell carcinoma and oesophageal adenocarcinoma are the two main histologic types of oesophageal cancer oscc is the predominant histological type of oesophageal cancer worldwide and is more common in asia whereas oa is main histologic type in high income western countries 4 5 6 the known risk factors for oesophageal cancer are tobacco smoking excessive alcohol consumption low fruit and vegetable intake high intake of red meat the consumption of very hot beverages genetic factors gastrooesophageal reflux and obesity 78 over the past few decades linear declines in oesophageal cancer incidence have been recorded worldwide 9 10 11 whereas in some regions its incidence has been stable 29 however the recent global trends have not been assessed in many regions including the middle eastern countries specifically in kuwait therefore this crosssectional cohort study assessed the secular trends in populationlevel oesophageal cancer risk by age sex and nativity in kuwait methods in this crosssectional cohort study oesophageal cancer incidence data were obtained either from the kuwait cancer control center registry or projected for each oesophageal cancer patient we obtained the date of birth age at diagnosis sex and nativity relevant kuwaiti population data were obtained from public authority for civil information ministry of interior kuwait midyear population counts for each year and by subcohorts were defined as the personyears agestandardized incidence rates of oesophageal cancer overall by year for unstratified data and by the subcohorts defined by crossclassification of period of diagnosis age at diagnosis sex and nativity were computed using world standard population as a reference across age sex nativity and periods were evaluated outcome variable ie count of incident oesophageal cancer cases was overdispersed with excessive structural zeros therefore it was analyzed using zeroinflated negative binomial model univariable and multivariable zinb models were fitted to the data and zinb models coefficients and their corresponding standard errors were used to compute both unadjusted and adjusted incidence rate ratios and their 95 confidence intervals respectively which were used for the models interpretation results during the study period a total of 496 cases of oesophageal cancer in 128 million personyears at risk were diagnosed of these 269 were oscc 147 ac and 80 cases were histopathological unspecified subsequently all the histopathological types were grouped as oesophageal cancer cases the overall asir of oesophageal cancer during the study period was 1051 the asirs by age sex nativity and time periods are shown in fig 1 the highest asir of oesophageal cancer was among 70 years old or older individuals the asir of oesophageal cancer was higher among males than females the highest asir of oesophageal cancer was observed during 5year period of 198084 followed by a consistently declining trend in subsequent 5year periods this declining trend was consistent across males and females as well the multivariable zinb model revealed that compared with the individuals younger than 30 years the oesophageal cancer risk significantly increased through the higher age groups the oesophageal cancer risk among males compared with females was only marginally significant furthermore compared with the nonkuwaiti residents the kuwaiti nationals were significantly at higher risk of developing oesophageal cancer during the study period moreover compared with 198084 period in each of the subsequent 5year periods adjusted irrs showed a significant and nearly a consistent declining tendency discussion the results showed that during the past four decades the overall asir of oesophageal cancer was 1051 in kuwait this estimate is comparable with those recently reported in eastern asia but is nearly twice as much of the estimates reported from southcentral asia subsaharan africa and other world regions 13 this global variation in asirs of oesophageal cancer may be owing to varying lifestyle and dietary patterns the two established risk factors for oesophageal cancer are excessive alcohol consumption and tobacco smoking parenthetically kuwait ranks very high worldwide for tobacco consumption prevalence in men and women 14 with parallel high asirs of oesophageal cancer which indeed fulfils the bradford hills criterion of coherence for causal link between tobacco smoking and oesophageal cancer the multivariable zinb model showed that increasing age was associated with the increasing trend in the oesophageal cancer risk which reflects a cumulative effect of carcinogenic exposures the modification of known risk factors for oesophageal cancer may lessen the risk later in the life moreover males had marginally increased oesophageal cancer risk than females which outwardly related to sex hormones and lifestyle factors including smoking and dietary factors 78 additionally over the past four decades oesophageal cancer risk consistently declined in kuwait towards the end of twentieth century oesophageal cancer risk had been increasing in both sexes in usa europe japan and china 1516 which in recent decades showed a declining trend in these regions as well 15 similarly downward trends with varying magnitudes in oesophageal cancer incidence were recorded in hong kong 17 and china 18 these declining trends in oesophageal cancer incidence ostensibly is due to varying distributions of contributory risk factors across different populations 1519 for example in kuwait tobacco smoking by any mode including cigarettes cigars and pipes showed a consistently declining trend with varying rates from 2000 to 2018 and stabilized thereafter which seems to concur with the decreasing trend of oesophageal cancer in kuwait 20 in conclusion an overall high oesophageal carcinoma asir was recorded asirs consistently declined from1980 to 2019 older adults and kuwaiti nationals were highrisk groups for oesophageal cancer an educational intervention based on the known risk factors may alleviate oesophageal carcinoma risk in this and similar settings future studies may contemplate to evaluate the effect of such an intervention data availability the dataset used in this study can be made available on a reasonable request to the corresponding author and additional approval of the director kuwait cancer control center registry competing of interests none declared publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

background this crosssectional cohort study assessed the inequalities in oesophageal carcinoma risk by age sex and nativity in kuwait 19802019 methods using oesophageal cancer incidence data from the kuwait national cancer registry relevant kuwaiti population data and world standard population as a reference agestandardized incidence rates asir per 100000 personyears overall and by subcohorts were computed the incident oesophageal cancer cases count was overdispersed with excessive structural zeros therefore it was analyzed using multivariable zeroinflated negative binomial zinb modeloverall asir of oesophageal cancer was 1051 95 ci 6621441 the multivariable zinb model showed that compared with the younger age category 30 years the individuals in higher age groups showed a significant p 0001 increasing tendency to develop the oesophageal cancer furthermore compared with the nonkuwaiti residents the kuwaiti nationals were significantly p 0001 more likely to develop oesophageal cancer during the study period moreover compared with 198084 period asirs steadily and significantly p 0005 declined in subsequent periods till 201519 conclusions a high incidence of oesophageal cancer was recorded in kuwait which consistently declined from 1980 to 2019 older adults aged ≥ 60 years and kuwaiti nationals were at high risk of oesophageal cancer focused educational intervention may minimize oesophageal cancer incidence in highrisk groups in this and other similar settings future studies may contemplate to evaluate such an intervention

with a similar alignment in values open scholarship has the potential to be considered part of decolonisation efforts decolonising the curriculum represents a broad notion typically referring to a focus on addressing the continued existence of embedded oppression and western privilege and attempts to achieve better recognition and development of alternative knowledge in practice decolonisation demands transformative change to challenge the disproportionate power represented and perpetuated through the systems and knowledge presented for example not to look at how western theories apply to the global south or to see work from the global south as an alternative perspective but rather to consider and voice knowledge created within different areas as contributing to cumulative developments in our shared understanding this work goes beyond developing a diverse curriculum or inclusive assignment to acting on the inequalities oppression and discrimination perpetuated by current structures cultures and practices towards greater social justice these movements of open scholarship and decolonisation are clearly not the same however there are several shared values inand shared barriers topromoting progression and it is hoped that this work in elucidating these similarities will promote further collaboration and synergy between such communities shared values the open scholarship movement is perceived to rely upon the mertonian norms which describe the ideal scientific ethos and include the principles of communism and universalism these values are often considered to be implicit in the practices adopted and are often inconsistently achieved for example the financial barriers to publishing with open access means the geographical diversity of represented authors tends to be less than that of nonopen access publications decolonisation is to decentre colonialdriven knowledge perspectives and practices instead transforming organisations and knowledge to represent a wide range of inclusive structures positions and voices such work is often framed within certain groups of institutional values such as equality diversity and inclusion or antiracism although the specific values and practices represented are commonly contested both decolonisation and open scholarship share an obvious moral motivation but there is little consensus in the central values held despite this they demonstrate shared priorities and goals in trying to promote longterm changes which challenge the problematic status quo and promote a more representative and accessible research and knowledge infrastructure in this manner developments in each domain are codependent for example we can better challenge the overrepresentation of white male eurocentric knowledge when there are fewer barriers for anyone to access engage with create and disseminate knowledge similarly we can foster more meaningful collaboration and inclusive environments and thereby create more alternative knowledge when we transparently recognise and reward different types of contributions to research and knowledge generation shared barriers decolonisation initiatives and open scholarship communities share a number of common barriers when attempting to drive change for example within both initiatives there are plenty of misunderstandings relating to the multifaceted nature and changing scope of action necessary to drive meaningful change many universities are currently implementing decolonisation initiatives which do little more than check that the reading list is not entirely white changes to course content and assessmentor indeed to the wider structures and policies of the universityare minimal other similar assumptions are made within open scholarship practices for example that sharing datafiles without associated codebooks data dictionaries or metadata is sufficient for transparency this being the case concern continues in relation to both developments about openwashing or tokenistic decolonisation work where there is an attempt to tick the box without clear quality control the institutional softening of more radical changes into narrow individuallevel metrics in both decolonisation and open scholarship is common and highlights the shared need for higher standards of implementation and greater structurallevel thinking to make incremental progress in either domain holistic and sustained change is required initiatives which do not consider all stakeholders and which disregard the problems with the wider systems and processes are unlikely to succeed the status quo tends to be welldefended by those who have historically secured privilege from it and in consequence there are often substantial amounts of both structural and individual resistance to any attempt to drive such dramatic change some communities and stakeholders are currently making developmental progress and slowly improving standards across institutions and geographical boundaries most universities in the united kingdom have decolonisation groups and there are international open scholarship groups such as the framework for open and reproducible research training for open scholarship pedagogy such communities are commonly led by early career researchers andor those who are most excluded by existing practices development in these areas is therefore heavily restricted by the lack of recognition the physical emotional and psychological burdens often experienced in attempting to overcome resistance and the wider structural issues in higher education like precarious work contracts groups attempting to tackle decolonisation and open scholarship simultaneously are only just forming for example the advancing big team reproducible science through increased representation team these are integral communities which require sustained support funding and infrastructure concluding thoughts both open scholarship and university decolonisation practices are of vital importance and require continued investment and championing by many stakeholders greater synergy between the communities leading such efforts could maximise positive impact open scholarship is about making things open but it is crucial to consider what should be open and for whom there is potential for open practices to perpetuate or extend existing inequalities rather than promote collaborative knowledge development and so the adoption of a decolonisation perspective could maximise the accessibility of work through more thorough consideration of power geographical differences and diversity in knowledge sources similarly greater sharing and transparency of decolonisation effortswhether through diversification of viewpoints dissemination of evidence about specific practices or the implementation of open materialswould facilitate more rapid developments in understanding and action whilst also exposing superficial practices thus through greater collaboration between the open scholarship and decolonisation communities we have the potential to drive further societal progress and justice

open scholarship and university decolonisation communities share several values in attempting to promote longterm changes which challenge the problematic statusquo and promote a more representative and accessible research and knowledge infrastructure initiatives from these groups often experience similar barriers when attempting to drive such change the current work therefore argues that further societal progress and justice could be possible with greater collaboration between open scholarship and university decolonisation communities open scholarship is a movement to make knowledge of all kinds more accessible transparent rigorous reproducible replicable accumulative and inclusive parsons et al 2022 whilst broad this definition includes a wide range of individual practices and structural changes including open educational resources citizen science opensource software open peer review and open data among many others such efforts can help tackle many inequalities by challenging changing or removing exclusionary practices which have been perpetuated by ideological hegemony for example preprinting research on open platforms like the open science framework osfio gives researchers the opportunity to disseminate knowledge and be acknowledged for their contributions making their work more widely accessible without the need for either researcher or reader to overcome privileged gatekeeping approval or financial barriers facilitating accessibility and inclusivity are key parts of most models and visions of open scholarship syed and kathawalla 2022 unesco 2021 for example open scholarship is considered highly compatible with feminist perspectives siegel et al 2021matsick et al 2021 where exclusion of women inequalities in invisible labour and recognition and marginalisation of knowledge created by women can be challenged open scholarship practices are considered predominantly but not exclusively positive in helping overcome the precarity faced by minoritised researchers when negotiating power championing their voice and democratising knowledge generation and dissemination fox et al 2021pownall et al 2021

introduction sexual violence victimization is unacceptably common in the united states with 183 of women and 14 of men reporting lifetime experience of sexual assault defined as attempted or completed forced penetration or alcoholdrugfacilitated completed penetration 11 of women experienced this in the past year 1 almost half of women and one in five men report lifetime sexual coercion andor unwanted sexual contact 1 the physical and mental health effects of sexual violence victimization include physical injury depression anxiety posttraumatic stress disorder attemptedcompleted suicide substance abuse and sexually transmitted infections 1 sexual violence has been estimated to cost individual survivors nearly 125 thousand dollars the population economic burden is estimated to be over three trillion dollars driven in part by physical and mental health treatment costs lost work productivity and property loss and damage 2 for young people in college sexual violence experiences have serious academic consequences 3 the recent wave of disclosures of sexual violence including emma sulkowiczs bcarry that weight endurance performance art tarana burkes metoo movement and times up has renewed public discourse around chronic sexual assault harassment and coercion of women and sexual minorities as an bopen secret in many fields and spaces college campuses are one such space 4 among women who report lifetime sexual violence victimization 37 first experienced it between 18 and 25 often while attending college 1 according to 2015 us department of educations office for civil rights data sexual violence complaints on campus increased more than 1000 between 2009 and 2014 56 reflecting an increased willingness to report sexual violence due perhaps to more universitybased reporting mechanisms as well as survivors unwillingness to maintain the secrecy upon which sexual violence perpetrators depend in response nationaland statelevel policies to prevent and respond to sexual violence emerged with some requiring prevention training for students faculty and staff although the evidence based on prevention programs for college students is limited key mediators and interventions include sociorelational skills consent bystander behavior and empowerment 7 just three campusbased prevention programs for men have been rigorously evaluated 8 9 10 and some bystanderfocused programs and a social marketing campaign have shifted bystander intervention attitudes intentions and behavior 11 12 13 14 rape resistanceselfdefense has shown efficacy for women 1516 but has not been tested among men although design and evaluation of sexual violence prevention programming has increased the majority of evidencebased prevention programs were designed for and evaluated in residential and nonurban college settings where the majority of students reside on campus and are white of all but one of the programs described above the percentage of nonwhite students in the samples ranged from 10 to 32 realconsent was tested on a sample of less than 50 white students with a third being blackafricanamerican or latinoax students and though the setting was urban it was not a predominately commuter campus many evaluations of sexual violence prevention programming do not report the proportion of sexual orientation andor gender identity minority students although some do 17 as we develop our understanding of urban commuter campus student experiences of sexual violence 18 there is an urgent need to focus on sexual orientation and gender identity minority students in general 18 a major gap in the prevention research base is that there are no sexual violence prevention programs designed specifically for urban commutercampus students who are more likely to be simultaneously racialethnic minorities immigrants lgbtq andor gender nonconforming in addition to occupying multiple often marginalized identities urban commuter campus students have qualitatively different experiences of bstudent life and often feel less connected to their campus 19 greek life has less prominence on commuter campuses and organized athletics may also have different influences on students social lives 20 socializing is more likely to happen at bars and clubs or at offcampus parties and student engagement is different and may be weaker 2021 some empirical research exists suggesting that the urban commuter campus setting merits focused study when bringing in the bystander 11 was tested among male students at an urban university with a high percentage of commuter students efficacy was diminished perhaps due to decreased feelings of connectedness to the campus and student community 22 urban commuter students may require tailored approaches 22 with focused research exploring sexual violence and sexual violence prevention among urban commuter campus students the commuter campus student perspectives on sexual violence study is a qualitative indepth interview study designed to begin to fill the gap in the literature and explore how urban commuter campus students conceptualize sexual violence and imagine prevention programming working in their lives methods procedures the study was conducted in spring 2017 at a public predominately commuter 4year college in a major urban university system in the us both print and online media outlets were used to recruit eligible participants flyers were placed where students congregate at the focal college and on other college campuses in the same urban university system participants who saw the flyer or clicked on the online ad were redirected to the anonymous online survey where the study was described interested participants engaged in a webbased consent process before completing the survey eligible participants had to 1 attendhave attended one of the urban college or university systems colleges in the past 24 months 2 be between 18 and 24 years of age 3 reside in the focal metropolitan area 4 report a recent sexual experience that meets criteria for sexual coercion harassment or violence and 5 communicate in english sexual coercion harassment or violence was defined by responding yes or maybe to the following questions bhave you ever had sexual contact that you consider to be unwanted or without your consent in any way andor bhas anyone ever tried or made you have sex with them when they knew you did not want to if eligible potential participants then completed the online contact card collecting minimal contact information so that an appointment could be scheduled of the 463 individuals who responded 20 were eligible and left contact information of these 19 made an appointment and engaged in an indepth interview upon arrival at the research site participants completed the written informed consent process and then engaged in the interview with a trained female interviewer in a private room all interviews were digitally audiotaped and transcribed professionally victim support and mental health resources were offered to all participants and support in accessing them was provided as needed city university of new york institutional review board reviewed and approved the study using these methods we conducted 18 indepth interviews interview content the indepth interview guide focused on several areas and was organized into three areas social identity and life sexual experiences and definitions of sexual violence and response to sexual violence in the first area we explored participants daytoday life and experiences as a student and the impact of their identities on various life domains in the second area we focused on sexual experiences how participants defined the spectrum of sexual experiences how they knew when someone is bcrossing the line factors that influence how students conceptualize sexual violence the role of alcohol and substance in sexual violence finally we explored student experiences with and thoughts on support services access sexual violence prevention and experience with prevention programs analysis thematic analyses were conducted to identify and describe the main themes that emerged from the data and analyze patterns in the data first after each interview to contextualize the data a transcript summary and a qualitative memo describing the interview context and immediate impressions were developed by the interviewer or project coordinator all transcripts were read by the first and last authors next in order to categorize the data coding was conducted by the first author using qsr internationals nvivo 9 qualitative software guided by conceptual maps that reflected the interview and focus group guide question domains as new domains or areas emerged new codes were added if an existing code needed subcodes to reflect better the nuance of the text subcodes were created next queries were run to group samecode text from different transcripts these were read by the analytic team to identify the themes the analytic team met regularly to discuss the data and aggregate codes into major themes the team reread all of the transcripts to ensure that the coding and themes identified were congruent with the data and refinements were made as needed next a matrix was created reflecting the major themes and key insights identified with coded text to support each area across all interviews results indepth interview sample we screened 426 individuals via an anonymous webbased survey of these 113 reported experiencing sexual violence in their lifetimes and were eligible for interview of these individuals half reported that they had also experienced it in the past year and were eligible for interview of this group 18 participated in the indepth interviews twelve participants selfidentified as straight females one selfidentified as queer female and one identified as straight male one identified as bisexual female two as gay male and one as bisexual male the average age was 21 with the youngest participant being 18 and the oldest 22 five participants selfidentified as white or caucasian and another five as latino or hispanic four identified as black or africanamerican and two as asian one identified as biracial and one did not identify in terms of race or ethnicity all participants were current college students 8 of them also had a job sixteen lived in the metro area two lived just outside the city interview participants did not differ significantly in terms of age raceethnicity or sexgender as compared with individual who screened eligible for the study thematic analysis results here we present thematic results in three broad areas the first are the general experiences and perspectives as commuter students that may be relevant to the development of sexual violence prevention programming including bcommuter student life and bsocial identity the second is how commuter students defined and identified sexual violence the third area is their thoughts on and experiences with support services and prevention programming to enhance confidentiality and because of the small number of interviews no descriptors and only numeric codes are used to label participant quotes commuter student life overlapping roles the majority of the students interviewed stated that bevery day is on campus and that they spent ba lot of time there the students daytoday schedules were reported to be bpretty hectic with some stating that they spend the rest of their time either at work or attending groups or clubs thus bits always either school or work and sleep bwhen they get the chance about half the sample reported holding a job and another half reported being involved in student groupsclubs either onor offcampus just one participant reported being part of an oncampus fraternity most of the students in the sample lived offcampus but it was clear that there were two different experiences reflecting the distinct social contexts each set of students inhabited five out of 18 interviewees lived in the college dorms and two split time between the dorms and their family homes the remainder commuted both commuter and dorm students highlighted the significant difference in the student experience between living in the dorms and commuting to school as well as the difference between the groups of students who live in the dorms and those who commute participants who lived in the dorms described it as bfun saying it was ba good experience that helped them bmeet a lot of new people and make friends several students noted that bpeople who live in the dorms are kind of in a closed circle another saying that everyone had their own bcircles three of the five students who lived in the dorms reported that they usually socialized with other people from the dorms some students who lived in the dorms noted the difficulty of socializing with commuter students one noted bright after class they leave because it takes them two and half hours to get home another student noted that commuter students had very busy schedules and no time to socialize commuter students bare always running from different places and like different schedules commuter students also reported difficulty making friends one participant said bsince its a commuter school its hard to make friends … because people just come here and they just leave because theyre just here for school and thats it difficulties in socializing with their peers and on campus emerged for commuters because of both the distance and time that commuting demanded as well as the insularity of students who either lived in or had a bhome base in one of the campus dorms when commuter students socialized students reported socializing in a range of spaces about half reported that they usually bhang out in the neighborhood two reported socializing in the dorms and the remainder in various places such as downtown andor midtown and other popular areas of the city just two commuter students reported that they have friends from classes past and present some commuter students reported not having time to bhang out one reported bi just do all my work here and then i go home once im done commuter students traveled into the campus neighborhood from a wide area with one student noting that commuters tended to be breally scattered students commuted from within the campus subarea as well the other subareas of the city and two key suburbs commutes to some of these areas represent an hour plus each way social identity the role of students social identities both sexual and gender and raceethnic identities emerged strongly as salient to both students who commute and who lived in dorms social identity acted as a lens through which they filtered their experiences in general on campus and at times of violence twothirds of participants identified skin color or raceethnicity specifically identifying as black latinoax or white as important to them three participants selfidentified as being ba product of immigrants highlighting the relevance of immigrant status to selfidentity at a university system in a city that is 40 foreignborn or born outside of the us some students also emphasized how important gender is to their identity and experiences bgender is a huge part of my identity said one female student further some participants noted that they are experiencing a stronger awareness of their raceethnicity andor sex gender in the current us sociopolitical climate noting that race and ethnicity is important bespecially right now bin todays day and age one female participant said that she is having bconversations that i never had before about femaleness that i do have now many of the female respondents particularly those who selfidentified as children of immigrant parents noted that they had been raised in btraditionalô r bpatriarchal ways by their parents who encouraged them to be bgirly girls one student noted that bpeoples view of me as a white person as well as being a white male is interesting several identified how intersections among their raceethnicity and gender influenced their lives and how they are treated on campus for example one respondent noted some students underlined the importance of agreeing and consenting prior to the sexual encounter by saying that crossing the line is when the sex partner does something that you have not consented to and that if a sexual actthat wasnt agreed uponwas enacted the line has been crossed and a violation has occurred just one participant described the dynamism of sexual interactions and the role of giving consent or not to each step or aspect of it in order to make it fully consensual and enjoyable for both parties they said bi mean you can first consent to something butwhich might excite the other person and basically get more into it and get more intense i would say which would later like a consenting experience would become a forceful experience just because youve basically leveled up like that person kind of made it more intense this student went on to say that a good sexual experience could bturn bad if a persons behavior … is not expected from the other person and is not experienced well from the other person this was the only student who described the role of consent in the escalation of sexual activity suggesting a diverse sexual repertoire that could benefit from specific consent agreements other participants suggested that consent could be bimplied for example when a guy btakes a girl out bpays for the dinner and the gas and then invites the girl to his house in such situations the guy would btry to initiate something and would then expect bsomething in return some students said then that they would bfeel like you have to because you are already in that kind of setting as if by doing all the previous steps especially bgoing to his house consent to the sexual encounter was given when asked how they knew that a sexual experience is bgoodbad wantedunwanted forcednot forced coercednot coerced some participants focusing on what was bgood or bnot good identified btrust as an important factor in order to label a sexual experience as a good one for some trust was intertwined with feeling good either bphysically and emotionally for others it was connected to the ability to be bopen and bvoice things out with the sexual partner one student said bwhen its wanted and when its what you consider good and youre happy about it theres not that kind of small thing in your head saying something is not right i dont know if i want this some students described bunwanted sexual experiences as ones when bsomething happens and you dont want to but you let it happen anyway because you bdont know how to say no another described it as something that byou do just to make the other person happy for some it seems that even if byou dont want to do what youre doing they would not say no because they want to bget together with the person or have a relationship with them other experiences that qualified as bunwanted included ones where the students did not feel comfortable saying no for example in the past when they were younger so they tried to just go through it without expressing their feelings a clear definition of an bunwanted sexual experience involved being intoxicated andor not being aware of what is happening support services access and reporting just less than half of participants never accessed any sort of support service in their lifetimes one participant reported accessing only bhealth checks while another two mentioned having a very good support system regarding their sexual violence experiences one student stated that they tried to bdeal with it by themselves another reported having never thought about reaching out for support services half though reported having accessed support services for general reasons most reported that bit was really helpful helping them blearn about themselves one proponent of support services noted bgetting support is always the best thing to do and nobody should ever face anything that they feel bad about on their own however one participant described the stigma that still surrounds accessing support services in fact in some cultures bit means youre weak or like the mentally ill of the participants who described their experiences of sexual violence andor coercion during the interview and reported accessing services two did not disclose the violence experience to the therapist one reported that they bsort of pushed that particular experience to the side the other reported that they did not realize how bbad it was another participant stated that it took a while to open up and disclose their experience with the therapist and that they were not really listened to until they said that they were sexually assaulted when asked about how and where to access sexual violence support services should they be needed as a student fully half of the participants stated that they would not know where to go or what to do either onor offcampus of those who had ideas about where to go they mentioned a range of options including reaching out first to public safety another two said that they would research it online first two identified the oncampus counseling center another mentioned oncampus selfdefense classes finally one student stated planned parenthood two emphasized the importance for a service to be anonymous and to protect peoples identities one student stated that the oncampus support services have breally inconvenient hours when asked if they would report a sexually violent experience no students immediately indicated they would report without qualification one stated that they encouraged a friend who has been sexually assaulted to file a police report and that they would definitely encourage somebody else to reach out to bsupport services for such a traumatic experience in considering reporting two participants pointed out the difference between being assaulted from an acquaintance or a stranger bif i was walking down the street and like a guy just raped or a guy like you know forced himself on raped me or whatever i would definitely go but like you know i wouldntand it sounds so messed up but if it was likenot a friend but if i was someone that i knew like i didnt report him another student said bif its some random person i guess yeah id report it but then if you were in a relationship somebody wouldnt really want to report that just because they may love the person or whatever another participant stated that they would not report it and would not even tell their parents if the perpetrator was an acquaintance because they would blame them for being in such situation they said bif it was someone i knew i honestly dont think i would tell my parents but if it was someone i didnt know i would tell my parents the student went on to say bi feel like they would say well why where you in that situationt his would trigger bthat feeling of like its your fault kind of thing commuter students views on prevention when asked if in their opinion it would be possible to prevent sexual violence the majority of the participants responded no with three saying that it is bnot possiblet o prevent sexual violence or in the bgrand scale of the world others were more qualified noting that it is bhard to say or that sexual violence could only be prevented bto a certain extent when asked how it could be prevented one participant stated that they would attend a selfdefense class because that it is the only way to prevent sexual violence other than bnot socializing not doing anything and staying in a bubble for the rest of my life another said that a way to feel a blittle safer would be carrying pepper spray as a precaution three students emphasized the role of the individual saying byou cant control what people do all the time or it is bbasically within each individual with risk varying from bperson to person just five participants described ways to reduce the risk of sexual violence victimization including having conversations having a good sense of selfawareness educating children and adults addressing societal stereotypes changing social norms understanding and discussing consent teaching girlswomen that they can say bno not blaming the victim and teaching people that there can be abuse within the queernongender binary community the majority of participants said that they would be interested in attending a prevention program because it is breally important but had bnever heard about or done anything like that and bpeople still dont know how to prevent it students said that they bwould encourage people other students to go and would like to bring other students in order to bshare the information one underlined the fact that prevention programming would be helpful especially for a commuter school because bas much as the school might protect while theyre in here i think when people leave campus…t hey need the knowledge and skills that programming could provide they went on to say that bi think there is a lot of like informing of informing students what the options are you know when theyre not on campus when asked for advice in order to plan an effective prevention program students brought up various suggestions almost all said that talking would be important and effective identifying specific topics such as bwhat sex is and bwhat sexual violence can bed iscussing consent was identified as critical and activities such as lectures and workshops were highlighted as possibilities two students noted the difficulty of talking about sex with adults one stated that talking about sex is bweird especially if it is a teacher talking about such topic during classes which it makes it bhard for students to listen they noted bwhen you feel equal to someone its easier to learn from them suggesting the desirability of nearpeer educators another student said that there is still a taboo about having conversations about sex before initiating sex because it is sometimes seen as unsexy so prevention should address that as a barrier other prevention ideas included selfdefense classes showing video clips and asking students to identify various situations as and label bred flags for sexual violence the importance of holding bplannedout activities was highlighted as well as basic educational activities such as distributing information on resources and support one person said that bwe respond to things when they personally hit home so bringing survivors of sexual assault in the conversations as well as their friends in order to share and support would be an effective strategy another stated that the key is bmaking it a topic that is not uncomfortable to discuss three participants underlined the importance of identifying and discussing the full spectrum of violence from physical to sexual to emotional two students said that they would split discussion groups into different genders one student pointed out that young people today bhave no attention span so it is difficult to hold their attention they suggested that a powerpoint presentation would not be effective and that novel youthoriented media would be required one person said that holding some prevention activity at venues such as bars or clubs would be an effective strategy in contrast another participant said that it would be btricky as bars often sponsor free entrance for girls so bfor them its business to recruit students to prevention activities participants suggested sending emails through university accounts sending bsnail mailt o peoples homes to reach students who are not on campus often and distributing flyers the importance of offering food and beverages was emphasized but the limits on the time and availability of commuter students were also reiterated comment the commuter campus students we interviewed held similar perspectives as some nonurban students studied in prior research 23 regarding what constitutes sexual violence these similarities are noteworthy and suggest that the foundations of existing sexual violence prevention strategies will be useful for urban commuter campus students specifically the use of bgut feelings to identify when and how initially wanted and consensual sexual experiences can evolve into unwanted coerced or violent ones is consistent with studies among young people both on and off university campuses 24 the lack of clear and specific communication around consent is also consistent with the general literature on sexual violence among collegeage young people 25 this supports the current focus of existing sexual violence prevention programming on clearly describing what constitutes consent how to communicate around consent and skills for establishing consensual sexual relations however we also identified experiences of urban commuter campus students that may demand specific attention when designing sexual violence prevention programming including the importance of multiple sometimes overlapping contexts roles and social identities one unique aspect of urban commuter campus students experiences is the lack of a single consistent and allenveloping social context experienced with their campus peers and bounded by campus geography urban commuter students do not universally possess strong and focused connections to their school contexts and campus peers via student clubs greek life sports living on campus and time spent on campus they also often have significant offcampus obligations that limit their ability to spend time on campus despite this students noted that prevention skills taught on campus would be useful off campus reflecting the importance of portable prevention skills further while some students who live in dorms on campus may experience more campusbased social contexts that offer key sites for prevention work many commuter students may need to be reached through strategies that travel with them such as prevention that they can access while commuting or remotely may be critical to these students for example online training tools such as realconsent and take care could be adapted as a mobile app that would permit commuter students to engage in the intervention while on a train or bus prevention strategies for urban commuter campus students must use examples and promote skills that reflect multiple salient contexts for example prevention might focus on educational activities or bystander intervention skillsbuilding while on the commuter campus but on workplace sexual harassment policies and protections while at work reflecting the importance of work and school contexts for many students commuter campus students also enact different social roles simultaneously to a greater extent than residential campus students thus prevention strategies need to connect with these multiple roles in addition to the various contexts within which they occur this may require not only adaptation of current prevention programs but the development and offering of a menu of prevention options based on context and role for this group of students for example students who are parents may be provided skills for how to communicate with their own children on prevention students who are siblings may also share prevention lessons with younger siblings and although this did not emerge as strongly as we expected students roles as children of adult parents living in the community may also need to be addressed testa and colleagues showed the effectiveness of providing resources to parents of incoming college students 26 adapting such an intervention for urban commuter campus students will require significant work to fully understand the connection between urban commuter campus students their parents the community and other salient contexts and roles finally the intersection of various social identities is crucial to include in the design and adaptation of prevention programs for this group students were clear that prevention efforts needed to meet them where and as they areto show them how it matters to their various roles and intersecting identities large urban areas often have populationspecific violence prevention or social service provision nonprofits and programming such as those led by sexual and gender minority individuals these organizations can receive communications from students who may seek information via university services but may be more comfortable seeking services from such a group finding a way to connect students to this diversity of resources in a userfriendly confidential portable and centralized way could be an important goal for improving campus response such organizations can also be involved in the design and implementation of sexual violence prevention programming on campus as experts in intersectionality and in working across varied community contexts representatives from such organizations can inform the appropriate adaptation of current evidencebased and informed programming an urban commuter campus can be a center for a multipronged multilevel community engagement approach to preventing and responding to sexual violence both on and off campus and for students staff and faculty as well as local community residents such campuses can organize a tailored communitybased approach in partnership with community leaders providing knowledge and skills for individual residents and higherlevel interventions for groups organizations and spaces this creates an opportunity for a much wider diffusion of prevention yielding a ripple effect of prevention efforts that are carried beyond the campus and local community this is both the challenge and the promise of prevention work in this unique context limitations our results must be considered in light of several limitations first our sample is a purposive one but also one of convenience recruited using webbased outreach and flyers while overall the sample is diverse in terms of ethnicity and age the size of the sample for interviews is small particularly given the size and diversity of the underlying population as well the study is set in a particular urban area and may not be generalizable to other urban areas second quality assurance and consistency in data collection were achieved by employing a highly skilled interviewer a comfortable interview environment and modest incentives however some participants may not have been totally comfortable discussing sensitive topics such as sexual violence and helpseeking on campus or with the cisgender female interviewer because of these limitations we reiterate that our results are suggestive and that further research is needed in this area conclusions urban commuter campus students reported limited exposure to prevention programming and are in need of the knowledge and skills that evidencebased programming could provide reaching large populations of commuter campus students who often move in and out of the student role and may even attend different campuses across an urban area is a challenge in addition urban commuter campus students have distinct campus experiences exist in multiple social contexts and play varied social roles all of which demand unique attention in the design and adaptation and evaluation of sexual violence prevention programming current programming has not been to date designed for them future prevention programming needs to be tailored to address their unique contexts and lived experiences further research is needed to explore in more depth how their intersecting identities and community experiences influence their experience and recognition of sexual violence as well as their helpseeing behavior this will inform the design of prevention programming which must be grounded in their lived experiences designed in consultation with them and in relation to campus and other communities important to and representative of urban commuter campus students data availability statement the data that support the findings of this study may be made available upon request from the corresponding author vf the data are not publicly available due to the nature of the data which contains information that could compromise the privacy of research participants publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

sexual violence victimization is unacceptably common in the us with nearly half of women and one in five men reporting lifetime sexual coercion andor unwanted sexual contact much violence occurs in campus settings the majority of sexual violence prevention programs designed to date were not developed around the needs of urban commuter campus students the present study explored qualitatively how these students conceptualize sexual violence and prevention facetoface indepth interviews were conducted with students on how they recognized sexual violence and understood prevention interviews were audiotaped transcribed and analyzed commuter students used bgut feelings to identify sexual violence reporting minimal direct consent communication intersecting social identities and multiple concurrent roles limit the potential impact of existing prevention programs further research to design and evaluate tailored sexual violence prevention programming for urban commuter campus students is needed

introduction the ageing uk population is associated with a corresponding rise in the number of people requiring longterm care 1 with those entering longterm care having increasingly complex healthcare needs 2 currently there is little evidence for much of the care provided in care homes 34 and concerns about the quality of care 5 have led to calls for a more structured and evidencebased approach to healthcare provision within care homes 6 however research involving frail older people living in care homes is more complex and resource intensive than in other healthcare settings 7 8 9 10 given the wide range of questions that require further investigation and limited research resources one solution is to encourage stakeholders to participate in decisions regarding the prioritisation of topics for future research research priority setting methods can assist researchers and policymakers to effectively target research that has the greatest potential benefit 1112 with a number of research funders incorporating the findings into their prioritisation processes 13 recent priority setting partnerships 14 have focussed on identifying priorities for research into the treatment of specific agerelated health conditions 1516 however care provided in care homes is unique as it encompasses a range of conditions and incorporates aspects of social care as well as healthcare the aim of this study was to develop an informed set of research priorities within the care home setting care home staff were selected as the expert panel as they have expertise in caring for older people in care homes 17 and a unique perspective not shared by the wider multidisciplinary team during limited visits or appointments there is also a strong relationship between engagement of stakeholders in the planning and design of research and the subsequent quality utilisation and outcomes 1819 therefore involving care home staff is essential in order to develop care homes as a research environment methods the delphi method 20 is a structured process that uses an iterative series of questionnaires to gather information and rounds are continued until group consensus is reached 21 this widely used method 22 allows for the inclusion of a large number of individuals across diverse geographic locations and unlike a facetoface meeting avoids the situation where a specific expert may dominate the consensus process 23 however it is not without its methodological difficulties commentators caution that it should be viewed as expert opinion rather than indisputable fact and that a clear decision trail is vital to ensure credibility 24 care homes providing nursing care and those without nursing care were included in order to maximise generalisability of the results incorporating diverse viewpoints such as those from different care environments is considered to improve the quality and acceptability of results in delphi exercises 24 other stakeholders such as care home residents their families and friends and healthcare professionals were not included as it was considered that their perspectives may be too heterogeneous to be combined into one priority setting exercise conducted entirely using remote survey techniques a number of priority setting exercises have exclusively used a single group of healthcare professionals 25 26 27 there are many differing forms of delphi in existence with few researchers using a uniform method of the delphi technique 22 this study used a modified delphi approach which utilised a combination of online surveys postal questionnaires and workshops while retaining the essential elements of the technique achieving consensus through using a forecasting process to determine predict and explore group attitudes needs and priorities 22 the study was piloted with staff from care homes participating in a separate study conducted by the same researchers 28 this project was conducted by the south east wales trials unit as part of a portfolio of research involving the older person ethical approval was granted by cardiff university school of medicine research ethics committee participant selection care home staff were defined as those who considered themselves as providing care for older adults in care homes which included registered nurses care assistants and matronsmanagers participants were identified through partner organisations and networks such as the national institute for health research enabling research in care homes programme 29 in england and scotland who disseminated the information via email and newsletters and care homes in wales that had previously participated in research and who were therefore known to the researchers information about the project was also shared by websites that are commonly accessed by care home staff potential participants were invited to take part by completing an online survey accessed via a url link completing and returning a printed questionnaire or by attending a local workshop event hosted by comprehensive research networks part of the enrich network project design the survey was conducted across three rounds demographic data and method of completion of the survey were also recorded round 1 elicitation of research topics participants were asked to identify areas where they felt there were uncertainties or questions about the care provided on a daytoday basis in care homes participants could provide as many or as few questions as they wished within a large free text space provided refining research topicsquestions the raw questions were collated analysed and formatted by one of the researchers with a clinical background and an interest in acute care in older populations into researchable questions a random 20 selection was also formatted in parallel by another researcher a medical sociologist with an interest in patientcentred care blinded to the refined question generated by the first researcher these double assessed questions were compared and where significant differences were found in either the interpretation of the question or question wording agreement was reached on the final refined question similar or duplicate questions were combined where appropriate questions that were considered impossible to formulate into a research question were removed a pragmatic literature search was undertaken for each topic identified research questions that were considered to have sufficient existing evidence and therefore not true uncertainties were removed the remaining long list of questions was taken forward into the next round for building consensus round 2 building consensus on priorities round 2 was the interim stage to proceed from a long list of research questions to a shorter list the research questions were categorised by the identified themes in order to provide structure and aid completion by participants these were sent to participants via post or email as indicated by their stated preference in their response to the first round the participants were asked to rate how much they agreed or disagreed with the statement this topic is very important to me for each question using a 5point likerttype scale 1 being the most important and 5 the least important median scores and interquartile ranges were calculated for the participants responses to each question median scores were calculated per question in order to characterise the answer category above and below which 50 of the answers fall iqrs which form the distance between the 25th and the 75th percentiles were used to represent the spread of the data and to assess the level of consensus per question responses where the median was ≤2 with a small iqr were considered important research questions that have reached consensus those with a median ≥4 with small iqr were considered to have reached consensus on a lack of importance the 15 most important questions were shortlisted for the third round round 3 reaching consensus on priorities in the final round the highest rated research questions from round 2 were randomly listed and the participants were asked to rank how much of a priority each research question was from 1 to 10 participants were asked to use each number only once leaving those that they felt were not so important blank incorrectly scored or illegible responses were not included in the analysis responses were inversely scored and collated priorities were defined as the research questions receiving the highest total scores results round 1 eightythree participants responded to the initial survey providing 144 individual responses representing a mean of 232 questions per participant of note 759 of these also provided demographic data and method of survey completion no significant difference was found between participants providing high and low numbers of questions or method of completion nine responses which could not be formulated into a research question due to insufficient content or context were removed fourteen were considered to be duplicate or identical to other questions and were removed the 121 questions remaining were categorised into 18 themes just over a third were considered to already have sufficient evidence a total of 76 research questions remained for prioritisation in the next round round 2 forty participants responded to the second round 95 provided some demographic data participants responses showed a high level of importance across all 76 research questions with few participants providing a response that they strongly disagreed with the statement that the question was important the 15 research questions receiving responses where the median was ≤2 and had a small iqr ≤152 were considered important research questions that had reached consensus round 3 fortythree participants responded to the third round and all provided demographic data with a further six questionnaires received which were incorrectly completed and excluded from the analysis the top 15 ranked topics are shown in table 2 a wider group than anticipated responded to the final round as a result of the link to the online survey being shared by interested individuals groups and organisations to individuals who had not participated in the first two rounds but wished to be involved the scores from these are not included in the main prioritisation findings but were analysed separately to assess the degree of consistency between the findings from the main cohort and two further groups a similar group of 60 care home staff who had not participated in the previous rounds and 33 professionals from both health and social care sectors including occupational therapists doctors social workers and care regulators the results from these groups had a similar ordering to the original cohort of participants discussion this is the first study to establish research priorities for older people requiring longterm care in the uk the top 15 research priorities identified by care home staff include questions on personcentred care dignity appropriate staffing levels and training and support requirements for care home staff a previous international survey of care home experts identified priority areas for future research rather than specific research questions 30 although the authors note the heterogeneous nature of the nursing home population internationally some common priorities with our study included a focus on the needs of cognitively impaired residents and palliativeendoflife care 30 the highest ranked priority in our study may have been as a result of recent policy developments across the uk which have highlighted the importance of a more personcentred approach within care services despite personcentred care being common parlance in older person literature in the uk and internationally there is a lack of consistency in how the term is understood this broad theme may have been rated highly as it incorporated a range of philosophical and practical approaches to care or it may have been due to its heightened prominence as a key aspect of quality care questions relating to staffing levels quality and training were ranked highly in our study which may reflect the persistent challenges in providing appropriate staffing and quality care in contrast to the usa few eu member states have systematic compiling and reporting of key quality indicators for longterm care however the situation is changing with more countries developing national standardised quality measurement systems endoflife care is increasingly being provided in care homes residents in care homes are in the last years of life and often present with multiple health needs cognitive impairment and particular palliative care needs due to their advanced age questions relating to early and appropriate discussions about endoflife care and the role of families and healthcare professionals in improving endoflife care were considered important limitations residents and their families and friends were not included as participants in this study the majority of participants were care home managers who may have less involvement in providing care for residents and whose views may not be representative of the wider group of care home staff care home mangers may have a heightened awareness of issues such as staff training and levels of staffing and exposure to current topical issues such as personcentred care in comparison to other groups of care home staff which may have influenced the ranking of these topics the relatively small number of participants meant we were unable to compare responses by different occupational groups or by care home type using a modified delphi approach there was a loss of participants during the three rounds which may have impacted on emerging consensus over time it was difficult to conclusively identify and track participants across every round which may account for small inconsistencies in the demographic data reported responses from two additional groups showed a high degree of consistency with the original cohort of participants however the research questions had been determined prior to their involvement research topics identified by health and social care professionals commissioners care regulators and the broader research community working with care homes may differ significantly from those identified by the participants in this study it is not known why participants allocated particular rankings this may be due to some topics being considered lower in importance less problematic or that participants felt there was less uncertainty about the evidence underpinning them conclusion a set of research priorities for older people in care homes have been identified by a key stakeholder group and endorsed by other professionals involved in their care it is hoped that sharing these results with clinicians researchers and funding bodies will help to begin the process of ensuring that the future research agenda can be focused on the areas of greatest need addressing research questions identified as priorities during this study may contribute to the development of a more evidencebased approach to care provision within care homes further research to identify the research priorities of other key stakeholders such as health and social care professionals commissioners care home residents and their friends and families is required in order to identify a more definitive set of priorities key points • an increasing number of older people are requiring longterm care many of whom have complex healthcare needs • currently there is little evidence basis for much of the care provided for older people resident in care homes • setting research priorities assists researchers and policymakers to effectively target research that has the greatest benefit • the research priorities included personcentred care dignity appropriate staffing levels and staff training and support • this is the first study to establish a set of research priorities for older people in uk care homes how can early and appropriate discussion with older people in care homes about endoflife care be supported 7 how can recruitment of carers with essential qualities such as compassion and empathy be improved by care homes 8 how can best interest decisions made for care home residents with dementia be properly documented in care plans 9 how can care homes be made to feel more like a home 10 what is the public and media perception of care homes compared with other care settings and what is the impact on care home staff attitudes 11 what is the impact of levels of oral hygiene on the nutritional status of older people living in care homes 12 how can families and healthcare professionals contribute to improving endoflife care for older people in care homes 13 what activities can improve the quality of life for care home residents with impaired vision or hearing 14 how can the provision of visual aids enhance the quality of life of people with end stage dementia 15 can education strategies improve care home staff attitudes towards the use of power and authority in their relationship with older people with cognitive impairments supplementary data supplementary data mentioned in the text are available to subscribers in age and ageing online conflicts of interest all authors declare no support from any organisation for the submitted work no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years no other relationships or activities that could appear to have influenced the submitted work funding the work was supported by the south east wales trials unit as part of the development of a portfolio of research involving older people

background currently there is little evidence base for much of the care provided for older people in care homes given the wide range of topics that require further investigation and limited resources one solution is to identify the priorities for future research methods a modified delphi technique was used to identify research topics and develop consensus among care home staff participants the survey was conducted across three rounds firstly to elicit topics that were considered by participants to require further research secondly to prioritise the long list of research questions followed by a third round to reach a consensus on the highest ranked 15 questions results eightythree participants responded to the initial survey providing 144 questions following analysis and review against existing evidence 76 research questions remained of note 4083 participants responded to the interim prioritisation round and 4383 participants responded to the final round which ranked the top 15 research questions by importance two other groups of health and social care professionals also participated in the final ranking the results from these groups had a similar ordering to those of the original cohort of participants conclusion this is the first study to establish a set of research priorities for older people in the uk care homes it is hoped that sharing these results with clinicians researchers and funding bodies will help to begin the process of ensuring that the future research agenda can be focused on the areas of greatest need further work to identify the priorities of other key stakeholders is required

introduction over recent years a substantial work has already been undertaken in hci around design for reflection spanning a range of applications including behavioural change 828 personal informatics 19 mental health 40 and emotional wellbeing 31 however while many of these works aim to lead to transformative reflection ie eliciting change in behaviour or mental schemas there is a clear gap in our understanding of how such indepth reflection can be facilitated through technology in particular it is not yet clear what are the key ingredientscomponents of a reflective process permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that copies are not made or distributed for profit or commercial advantage and that copies bear this notice and the full citation on the first page copyrights for components of this work owned by others than the author must be honored abstracting with credit is permitted to copy otherwise or republish to post on servers or to redistribute to lists requires prior specific permission andor a fee request permissions from instead as baumer 2 notes prior work carries an implicit assumption that just by providing access to data that has been prepared combined and transformed for the purpose of reflection reflection will occur such a view of the reflection process as purely triggered by providing information about the situation is however in direct conflict with the underlying reflection theorists who highlight the extensive support and scaffolding needed for transformative reflection to happen as such although for example a reference to schöns reflectioninaction is common in most of these works the intricacies of how people do reflect and how the reflection process can be supported through technology seems to be mostly missing from the hci work so far this paper aims to address this gap and argues for a framework to design for transformative reflection by highlighting the need to scaffold the reflection process rather than assuming the ability to reflect is a trait that can be readily triggered by providing the relevant information we develop this line of argument in four steps we start by reviewing the concept of the reflective practicum by schön 33 as an articulation of mechanisms to scaffold transformative reflection arising predominantly from schöns empirical work in architectural studio settings in essence schön emphasises the importance of the right sort of experience for the learners which is deliberately scaffolded through an interplay of curricular components second we illustrate how these core aspects of the reflective practicum can serve as a useful sensitising concept 4 to help identify the mechanisms supporting transformative reflection in other settings in particular we retrospectively analyse the findings of two long term case studies unpacking the learning processes challenges and opportunities for technology in two socialemotional learning contexts masters counsellor training 39 and primary school education 36 37 38 third this analysis enables us to extend the concept of reflective practicum into a framework to guide technology development in sel we do this by abstracting key strategies and curricular components across the case studies particularly highlighting the considerations of what makes experiences the right sort of experience for sel learning and identifying the roles technology can play in three identified curricular components finally we illustrate how approaches to scaffolding transformative reflection similar to those described in the reflective practicum and our own case studies can be found in other previous hci work in varied settings such as those supporting reflection of diabetes patients 21 eating habits 26 or within romantic relationships 41 overall this suggests the potential value of reflective practicum framework as a lens to understand designing for transformative reflection also outside the immediate domain of socialemotional learning related work over the last decade hci researchers have shown increasing interest in designing systems to support reflection these have been fueled by the realisation of the key role that reflection plays in areas such as education 12 behavioural change 8 design for wellbeing 3140 personal informatics 19 or reflective design 34 these developments are further emphasised by a series of recent review papers taking stock of the field 1213 as such we do not replicate their synthesising work in what follows and instead directly build on their analyses to motivate and set the gap addressed in this paper while various conceptual and theoretical accounts of reflection coexist across hci work there is a shared understanding that reflection can take multiple forms differing in its depth from simple revisiting of an event to transformative reflection that leads to change in practice or understanding of why and what happened 11322 such a transformative effectie leading to a change in behaviour or an insightis what makes reflection a key process for education 618223233 as well as a crucial part of systems in behavioural change personal informatics and wellbeing despite more than a 75 hci papers on reflection in the last 7 years 2 there is still a lack of understanding of how transformative reflection can be supported through technology in particular although it was raised as an open question already by fleck and fitzpatrick 13 in 2010 supporting transformative reflection was still seen as the most difficult challenge for designers in 2015 1 p591 as baumer et al 2 point out one possible explanation for this gap is thatfor majority of hci projectsreflection was implicitly defined as something that would happen by providing the user with some type of information about a particular situation and as a result the user would have a newfound awareness in the interventions domain of interest kay 17 goes even further to characterise the reflection strategy of many current systems as show the user a graph and hope while there are exceptions within the body of prior work that do not conform to this trend of triggering reflection through presenting data to the best of our knowledge there is little systematic understanding in hci of what transformative reflection entails how it can be scaffolded and how such a process could be meaningfully supported by technology in contrast the educational literature has long acknowledged the importance of reflection and worked to develop practical approaches to promote transformative reflection for the purpose of learning 22 what connects many of the leading scholars in this areasuch as boud 6 kolb 18 moon 2223 and schön 3233 is the emphasis on the reflection process as requiring substantial scaffolding while being tightly linked to a learners particular experiences in the rest of this paper we draw on one such approach schöns work on identifying the strategies to scaffold transformative reflection in what he labels a reflective practicum 33 schöns treatment of how practitionersparticularly in the design studiomanifest and develop expertise through reflectioninaction has been highly influential in hci work with the concept of reflectioninaction referenced in over 70 of research papers 2 however the associated idea of reflective practicum as a set of strategies to promote and scaffold reflectioninaction has received much less attention moreover we argue that in fact it appears that much of the complexity underlying schöns idea of reflectioninactionsuch as the crucial intertwining of reflection as a discussion with the ongoing experiencehas often been lost in hci applications the aim of the next section is thus to draw out the key concepts and ideas underpinning the concept of reflective practicum providing the articulation of reflective practicum as a sensitising concept driving the discussion in the rest of this paper sch ons reflective practicum it is as if the mentor said i can tell you that there is something you need to know and with my help you may be able to learn it but i cannot tell you what it is in a way you can now understand i can only arrange for you to have the right sorts of experiences for yourself you must be willing therefore to have these experiences donald schön educating the reflective practitioner p93 in schöns description reflection has both a crucial importance for helping the expert to orient and make sense of the unique situation they are facing but is also also seen the method through which the experts develop their competence in particular a practitioners expertise relies on patterns that the practitioner can consciously or unconsciously draw on and appropriate within the novel situation and these patterns are learnt through earlier reflectioninaction importantly reflectioninaction is strongly grounded in specific experience schön describes it as necessarily including a discussion as part of the experience in which the expert probes and works with the situation to transform their understanding of how a solution might look as such doing and thinking are complementary in reflectioninaction as d oing extends thinking in the tests moves and probes of experimental action and reflection feeds on doing and its results each feeds the other and each sets boundaries for the other 32 p280 in other words though reflectioninaction the actor experiments within the situation by acting on the experience with the expectation of a particular reaction and analyses the reactionthe backtalkof the situation to inform further action reflectioninaction occurs while we are still engaged with the situation as such one of its core aspects is the opportunity to experiment with and affect the ongoing activity in contrast we may reflect on action by thinking back on what we have done in order to discover how out knowinginaction may have contributed to an unexpected outcome 33 p26 for schön the defining characteristic of reflectiononaction is that it has no direct connection to the present activity it is thus closer to the reflection process as understood in the work of other reflection theorists such as kolbs experiential learning cycle 18 as well as the posthoc reflection processes in learning that boud emphasises in his work 6 as we will see in the following sections the distinction between reflectioninonaction is complex for reflection within sel curricula and a subtle combination of both is key developing expertise the reflective practicum going beyond describing the reflectioninaction as the defining component of expertise schön also looks at strategies by which reflectioninaction can be taught he draws on the architectural design studio and the training process in psychotherapy supervision as two key examples to identify a set of learning processesthe reflective practicumthat underpin the learning in these two domains in the rest of this section we outline the main characteristics of reflective practicum what is a reflective practicum schön characterises the practicum as multiple layered settings whose sole purpose is the structuring of the learning process in a context that approximates a practice world students learn by doing although their doing usually falls short of realworld work they learn by undertaking projects that simulate and simplify practice or they take on realworld projects under close supervision 33 p36 as such the practicum is seen as a virtual world that is that is free of the risks of the real one this virtuality of the practicum is crucial for the learning processes to happen it provides the opportunity for safe exploration as well as structures the tasks so that the core aspects of the learnt competencies are highlighted it seeks to enable students to experiment at low risks vary the pace and focus of work and go back to do things over when it seems useful to do so 33 p170 as such it frames the activity as happening within a particular wedothisforlearning mindset which is crucial for the reflective engagement with the experience paradox of learning by doing the paradox of supporting students reflectioninaction rests in the fact that the students do not at first have the necessary mental concepts so that they cannot understand what they need to learn and can learn it only by beginning to do what they do not yet understand 33 p93 the mentorsand more broadly the practicumsrole is in arranging the right sorts of experiences for the students 33 ibid this points to what we argue is the key characteristics of reflective practicum as reflectioninaction and the underlying expertise cannot be directly taught to students the role of the practicum is to arrange the right sorts of experiences for the students in other words active engagement with the experience is necessary on part of the learner and the practicum is there to carefully scaffold the learning experiences so that these can successfully grasped by the learner in outlining the structures by which practicum accomplishes this scaffolding schön strongly emphasises the mentors role in his view it consists of two equally important parts they need to scaffold the right sort of experiences for the learner through well chosen tasks but then also support the reflectioninaction process on these experiences so that the learner can learn as such the process is more like coaching than teaching 33 p157 in that the role of the mentor is in providing modelling and an opportunity for a dialogue around students experience it is this inaction feedback and support that is used as means to scaffold students attempts at reflectioninaction and is thus seen are instrumental to successful learning on part of the student as schön says whatever the coach may choose to say it is important that he says it for the most part in the context of the students doing he must talk to the student while she is in the midst of a task 33 p102 the scaffolding of reflectioninaction itself thus comprises three essential features it takes place in the context of the students attempts to do the activity ie their immediate experience it makes use of actions as well as words and it depends on reciprocal reflectioninaction between the student and mentor reflective practicum summary based on the literature above we now summarise schöns concept of reflective practicum into a set of core points the key assumption that the expertise cannot be taught to the learners but needs to be actively constructed by the students who rely on the practicum to facilitate and scaffold their experiences to lead to learning reflective practicum is a setting designed specifically to generate a particular sort of experiences that allow the students to explore by doing through an enmeshed interplay of action imitation and reflection leading to further action this includes appropriate teachable moments that provide the experience to work with and the processes of reflection that facilitate the act of grasping of the experience and transforming it into learning in particular the reflective curriculum provides a virtual space where the core of the tasktobelearnt can be exploredpracticed repeatedly but without the adverse effects of failure the main difficulty is then in facilitating activities that include the core characteristics of needed expertise but without the full associated pressures of the realworld such right sort of experiences often do not arise automatically they are generated through an interplay of the varied curricular components that comprise the practicum in schöns apprenticeship contexts the curricular structures have predominantly relied on the role of the mentor mentors played an instrumental role in facilitating meaningful teachable moments through wellselected tasks while at the same time providing modelling and inthemoment scaffolding to help students make sense of the resulting experience through reflection before moving onto the case studies we briefly mention two aspects that are missing in schöns account but would be beneficial for hci applications first as a learning theorist schöns interest was predominantly in understanding how the existing curricula work as such his framework does not directly address how technology might be drawn in to augment or support reflective processes second the reflective practicum as described by schön relies strongly on mentors inthemoment support as the main curricular structure this is mainly as both architecture and freudian psychotherapy training come with a strong apprenticeship focus as such other possible curricular components are not described in detail we will touch on both of these aspects in the rest of the paper sel case studies we begin by briefly reviewing the two sel case studies offering an overview of each and summarize the key findings as they relate to supporting reflection in particular we draw on two long term projects aimed at understanding the learning processes existing challenges and the opportunities for technology within a masters counselling course where the future therapists are going through an indepth sophisticated training aimed to develop expert socialemotional competencies 39 universal prevention programs in primary schools where the students are taught basic life skills such as selfawareness selfregulation or relationship skills 36 37 38 the case studies presented here will help us further two arguments first the next section will use these empirical observations to exemplify how reflective practicum sensitises to particular aspects of the reflection process that have not been unpacked by previous work 36 37 38 39 as well as provides a conceptual framework that allows us to identify the strategies through which reflection is scaffolded across these two very diverse contexts we note that such fit of schöns within the sel context was not immediately apparent as neither the counselling nor prevention science are directly building on or even referencing schön second such analysis allows us to extend the concept of reflective practicum with considerations of the possible roles for technology given that both of the case studies included usercentred design methodologies and focus on meaningful technology involvement as core part of the research process given the challenges with developing se competenciessuch as their intangibility embeddedness in social interaction and the inherent role of emotion that disrupt reflectionwe will see how the curricula draw on a broad set of evidencebased strategies and mechanisms to both generate meaningful teachable moments and scaffold students reflection on these in doing so the case studies exemplify how that the opportunity for transformative reflection was deeply tied with the underlying experience of the learners and how such experiences were painstakingly designed for and orchestrated by the curriculum setting similarly neither curriculum took the learners ability to reflect on their experiences for granted and it was instead carefully scaffolded within the experiences through an interplay of curricular components sel in counselling the first case study drawing on 39 is unpacking the learning processes of a personcentred counselling masters course at a major uk university in what follows we briefly summarise the aim of the curriculum the methods used to teach students as well as the challenges and opportunities for technology identified by the previous work the counselling curriculum has a strongly experiential focus emphasising the importance of an indepth understanding of the client and welltuned selfawareness ability the program had very explicit processes and tools to promote reflection of students always closely tied to a particular experience for example the interpersonal process recall was used throughout the course ipr is a traditional technique developed by kagan 16 in the 1970s aiming to facilitate counsellors deep reflection on and awareness of their own feelings and thoughts during counselling sessions 1 however these were complemented by carefully designed learning sessions as well as intricate set of social norms encompassing all interactions the aim of such curricular scaffolding was twofold first to create real experiences for the students whether that was working with actual emotions of a peer client or getting to grips with their own emotional states facilitated by a particular lesson and second to then allow for experimentation and reflection on own behaviour in the safe learning space established by the curriculum to allow students to do so the full first year of the course was dedicated to developing their reflective abilities so that they were able to process and analyse their experiences in detail even without an inthemoment support from the mentor in terms of existing challenges and possibilities for technology support the study identified a key issue around the difficulty to close reflection loops within the interpersonal settings of clientcounsellor sessions in particular fundamental difficulty in the counselling practicum lies in directly supporting reflectioninaction within the practice counselling session experience the counsellor cannot step out of the role to ask the client if they wouldnt mind going two questions back and taking it from there to try another way of framing it as that would break the emotional realness of the situation to limit impact of this mismatch between what is possible and what would be preferable the curriculum in our case study focused on extending the experience beyond the practice session such processes so far relied on scaffolding students reflection through reliving the counselling situations including various ways of engaging with the video replay albeit mostly relying on penandpaper methods the designed technology took up this challenge to extend and deepen this reflection process through a custom made annotation tool the aim was to allow for localised reflection as well as bringing in clients reflection as a way to sense check and close the reflection loops these then built on the reflective support structures such as the ipr to help counsellors to return as closely as possible into their experience within the session reflecting on their assumptions at that time as well as identifying the reasons for the decisions misunderstandings or blunders in the session sel in primary education the second case study focused on understanding the learning strategies and challenges of existing social emotional curricula in education including review 36 interview study with experts 37 and usercentred design of a pilot system 38 overall sel curricula are part of universal prevention programs in education so working with all kids in primary schools coming from a long line of evidencebased research such curricula are now in more than 44 of us schools 7 the skills taught in sel curricula are those that have been identified by psychologists and educators as crucial not only to development in childhood and teenage years but more importantly as key skills for adult life such as selfawareness selfmanagement social awareness relationship skills and responsible decision making the curricula depend on mostly inclass scripted lessons delivered over longer periods of time the learning strategies strongly rely on roleplays inthemoment coaching from an adult such as the teacher and mental tools 42 mental tools are simple cognitive or behavioural strategies designed to serve as an internal scaffolding that allows the learners to recognise and work with the naturally occurring situations as teachable moments if working well they provide a space to take a step back reflect and reengage with the situation only after it has been processed an example of such mental tool is the turtle technique 29 the children are taught to withdraw into their shell at specified occasions such as when they feel increasingly angry this is followed by a relaxation phase where specific muscle groups are tensed and released once this technique is mastered children discuss appropriate alternative strategies for dealing with stressful situations now that they are able to consciously reflect and react to them the aim is thatthrough the use of these toolsthe children will reinterpret the ongoing realworld situations as learning experiences and opportunities for applying the developing competencies in addition the mental tools serve as external triggers that can be tapped into by teachersadults more broadly if the child has not appropriated these fully this points to the strong reliance on the social support structures provided by teachersadults more broadly which we turn to below as the roleplays and other scaffolded interactions are not seen as real enough the curricula rely on complementing the inclass roleplays with appropriating everyday moments from the naturally occurring situations this however brings issues with such natural situations lacking any explicit scaffolding as such there is a strong risk of the situations becoming too real overwhelm the student and lead to the loss of the learning focus as such outoflesson learning is still strongly dependent on coaching by an adult who provides the ongoing cues prompts and reminders needed by learners the key challenge is then in the lack of scalable techniques to get beyond classroombased learning and support the inthemoment reinforcement and scaffolding in everyday settings as these are needed for the skills to be transfered from inclass intervention to practice to explore one possible solution the technology probe in 38 aimed to provide a shared experience for parents and children together through an interactive story a key part of the design was focused on facilitating the inthemoment scaffolding role of the adult to help children reflect on the experience that the interaction generated how is transformative reflection scaffolded in sel we now apply schöns reflective practicum as a sensitising concept to understand the reflection processes underpinning learning across the two sel contexts by emphasising two key aspects first the focus on understanding what constitutes right sort of experience for the learners and second the interplay between different scaffolding structures within the practicum that then generate such experiences through this discussion we suggest that the reflective practicum serves as a useful sensitising lens to help us dissect the reliance of sel curricula on carefully facilitated sets of experiences for learners as well as identify the strategies through which reflection is scaffolded across the two settings the resulting framework then prepares ground for the next section proposing how such analysis can inspire and guide future hci work in this area characteristics of the right sort of experience one of the key arguments in schöns work is that only the right sort of experiences can be expected to lead transformative reflection for example the right experiences within the architectural studio were seen as act of reflective designing 32 p79 a combination of the students active involvement with a particular design case they struggle with such as sketching a solution to a design problem with their reflection scaffolded by the inthemoment support from the mentor and doing so in a safe space where experimentation was encouraged and effect of failure low in other words real enough but not too much the experience must be meaningful for learning the experience must be available to be reflected withon in sel this means eliciting actual emotions andor interpersonal interaction for the learners this requires the opportunities for reflection inon action which includes the ability for safe exploration of alternative actions and thus closing of the reflective loop characteristics of the right sort of sel experience it was the experience of grappling with a design problem that felt hard to do coupled with access to scaffolding such as the mentors inthemoment feedback that allowed for reflection as part of the experience while knowing it is embedded in the lowrisk virtual world of the curriculum applying this analytical concept to the sel learning we argue there are similarities between such realenough but nottooreal experiences that schön draws out and the sel contexts in particular we propose that the right sort of experience in sel can be then characterised to include an element of tension between eliciting emotions andor experience of interpersonal interaction that feel real but at the same time not too overwhelming so that it can still be approached with a learning mindset and reflected upon we see this realbutnottooreal quality as fundamental to what schön describes as the virtuality of the curriculum in the architectural studio that might mean that a failed design leads to an enlightening design crit session with the mentor rather than a loss of money and customers analogously for sel such virtuality might for example suggest that if one learns about dealing with conflictsand thus must experience to some extent a real conflict with anotherboth parties preferably understand this is a learning situation done for the purpose of competency development and will not generate hard feelings regardless of the outcome we can interpret the sel curricula as aiming to resolve this tension between realbutnottooreal experiences by careful balancing of the emotional strength of the experience for the learners as shown within the case studies this then means generating or appropriating situations where the learners themselves experience actual emotions or interactions while preventing the emotional strength of these experiences from spinning out of control one example of such careful balancing embedded within the structure of sel curricula can be seen within the counselling practice sessions on one side the emphasis is placed on discussing personal issues in the peerclient experiences in order to create a real counselling scenario that is the mentors make clear that very little can be learnt unless the peerclient is willing to talk about matters that emotionally affect them giving the peercounsellor the chance experience and work with situations that are emotionally real for the client on the other side however extensive care also goes into how these sessions are scaffolded and perceived by the participants to ensure the learning goals of the generated experience are kept this includes multiple mechanisms that reinforce the learning focus at various points such as the learning contract of being here to help each other the immediate postsession debrief the use of reflection processes such as ipr as well as the availability of mentors should the issues get out of hand in highlighting the realbutnottooreal experiences we need to clarify what real means in the reflective practicum context in line with the strong focus on learners experiences we suggest it is the notion of perceived realness which is key here what matters is if the emotion or social interaction feels real to the learners rather than whether the experience has been staged or naturally occurring for example if one wants to learn to selfregulate then the essential feature of the learning experience is a strong enough emotion so that controlling it becomes an issue while appropriating moments of stress in the realworld such as everyday conflicts within the classroom is one possible option a well made horrorgame can provide a similarly real feeling of stress and pressure for the learner albeit in actuality completely staged in the architecture training the students need not work on designing houses that will be built instead what matters is that the assignment creates meaningful design choices to be solved overall across both domains the aim was to always work with the most real situation that can be still grasped as a teachable moment rather than being swept away by it the next section discusses how such right sort of experience is then generated through the learning structures of the practicum three scaffolding components of reflective practicum schöns analysis highlights how the reflective practicum comprises a range of structures that all contribute to facilitating learning experiences for students for example schön argues how the architectural studios have evolved their own rituals such as master demonstrations design reviews desk crits and design juries 33 p43 within which the crucial coaching role of the mentor is embedded in other words the reflective practicum can be seen as an interplay of different types of components all working together to generate the right experiences for the students and scaffolding their reflection on these so how does this view map onto the empirical observations of the two sel curricula similarly to the settings described by schön the right sort of experiences did not appear automatically in neither the sel in education nor counselling curricula instead a number of specifically designed curricular components scaffold experiences and the associated reflection process we unpack the characteristics of such components within sel case studies into the explicit components in the practicum the social components and the personal components moreover this distinction will further help think about the possible role of technology as part of reflective practicum figure 2 provides a summary diagram of these three components and their relation to the characteristics of the se learning experience explicit components we propose that the role of the explicit components can be interpreted as directly restructuringshaping the experiences of the learners through tasks or specific tools to scaffold reflection for example tasks such as the roleplay vignettes in education the counselling practice sessions or a design crit in architecture provide boundaries on which experiences can arise for students similarly reflection tools such as the ipr process in counselling or mental tools in education structure particular ways of working with the experience and mediate how learners relate with the world as such explicit structures include both shaping the situations through which experiences are generated but also providing explicit scaffolding processes to facilitate grasping of these through reflection social components in contrast the role of the social components can be seen as to provide a supportive learning environment and a set of social resources the learners can draw on as they proceed with the training this might include establishing specific norms and access to expert inthemoment feedback and peer support specifically strong social structures play an important role in creating a safe practicum space in which the other training components are embedded this includes the expectation that the interaction will be seen through the learning lens ie understood and supported by others as learning material personal components finally the personal components correspond to the learners internal qualities that are crucial for the learners grasping of the experience this includes the students motivation to actively engage with and learn from their experience as well as their existing abilities to reflectinonaction for example the practice sessions within counselling curriculum strongly rely on the presumed abilities to reflect that the students are expected to develop earlier designing for transformative reflection in socialemotional learning contexts we argue that the lens of the reflective practicum can serve as a guide to designers aiming to develop a technologybased system for transformative reflection in the context of sel building on the understanding of how reflection is scaffolded in existing curricula we suggest a two step process the first step offers a set of questions aimed to help understand characteristics of the right sort of experiences that are likely to be conducive for transformative reflection the answers to these can inform the initial design brief to be taken to the next step second we propose that the three curricular components highlight possible roles that technology might play in scaffolding the selected experiences in particular these aim to translate the strategies used in the curricular components into plausible directions for technology scaffolding step 1 reflective experience space this set of sensitising concepts highlights the decisions and considerations that the designers might find useful to take into account when scaffolding transformative reflection in the sel context what constitutes a realenough experience the three questions below emphasise what we see as core aspects of the tension between experiencing a strongenough emotioninterpersonal situation while keeping the reflective focus needed for learning q1 what characteristics make the experience realenough this question aims to help the designer explicate what are the essential features of a practice to be learned 33 p170 that will make the experience seem real for the learner given that se competencies are normally embedded in complex social settings it is important that designers unpack the minimal set of features that are essential for a meaningful learning experience for example as mentioned earlier in learning to selfregulate it is the strength of actual emotion perceived by the learner that is importantthis is regardless of whether this is triggered by a scary movie a recollection of a memory or a realworld event such as a conflict with a significant other q2 how real should the experience feel we noted above how the curricula endeavoured to create the most real situation possible that still allows for a learning focus rather than being swept away by emotions thinking of experiences as being positioned along a perceived realness continuum is useful in understanding the type of experience and the associated learning trajectory the systemintervention aims to facilitate again we note that it is the felt realness that matters rather than whether or not the experiences are directly embedded in the realworld settings q3 how much balancing support should be available we saw how the existing curricula carefully balance the perceived realness of the experience through multiple mechanisms such as adding scaffolding to structure the experiences or facilitate the reflection process that the learners should go through around these this emphasises the focus on the mechanisms of transferring the learnt competencies from inclass or otherwise externally supported context to realworld unsupported situations by reducing the balancing support available to learners this highlights decisions such as whether the aim is to transfer a competency mastered in one context to another or the focus on creating a safe space with plenty of support where the initial seeds of competencies can be created what are the challenges to reflection we saw from both case studies how several inherent characteristics of se experiences can make reflectioninonaction difficult for learners in particular we emphasise the danger of emotional entanglement the implications of intangibility of some se competencies and more broadly the inherent challenge in closing reflection loops as exploration of various responses to the same situation is often not possible the extent to which each of the three challenges is relevant for a particular se competency can markedly differ however if present they might imply the need for additional scaffolding to support reflection and mitigate the effects q4 is emotional entanglement likely we discussed the danger of particular experiences becoming emotionally too real so real that the learners become entangled in the emotional states and lose the learning framing necessary for reflectioninonaction if this is the case the existing curricula can provide an inspiration in how this can be mitigated through balancing the perceived realness of the experience through the support components this might include providing the learners with inthemoment scaffolding from a mentor or mental tools to be triggered in these situations as well as recording traces of the key aspects of the experiences in order to facilitate reflection on the relived experience q5 how directly visibletangible is the process of doing we saw how many of the socialemotional competencies are ephemeral and intangible this makes them hard to model effectively for the teachers and similarly difficult to grasp for the learners for example the experience of being selfaware has some visible implications but the process of becoming selfaware as well as the work that goes into it remains hidden if this is the case additional scaffolding might be needed to help learners both see what the mentor does as well as make their own reflective processes more tangible q6 how easy is it to close the reflection loops socialemotional situations can be a highly continuous flow of action and thus do not allow for exploration of multiple possible responses within a single situation as such it may be difficult for students to close the reflection loops quickly enough to understand how their current behaviour worksdoesnt work and what might be the alternative approaches under such circumstances this suggests the need for the practicum to either generate multiple highly analogous situations if that is possible or provide scaffolding to extend the reflection phase beyond the situation itself how are the experiences achieved the case studies point to two main approaches through which sel curricula facilitate the right sort of experiences for the learners the first corresponds to setting up of a particular situation that is likely to generate such right experiences examples are the roleplays in education or the practice counselling session in counselling the second relies on providing support so that the learners can appropriate realworld situations into the context of the curriculum such as the coaching expected from teachers or parents within the sel in education or the supervision model in counselling in effect this reinterprets otherwise unsolicited experiences into teachable moments these two approaches can be interpreted as bringing complementary benefits and challenges generating the experiences allows for good control and ontask support for the learners but might struggle with eliciting realenough experiences once the learners pass beyond a certain competency level for example recall the need of education curricula to move beyond roleplays in contrast aiming to appropriate realworld moments requires the curriculum to be much more opportunistic and presents difficulties in providing the necessary scaffolding for reflection and balancing emotional realness within the realworld settings step 2 technology design space seeing the questions from the previous section as leading to the design brief this section illustrates how the reflective practicum can help unpack the design space for scaffolding the selected experiences we structure such discussion independently for explicit social and personal practicum components as each of these suggests particular mechanisms to scaffold the right sort of experience for the learners and thus also the prospective roles for technology systems explicit components the explicit components directly restructure and shape the experiences of the learners through tasks or specific tools to scaffold reflection looking across the case studies we propose that these components can be further interpreted as addressing three possible roles structure tasks or social interactions to generate particular experiences provide mechanisms to appropriate realworld experiences as teachable moments directly scaffold the reflection process each of these then suggests a particular role for technologies in support of transformative reflection in sel as well as underlying strategies and mechanisms that could be incorporated into technologybased systems we discuss each briefly below r1 generate emotionalinterpersonal experiences both sel in education and counselling relied on highly structured tasks that helped generate experiences for learners these might have taken the shape of simple vignettes and role plays as well as the intricate structure of practice counselling sessions this points to the potential technology might play in facilitating emotionalinterpersonal experiences such as through interactive media 3 or games for a specific sel example the system developed in 38 used an interactive animated story to scaffold a particular emotional situation for the parent and child to work with r2 appropriate the naturally occurring experiences components helping to appropriate naturally occurring instances as teachable moments were present in both counselling and educational settings such components supported learners in identifying the teachable moments balancing the emotional realness of the situation or making it available for reflection later each of these aspects could be addressed by the emerging wearables and other ubicomp technologies sensorbased systems could help identify key situations as well as trigger selfregulation strategies as well as collect traces that create timewindows into the experience for future reflection r3 directly scaffold the reflection process while the previous two strands focussed on facilitating access to the underlying experience this strand of explicit components aims to scaffold the reflection process on that experience both education and counselling curricula relied on tools that emphasise or problematise particular aspects of experience as well as providing structured ways of working with traces to revisit and relive the underlying experiences the implications for possible roles of technology are for example by thinking about systems that can deepen the link between reflection and experience in one of two ways by embedding the reflection scaffolding into the experience itself or through extending the possibilities to work with a trace of an experience posthoc social components the role of social components is to provide a supportive learning environment through enabling a set of social resources the learners can draw on as they proceed with the training in contrast to the explicit components the focus of social components therefore shifts from directly affecting the learners experiences to providing support to others who support the learning in particular the common strategies across sel curricula can be interpreted as either supporting inthemoment coaching as exemplified within the education settings or the more diffuse set of social norms that promote reflection and learning processes from situations that happen in the space this suggests two example roles for technology in this space r4 scaffolding mentors scaffolding role the scaffolding role of the mentor is a key component across both sel contexts the emphasis is then on the need of mentors own competency through which they model and facilitate reflectioninaction this suggests potential for technology to scaffold this role for availablebutuntrained mentors as well as providing support so that mentors become more effective such as through streamlining the scaffolding process for an example of the former the system developed in 38 was deliberately designed to support parents with prompts and questions to structure their interaction with children for the latter 37 provides mentors with tangible record of students reflection with the aim of making it easier and quicker to provide indepth feedback during a oneonone session with the student r5 support establishing learning culture and peer support the analysis of both sel contexts has highlighted the importance of the social support grounded in learning culture and direct peer support in doing so we argue that while such social norms and support are beneficial for any learning they are of particular importance for sel where most teachable moments require the presence and interaction with others prior work in hci suggests that technology could facilitate such social support both within existing peer groups as well as connect networks of strangers together around a single cause personal components the personal components correspond to the learners internal qualities that are crucial for the learners grasping of the experience this includes the students motivation to actively engage with and learn from their experience as well as their existing abilities to reflectinonaction as such we see these as much harder to directly affect by technology than the other two sets of components in fact limitations of personal components in the target user group might suggest the need to compensate for these through explicitsocial components such as the reliance on coaching and mental tools in sel in education r6 supporting motivation to engage that said we see opportunities in technologybased systems to facilitate motivation to engage for the users for example gamification elements have been shown to be successful to increase motivation in other contexts 935 and there might be potential for technologybased shortterm interventions that reduce internal barriers to action such as those building on mindset interventions 2543 discussion moving beyond sel contexts this section aims to extend the argument by illustrating how aspects of reflection scaffolding similar to those described by the reflective practicum framework in sel can also be seen in other hci work as an example we discuss three otherwise unrelated hci projects coming from areas of diabetes management 21 healthy eating behaviours 26 and romantic relationships 41 2 we suggest that the reflective practicum framework proposed here provides a language to revisit these studies helping to identify similarities in the underlying design strategies through which reflection is scaffolded in their localised contexts moreover we conjecture that such similarities in successful designs could reflect shared mechanisms through which transformative reflection might work across domains that is similar to how schöns observations of the learning process across architecture engineering consulting or music 3233 can be translated to socialemotional learning contexts we argue that these are applicable to a range of other areas that aim for transformative reflection in line with the key features of the reflective practicum each of the three systems is designed to deliberately scaffold particular experiences for users incorporating active engagement with these as the crucial part of the design for reflection in mahi 21 the users are newly diagnosed diabetes patients enrolled in an educational program helping them manage the new limitations the mahi system helped patients capture key measurements associated with what happened and most importantly engage in sensemaking on this experience with asynchronous feedback from the educators the authors draw out how this articulation work scaffolded by the system led to deep reflection and over time marked shifts in how patients viewed and understood the implications of their actions 20 p121 community mosaic 26 is designed to help underprivileged communities eat healthy food the design was driven by a strong collectivistic focus with the users asked to take photographs and descriptions of food they are preparing to inspire others in the community to eat healthier parker draws out the notion of reflectionthroughperformance as the underlying design principle she showed how the act of crafting a message for the unseen audience served as a strong scaffolding for reflection making the participant go through a process of looking at their behaviour from the others perspective finally the lovers box by thieme at al 41 examines how a digital artifact can scaffold reflection for partners in new romantic couples the design combined a physical artifact and video messages that participants create for each other with the support of a video artist the authors argue that the principal vehicle for promoting reflection was the creation exchange and sharing of video messages further mediated by the interaction with the video artist who served as a crucial component of the reflection system each of the designs can be interpreted as a combination of explicit social and personal components providing similar mechanisms for the scaffolding of experience and reflection as in the socialemotional contexts for example the design of the task in mahilinking the measurements and food logs with personal annotationshelps users appropriate particular experiences as teachable moments they can reflect on while providing specific instances for modelling and support from the mentor the system then relies on the strong inherent motivation of the participants who struggle to accommodate their newly diagnosed illness and supports the development of their competencies to reflect on and make sense of their experience over time overall these observations suggest that even if these authors do not reference each other work in different contexts and use different design strategies seeing their work through the reflective practicum lens can point to similarities in the underlying design strategies through which transformative reflection is accomplished as such these systems can be interpreted as providing additional exemplars of practical instantiations of the strategies underlying reflective practicum further populating this design space conclusions this paper draws on the combination of schöns reflective practicum and two sel case studies to argue how the process of transformative reflection is carefully scaffolded in two wellestablished training settings using the core aspects of the reflective practicum as sensitising concepts we abstracted the strategies and curricular components that provide such scaffolding and suggested a framework of questions and roles for technology that might guide designers in designing for transformative reflection in sel we argue that this design framework could be also used in contexts beyond sel emphasising the need to move past triggering reflection on data and toward scaffolding reflection within experience if transformative reflection is to arise

designing for reflection is becoming an increasingly important part of many hci systems in a wide range of application domains however there is a gap in our understanding of how the process of reflection can be supported through technology in fact an implicit assumption in the majority of existing work is that just by providing access to wellselected data indepth reflection can and will occur to counter this view we draw on schöns notion of reflective practicum and apply it as a sensitising concept to identify the complex interplay of factors that support transformative reflection in the context of two socialemotional learning sel studies the results highlight the need to carefully scaffold the process of reflection rather than simply assume that the capability to reflect is a broadly available trait to be triggered through data building on this analysis we develop a conceptual framework that extends the concept of the reflective practicum towards identifying appropriate roles of technology to support transformative reflection while our case is within the context of sel we argue that a deeper understanding of these opportunities can also benefit designing for reflection in other areas

background spontaneous abortion also called a miscarriage is considered as poor sexual and reproductive health outcome with higher consequences 1 around 23 million spontaneous abortions occur annually equating to 44 pregnancy losses every minute 2 women at higher risk of pregnancy loss include those under the age of 20 or over 35 years particularly those who experienced intimate partner violence have a very low or very high bodymass index have a history of miscarriages smoking stress or are exposed to pesticides and pollution 3 these issues are common among people of lower and middleincome countries especially urban slum dwellers due to inadequate understanding and access to sexual and reproductive health rights related information and services 4 5 6 7 spontaneous abortions have severe psychological impacts partly because they are unexpected by nature and have multifaceted impacts 8 depression and anxiety are the most common mental health conditions among women from both lmics and highincome countries who experience spontaneous abortion 9 in mexico 4170 of women who experienced spontaneous abortions had depression and anxiety 10 a large scale casecontrol study conducted in china also reported anxiety and depressive symptoms among women with a history of spontaneous abortions and the risk was higher among those who had recurrent miscarriages 11 another chinese longitudinal study reported that 55 of women stated depressive symptoms three months after the spontaneous abortion 12 this was also found to be the case in the united kingdom where a similar group of women exhibited moderate to severe anxiety and depressive symptoms 13 a systematic review reported the major risk factors for depression and anxiety among women with spontaneous abortions 14 a review stated anxiety was common among women with a history of poor mental health lower spousal support no children a history of miscarriage and unplanned and assisted pregnancy along with these factors depression was also found among women of younger age poor relationships with partners and a history of infertility 9 despite the aforementioned burden of depression and anxiety among women experiencing spontaneous abortion reported worldwide no previous evidence has been found in bangladesh that interlinked these mental health issues among women with spontaneous abortion especially those living in urban slums in bangladesh about 7 million people in urban areas live in slums they are especially at risk of poor health and are deprived of basic health care and family planning services 1516 female slumdwellers often face socioeconomic challenges ie poverty low education violence food security and other social disadvantages that exacerbate mental health impacts 17 18 19 20 21 22 23 research is lacking in bangladesh into these factors which together with the inequitable distribution of major health services could put additional strain on the mental health of the slum women moreover early marriages low prevalences of family planning and early unwanted pregnancies are common in urban slum women due to inadequate access to health and srh services 1524 consequently most early and unintended pregnancies can potentially result in spontaneous abortion however the uptake of srhr and postabortion care services are notably low in the slums due to high costs and a lack of awareness 25 26 27 28 29 additionally restrictive laws and costly formal care push vulnerable women to perform unsafe abortions they then fail to use the postabortion care services 43031 the available pac service packages accessible to bangladeshi slum women comprise emergency treatment for complications and advice regarding family planning 32 but there is no arrangement for any services related to mental healthcare however global studies indicated specific mental health support interventions such as counseling are beneficial for women after a spontaneous abortion 33 34 35 36 moreover previous studies stressed the need for integrating psychosocial support services into the pac package for women who experienced pregnancy loss or abortion 934 the mental health consequences of spontaneous abortion among slumdwelling women are largely understudied also very few studies have explored the association of factors such as employment education wealth index srhr knowledge and utilization of pac services with the mental health of these women therefore it is essential to explore the mental health issues of women who have experienced spontaneous abortion in poorresource settings and informal settlements furthermore such evidence is empirical and can guide the relevant policymakers to integrate mental healthcare into pac services in the future this study was conducted to estimate the prevalence and possible predictors of anxiety and depression in women with experience of spontaneous abortion living in slum areas in dhaka bangladesh methods study method and settings this crosssectional study was conducted among married women living in selected informal urban settlements and communities of dhaka north and south city corporations and gazipur city corporation where the urban health and demographic surveillance system was implemented the baseline information on the pregnant women was gathered from the urban health and demographic surveillance system one of the biggest surveillance systems of informal urban settlements in bangladesh the surveillance system has been running since 2015 directed by the health system and population studies division of the international centre for diarrhoeal disease research bangladesh the total five most significant informal settlements ie mirpur korail shaympur dhalpur and tongi were under the surveillance system the field workers were recruited and trained to gather information quarterly on basic sociodemographic characteristics and events including pregnancy outcomes for surveillance the details of the surveillance were reported elsewhere 37 we included all married women with pregnancy outcomes from july 2020 to december 2021 the baseline information on these pregnant women was gathered from the uhdss database among those we identified the women who had experienced any form of abortion during the study period and found 361 spontaneous abortions and 169 induced abortions we consider one and a half years based on the broen et al study which mentions the adverse effects of pregnancy on womens mental health over time thereby we conducted a crosssectional survey among those women with spontaneous abortions at the time of the survey 115 women had migrated from the surveillance areas since this population is also known as the floating population because of their remarkably high migration rate which is a result of unstable living conditions and nature of jobs 38 furthermore the field team approached the rest of the 246 women who met the inclusion criteria of having a spontaneous abortion the final sample size included 240 who agreed to participate data collection process a semistructured bangla questionnaire was developed through an extensive literature review and was later developed into the javasqlite software this digital questionnaire was mounted on android tablets to be administered by trained uhdss field workers these field workers were also trained by the research team to collect sensitive mental health reproductive healthcare service utilization and abortionrelated information from the vulnerable women the field workers were given lists containing the names and household information of 246 participants extracted from uhdss data they tracked the respective participants and approached them for an interview time and place convenient to them proper privacy was maintained during the interview by conducting it in the absence of the husbands and other members of the family all the interviews were conducted at the participants households as per their preference the questionnaire had sections on sociodemographic characteristics collected from the uhdss database sexual and reproductive healthrelated knowledge receiving postabortion care and experience of violence moreover the assessment of anxiety and depression was done using two psychometric assessment tools the general anxiety disorder and the patient health questionnaire 1539 variables of interest dependent variables the scores of generalized anxiety disorder and patient health questionnaire scales were considered as the dependent variables for this study generalized anxiety disorder scale anxiety symptoms among the participants were assessed by the generalized anxiety disorder scale 34 the gad7 scale consists of seven items and this scale has been validated and used in bangladesh in several studies 4041 participants were asked how often they had experienced each symptom during the last two weeks the response was scored on a fourpoint likert scale 34 the total scale ranges from 0 to 21 the symptom severity scores were 04 for minimal 59 for mild 1014 for moderate and 1521 for severe 2335 for the purpose of modeling gad7 was considered into two categories minimal renamed no anxiety and others three groups presence of anxiety in this study the case of anxiety was considered when women had the mild to severe anxiety category 2 3 4 the internal consistency of the gad7 is reported as excellent with an average interitem covariance of 0477 patient health questionnaire patient health questionnaire which has previously been validated in bangladesh was used to evaluate the level of depressive symptoms 42 it has nine items each with a fourpoint likert scale ranging from 1 to 4 the total score ranges from 0 to 27 the scores for symptom severity were counted as 04 for minimal 59 for mild 1014 for moderate 1519 for moderately severe and 2027 for severe symptoms of depression 43 additionally for the model phq9 was categorized into two groups ie no depressive symptoms and the presence of depressive symptoms the minimal category was considered as no depressive symptoms and the rest of the categories were considered to have depressive symptoms the case of depression was considered when womens scores in the phq9 included them in the mild to severe depression category 2 3 4 5 the cronbachs alpha of the phq9 in the present study was estimated at 08628 with average interitem covariance of 0433 independent variables sociodemographic variables included age and year of education as continuous variables household wealth index and working status in addition the history of live birth stillbirth and contraceptive use were also included the principal component analysis was used to calculate the factor score of each variable and the index was constructed as a weighted sum of these items the index scores were ordered ascendingly and classified into three categories matching the economic status of the slum population the women were classified as poorer if they belonged to ≤ 20th quintile poor if they belonged to the 21st to 79 th and wealthier if more than the 80th quintile having srhr knowledge receiving postabortion care and experiencing any violence either physical or verbal were also considered as explanatory variables for the mental health status of the women statistical analysis descriptive analysis bivariate and logistic regression analyses were performed to assess the correlates of depressive and anxiety symptoms heteroscedasticity was tested using the breuchpagan test for heteroscedasticity and multicollinearity was tested using the variance influence factor at the accepted score 500 44 a pvalue less than 005 was considered significant with a 95 ci all statistical analyses were performed in the stata windows version 150 results characteristics of the participants the mean age of all participants was 2612 years whereas the mean age of women with depressive symptoms and anxiety was 2627 years and 2652 years respectively participants had a 486 years of schooling and were mostly unemployed in both of the mental health outcomes in general more than half of the women lived in poor households followed by the wealthier and poorer quintiles approximately onethird of the women had no live births used contraceptives and 12 of the respondants had previous experience of stillbirths at the time of the survey the majority of women developed depressive symptoms whereas more than half of the respondents reported to have anxiety following a spontaneous abortion the distribution of socioeconomic and reproductive healthrelated attributes of the women with depressive symptoms and anxiety is given in table 1 prevalence of depressive symptoms and anxiety one of every ten women had severe forms of depressive symptoms and anxiety the prevalence of women with moderate levels of depressive symptoms was higher than that of women with moderate levels of anxiety one in three women had mild levels of depressive symptoms and anxiety additionally more women experienced depressive symptoms than anxiety after the spontaneous termination of the pregnancy associated factors of depressive symptoms and anxiety based on logistic regression education srhr knowledge and receiving pac were significantly associated with higher gad scores on the other hand working status srhr knowledge and taking pac were significantly associated with phq scores with every increasing unit of classes of formal education there was a 18 reduction in the odds of developing anxiety women who received postabortion care had a 90 lower risk of developing anxiety and depressive symptoms compared to those who did not on the contrary the chance of developing depressive symptoms and anxiety was more than 70 higher for the women who has higher knowledge about their srhr aor 172 95 ci discussion spontaneous abortions are known to have longlasting and severe effects on mothers a pregnancy loss has been known to cause a lack of selfefficacy hinder relationships with family members and decrease quality of life 4546 however the studies on these relationships were either conducted in developed countries or focused on the physiological repercussions therefore the psychological consequences of loss of pregnancy in disadvantaged populations in developing countries were lacking to the best of our knowledge this paper is the first to evaluate the impact of spontaneous abortion on mental health among the women slum dwellers of bangladesh the findings of this study can encourage policies to restructure the existing maternal health care services and improve the wellbeing of women who belong to the most disadvantaged portion of the population our study reported a mild to severe anxiety and depressive symptoms rate of 5875 and 7750 respectively among the women who had spontaneous abortions we included the mild category for both mental health conditions as it is regarded as the early stage and early detection of these difficulties will better ensure the impact of any therapeutic intervention preventing the onset of complex mental health disorders fig 1 prevalence of anxiety among the slum women with experience of spontaneous abortion fig 2 prevalence of depression among the slum women with experience of spontaneous abortion 47 the prevalences of depressive symptoms and anxiety are much higher than the prevalences reported in the national mental health survey2018 of bangladesh 48 moreover the rate of depressive symptoms in women who experienced spontaneous abortions in our study is higher than that of sri lanka and the level of anxiety is higher than that of eastern and southern african countries 4950 so it is crucial to address this greater burden of mental health consequences among slum women as this can also affect their subsequent pregnancy and compromise the overall fertility span 4551 our findings stated that women from urban slums who received a higher level of education had lower anxiety symptoms it has been reported that low education in women increases the possibility of accepting misinformation overestimating risks and underestimating the benefits of abortion services 5253 these misconceptions about the health risks of abortion may exacerbate anxiety among women with lower education about the procedure and affect their ability to cope afterwards 52 53 54 55 56 in addition such misperceptions generate negative stereotypes about women who have abortions contributing to stigma and exaggerating the risks of the abortion procedure 55 56 57 on the other hand women with more education are expected to be aware of the safety and consequences of abortion and contraception making them more resilient and denoting less restrictive abortion beliefs 52 moreover evidence supports that integrating selfcare education into prenatal service programs effectively reduces anxiety and depression after a spontaneous abortion 41 therefore ensuring education for women living in slums that incorporates srhr and mental health components would be crucial to reducing the consequences of an abortion in addition a lower depression score through phq in slum women was found in those who were employed compared to unemployed women past studies also reported that working status could improve physical and mental health outcomes especially lowering depression among individuals 58 financial stability gives women the autonomy to make decisions and enables them to seek healthcare quickly 59 moreover peer support in the workplace increases the opportunity to share inner distress learn about abortionrelated information and get support from women with similar experiences which can help reduce mental health complications 6061 the low affordability of quality pac services has been linked to depressive symptoms in slum women 62 therefore promoting womens participation in economic work is crucial enabling them to exercise the decisionmaking process and increase their access to needbased healthcare services 51 the multivariate analysis reported that increased levels of anxiety and depressive symptoms were associated with having higher srhr knowledge global studies support that the prevalence of spontaneous abortions is independent of the womans will or even her understanding 63 our study findings reported significantly higher scores of gad7 and phq9 among the women with a higher level of srhr knowledge this might be due to their inability to prevent the event despite having srhr knowledge furthermore a higher understanding of srhr does not ensure uptake and compliance with the services by women 6364 hence the communitybased promotion of srhr services might increase womens reproductive healthcareseeking behavior and utilization of services which will aid in limiting psychological complications 65 our study also reported that receiving postabortion care was significantly associated with lower rates of anxiety and depressive symptoms as per the evidence delaying or not receiving postabortion care might cause inescapable losses such as physical disability and losing childbearing capacity leading to further mental health complications 66 standard postabortion care usually comprises quality screening and counseling procedures which can help minimize psychological impacts among women 6567 in bangladesh formal pac care services only include support for incomplete abortions and advice regarding family planning with no psychosocial support services 68 however evidence supports psychosocial support services combined with appropriate medical consultation can reduce grief and improve womens functioning through proper coping guidance and information about future pregnancies 6970 therefore further research could explore integrating psychological counseling by training service providers to provide basic psychosocial support and followup care in pac these could be possible solutions to mitigate the psychological burden among the women who experienced pregnancy loss 69 in addition increasing awareness about the availability and importance of accessing pac services should be ensured to improve the quality of life of the slum women who have had a miscarriage or induced abortion implications for future practice the findings highlight important considerations for public health policy and the provision of mental health and srh services for socially disadvantaged women particularly those who live in urban slums recent studies highlight the importance of fulfilling srhr needs to improve the overall wellbeing of women since poorer mental health outcomes occur among women after a spontaneous abortion it is critical to enhance existing pac services by including mental health services such as postabortion mental health counseling psychiatric medications followup and referral for severe psychological risks also it is essential to investigate the womens experiences and healthcare needs following abortion moreover it is necessary to raise communitylevel awareness reduce stigma and build capacity of local communitylevel healthcare workers to provide basic psychosocial support and srh care for lowincome women and adolescents strengths and limitations a few limitations should be considered while interpreting the findings one of the potential limitations was that as a crosssectional study it did not establish any causeandeffect relationships among variables future studies assessing anxiety and depressive symptoms among women who did not experience a spontaneous abortion should be conducted to better understand the situation moreover abortionrelated data was collected via a retrospective inquiry which may lead to recall bias and memory lapse in line with this the current study explored mental health soon after the event but the longterm effects and possible demographic predictors should also be investigated additionally this study only included quantitative data and future studies should be conducted to explore indepth womens experiences after an abortion lastly the study was conducted on women living in the selected informal settelments of dhaka city and the findings are not generalizable to all slums in bangladesh despite the limitations one of the major strengths of this study was that to the authors best knowledge it is one of the first in bangladesh to explore the mental health conditions of women with a history of abortion additionally it assessed it in a population of marginalized women largely understudied in research moreover the data were collected from a surveillance system which followed a scientific approach for tracking the demographic and health outcomes of the slum population which could be beneficial for designing largescale studies furthermore as the population is under a surveillance system monitoring and evaluation of the behavioral change is possible in the future if an intervention is provided by comparing the data conclusion the present study is one of the first to the authors knowledge ever to explore the association between spontaneous abortions and the mental health conditions of slum dwellers in dhaka bangladesh it provides evidence that the rates of anxiety and depressive symptoms amongst this vulnerable population are very high and provided an indication as to which factors could be driving them the findings showed that higher education and employment rates among women are protective against mental health difficulties after an abortion this highlights the need to ensure that slum dwellers have access to education in addition this study also recommends empowering women by improving their participation in economic sectors paving the way for increased autonomy and decisionmaking rights most importantly this study showed that accessing pac services helped prevent mental health distress and therefore immediate action is required to integrate mental healthcare into the formal pac service package while ensuring its availability accessibility and affordability in bangladesh abbreviations aor adjusted odds ration gad7 general anxiety disorder7 phq9 patient health questionnaire competing 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background globally major emphasis has been placed on understanding the physiological consequences of losing a pregnancy however its mental health impact on socially disadvantaged women remains unexplored to further inform the field the present study investigated the prevalence and factors associated with the development of depressive symptoms and anxiety among women with a history of spontaneous abortion living in the urban slums of dhaka bangladesh methods information was obtained from 240 women who experienced a spontaneous abortion from july 2020 to december 2021 it was obtained through the urban health and demographic surveillance system uhdss survey generalized anxiety disorder gad7 and patient health questionnaire phq9 were used to measure mental health symptoms bivariate and multivariate linear regression analyses were performed to assess the associated factors with the mental health outcomesof the 240 women majority 7750 of the women experienced mild to severe depressive symptoms and more than half 5875 of the respondants experienced mild to severe anxiety within one and half years of experiencing spontaneous abortion a higher level of education and being employed were protective factors for anxiety and depressive symptoms respectively however women with higher sexual and reproductive health rights srhr knowledge had significantly increased anxiety and depressive symptoms in contrast receiving postabortion care pac was associated with decreased anxiety and depressive symptomsthe findings indicate that ensuring access to affordable pac services and integrating mental health services into the standard pac service package is crucial this study also emphasizes the importance of providing education for women living in urban slums and encouraging them to participate in economic activities

introduction the family pattern in nepal is patriarchy known as families dominated by men only regarding this situation in my opinion and experience there are other aspects also which enhance discrimination and domestic violence in nepalese family systems many people have false beliefs about how and why violence against women happens for us to effectively respond to violence against women we must confront these myths not just physical violence is considered to be violence against women it covers financial emotional psychological and sexual abuse in addition to other types of abuse violence against women refers to any genderbased act that causes or is likely to cause bodily sexual or psychological injury or suffering to women including threats of such acts coercion or arbitrarily denying them their freedom whether it takes place in public or private life feminism also has a connection to violence and prejudice against women pluckrose lindsay have examined the relationship between feminism and gender and found that for well over a century feminism has been one of the most important social movements in human history working to improve the lives of slightly over half the planets population it has always been divisive and extremely unpopular possibly not least because of its triumphs but by the year 2000 however something in feminism altered it can be imagined that women got something as freedom in ngos and ingos documents but it remained a dream in reality in the life of women a significant threat to many women is domestic abuse to learn how to escape a risky situation and recognize the warning signs of an abusive relationship one of the most pervasive human rights violations in the world violence against women and girls occurs daily numerous times all across the world it prevents women and girls from participating in society fully and equally because of the severe shortand longterm physical economic and psychological effects it has on them there are no words to describe how much of an influence it has on peoples lives families and society at large the following feminisms have also been highlighted by pluckrose lindsay intersectional feminism radical feminism materialist feminism and liberal feminism they further added that during the second wave which took place between the late 1960s and the mid1980s liberal feminism was the most broadly based activist movement similarly the two prominent scholarly streams of feminism at this time were radical and materialist feminisms which are somewhat overlapping and rival from the middle of the 1990s on intersectional feminism has supplanted the previous varieties in academic and activist circles in the new millennium intersectional feminism is firmly in control and it is this perspective that has led to the tremendous change just mentioned the abovementioned analysis is a theoretical perspective regarding gender and violence the following is an excerpt from pluckrose lindsay argument that the three primary feminisms in the 1960s were radical materialist and liberal progressively extending to women all the liberties and rights of a liberal society is the goal of liberal feminism materialist feminists were worried about how capitalism and patriarchy collectively limit women particularly in settings like the workplace and the family radical feminists emphasized the patriarchal system and saw men and women as oppressed and oppressor classes respectively they were revolutionaries who sought to transform society and destroy the idea of gender as well as capitalism and patriarchy they have further added that the most crucial thing to realize is that while the liberal feminist approach had the most support from the general public radical and materialist feminism predominated in the academic especially from the 1970s onward the abovementioned text has shown that women need freedom for their identity on the other hand liberal feminism is in favor of women but materialism and radical are in favor of keeping women under the control of male patriarchy under the two frames of oppressed and oppressor postmodern inter sectionalism has mostly supplanted other types of feminists as well such as radical and materialist ones postmodern feminists also outnumbered liberal feminists who have historically been more active in political activism than academic research liberal feminism has been the clear primary target of postmodernists because it adheres to modernist values of secular liberal democracy and individual agency within the context of universal human rights similarly women in nepal have been living under high pressure of discrimination and domestic violence mostly the victims are daughterinlaw wife and also girl child in a family in many families women have to live outside of the familys mainstream although some women have got freedom they have extreme freedom in such a way that other women in the world have not got such type of freedom on the other hand most women are in such a situation that their human rights have been violated in such a way that they cannot be found in another world i think any act of genderbased violence that causes physical sexual or emotional pain or suffering to women and girls is known as violence against women and girls this includes threats of such actions coercion and arbitrary deprivation of liberty whether they take place in public or private life the term violence against women and girls refers to a variety of crimes including but not limited to physical sexual and psychological assaults committed against women and girls within the home or in the larger community and those crimes that the government either supports or condones objective the objective of this study is to show some examples of the nature of domestic violence against women in nepalese families and societies research questions the research questions framed for this study are 1 what types of domestic violence do women face in nepalese families 2 what are the reasons for torturing women in nepalese families 3 how will it be possible to stop domestic violence against women in nepalese families methodology the methodology of this study is qualitative the data collection process was purposive including snowball sampling with five women who were from different parts of nepal and they were living in kathmandu nepal the women had experienced domestic violence made on them as well as had got true experiences of domestic outbreaks of violence made on others in their locality and relatives to collect data some girl students studying social work subjects were used so that the women could tell their stories without any hesitation the data collecting tool was an openended interview and the technique of analysis was description and interpretation using language but no quantitative technique was used a narrative approach is used to conduct this study this study fulfills the gaps of the extreme nature of domestic violence made on women in the family which was not exposed previously through other research literature review the literature review made for this study is on domestic violence discrimination of women exclusion of women in families and feminism theory domestic violence it is generally known that women have been subject to domestic violence in nepalese families it may be the same in other countries and families women are found to have been tortured burned to death alive asked for dowry from their parents and taken as not human beings by their married families regarding domestic violence hilder bettinson referred to the moral and legal responsibility to address domestic violence and abuse as a matter of current worldwide concern this view shows that domestic violence against women is experienced in every country in the world regarding this concern civil society has also been found to have remained outside the gate of the entrance of domestic violence similarly in light of the current circumstance the council of europe has noted that at a regional level the council of europe convention on preventing and combating violence against women and domestic violence council of europe provides legally binding standards to enhance the prevention of violence the protection of victims and the prosecution of perpetrators through a set of integrated policies calling for stronger coordination of legal and communitybased response although different organizations make rules and regulations to stop domestic violence against women it has not been much more successful furthermore according to mcquigg a prevalent reluctance to regard the conduct of such behaviors as a fundamental violation of a persons human rights is maybe one of the intrinsic weaknesses of societies in effectively addressing the issue of domestic violence domestic abuse evidently violates a persons right to life as well as their freedom from torture and other cruel or inhumane treatment as well as their right to respect for their private and family lives as mentioned above however it hasnt been until recently found that domestic violence has been acknowledged as a problem covered by human rights law although we talk of different organizations concerning the enhancement of women they are on paper but not in the real world the degree of complexity tends to rapidly rise when it comes to understanding domestic violence according to ross who claims that humans are the most complex species on the planet also domestic violence has been the subject of several theoretical explanations that have developed over the years as mentioned here these explanations offer fresh perspectives on actions that are seen to be exceptionally terrible and cruel sociological explanations of the causes of domestic violence have received more recognition among academics from many intellectual traditions despite their divergent views in nepalese families also violations against women are highly increasing despite a modern system of family discrimination of women from the very time of birth girl children are discriminated against in their beginning family it is known that sons and daughters are treated differently regarding women haralambos holborn have stated that women are generally underrepresented in highprestige jobs and positions of power although females have children and are mothers spouses and caregivers for all home tasks similarly women everywhere feel discrimination in families girl children are provided cheaper clothes than sonsboys daughters are sent to cheap schools but sons are sent to costly schools ways of dealings are also different for a son and a daughter as a whole women are devaluated in family and community ortner referred to this circumstance by stating that culture is valued more highly in every community than nature mans ability to govern and regulate nature is mediated through culture the fundamental justification for the undervaluation of women is the widespread belief that culture is superior to nature women are thought to be less superior to males since they are perceived as being closer to nature ortner argument is supportive of the present situation the husband and his family relatives beat her and abuse highly thinking that she has not got any credit although this view was framed long ago it seems as relevant today as it was in the past in nepalese families women have been looked at in a very narrow background furthermore a daughterinlaw has no any credit in many families regarding this situation rao has stated that men and women have never been treated equally or given the same statuses throughout the history of the human race despite their desire for equality women have not been able to live lives exactly on par with men but women face inequality discrimination and exploitation everywhere as mentioned by rao the gender role in india and nepal is the same because of cultural similarities on the other hand swami vivekananda has mentioned that in any community the kind of status given to women reflects the nature of that countrys cultural diversity and the degree to which its civilizational ideals have been attained also neither can the nation or the country that does not appreciate women ever rise to greatness rao the view of swami vivekananda is highly acceptable as we say human beings it composed of both men and women so keeping women back progress is not possible theoretical review theory helps to build the direction of a persons opinion about what works and how it is done in this way the theory applied to this study is gender inequality regarding this situation ritzer has stated that men and women are situated in society differently and unequally women in particular receive fewer material resources social status power and opportunities for selfactualization than do men who share their social location furthermore this inequality is caused by the way society is set up but not by biological differences between men and women liberal feminism similarly to the feminist theory this study adheres to liberal feminism according to ritzer liberal feminism is the main manifestation of gender inequality theory it asserts that women can make a case for equality with men based on a fundamental human ability for reasoned moral agency and that sexism and patriarchy are the root causes of gender inequality in the workplace as mentioned above liberal feminism which asserts that womens inferior standing in society is based on uneven opportunities and isolation from males is one of the first versions of feminism as was previously established this corpus of feminism which sprang from the abolitionist and womens movements in every nation is concerned with eradicating gender inequity data presentation and discussion to collect data about domestic violence and discrimination five women were selected and they were interviewed their pseudo names are mentioned here some girl students were managed to interview them the pseudo names of the participants are goma harikala janaki dil kumari and astha regarding domestic violence experienced by goma said that she had been married to a very cruel brahmin caste person if she had known the person was so cruel she would not get married to him her marriage was arranged marriage there was a widow sister of her husband in the family she always put the blame on her before her husband and immediately her husband would become fire with anger and used to beat her using whatever things were handy for him he used a fist and stick to beat her once after many years of torture like this she thought it would be better to die rather than to live and be alive thinking so she picked up a strong rope and went to a forest to hang up and die rather than be alive with such torturous life but some other people knew about it and stopped her from hanging and die the people brought her home and her husband was so much afraid that he left home and did not return for some years the reason for the domestic violence against her was his husbands sister and also her motherinlaw harikala had also the same type of domestic violence in her family her husband was also very rude and always looked down on her with his male superiority true patriarchal power was visible in her family she was almost daily beaten and given mental torture by her husband she always lived in extreme terror and fear until the death of her husband she rather told that she was not worried about her husbands death it was because of the torture given to her by her husband janaki reminded her sisters story and added to her story that her sisters husband was also very cruel and dangerous according to her story when her sisters husband had time to take food she had to give fodder to the cattle and the cattle had to finish eating fodder by the time he would finish eating food and otherwise if the cattle would not finish eating fodder he would beat her very harshly and dangerously at last she thought it difficult to stay there and left the house and family along with a son the son was separated from her after a few years she died but her husband and son were alive it was also heard that the father became harsh with his son too dil kumari also added to her story that she got married to an educated person who had not got so much property he had got only a mother in the family but dil kumari had not known that a widow can be so much dangerous it means that her motherinlaw was very active in the matter of domestic violence and could not see her daughterinlaw with her eyes she dominated her daughterinlawfrom the very time of the day of marriage but the marriage was arranged marriage she forced her son to abandon dil kumari and the reason was that dil kumari had not got a dowry from her parents but her husband being an educated person and without greed for property he could not accept his mothers force being put on him to leave his wife forever and get married to another woman she further added that her motherinlaw managed to feed a herbal medicine with the help of a witch doctor which could stop the birth of a child so that she would be barren all her life but she was clever and did not eat the medicine but also the effect of touching the medicine with magic chanting of the witch doctoraffected her and she had to take help of another witch doctor and herbalist to return her condition to give birth to a child and now she has got a son and a daughter they are grown up and her daughter is now married and her son has completed higher education in an engineering program according to her story when her motherinlaw could not convince her son to leave her she stayed alone to blame both her son and daughterinlaw now dil kumaris motherinlaw is dead and she remembers the harsh situation got from her motherinlaw but her husband was a polite and educated person so he did not follow domestic violence as forced by his mother astha also told a serious story about her husband that he always used to beat her in the small matter but her sons took favor of her and he was made a bit under control but when he died she says she got some relief now she does not even remember him because of his habit of giving torture to her findings the aboveexplained data show that domestic violence is often made to the daughterinlaw and wife this is male dominant family supported by the husbands family members and a married womans motherinlaw becomes jealous of her daughterinlaw thinking of her as a piece of metal object and a piece of wood an object in such a situation domestic violence takes the highest strength so a married woman goes for suicide an important finding of this study is that if a motherinlaw becomes friendly with her daughterinlaw all types of domestic violence can be taken into control this is the point of a gap this research tries to fulfill it is because only sons and daughterinlaws have been on the blame because of disciplinary barriers civil society also does not take favor of a daughterinlaw and her innocent behavior in this way a family becomes hell due to the high level of domination made on a daughterinlaw and a wife in the family the main reasons for domestic violence are the greed for money to obtain from the wifes parents with the support of a husbands family members conclusion in terms of domestic violence it can be said that an innocent girl gets into a deep hole of hell which is very difficult to cross and jump out of as well in our community civil society also does not make convinced people that a girl brought into a family through the process of marriage is also a human being and should be treated as a human being but not like an iron nail if a married girls motherinlaw supports her the husband also does not dominate her but thinking of a girl in her husbands family as good as possible is a nightmare dream so i have mentioned this situation as an unsolved responsibility it means that events are taking place but no society goes to solve it in favor of the victims of the event but members of the community burn a fire for such a situation

the purpose of this study is to present domestic violence existing against women in nepalese families and societies although people are educated domestic violence against women is not minimized and appears in many families as before this research study also shows that patriarchal families and societies are extremely dominating women designmethodologyapproach furthermore regarding methodology this is a qualitative study and data are collected through interviews and document analysis this is an ethnographic design under qualitative study the study maintains convenience sampling under purposive sampling related to a qualitative study a woman fallen victim to domestic violence will be identified and interviewed and through her another woman of a similar category is identified to interview and collect data findings nepal is a small country situated between two large countries china and india nepal is surrounded by china in the northern part and by india in the eastern southern and western parts so the lifestyle of the people in the northern part of nepal is like that of the tibetan tribes and similarly the lifestyle of the people in the eastern southern and western parts is similar to that of indian people the findings of this study show that society has not taken responsibility to control discrimination and domestic violence taking place against women this is an unsolved social responsibility research limitation this research study is ethnography in research design that does not cover more aspects of the male population and also it is a qualitative study and does not point out any statistical tools and numerical data managerial implications this research implies that women need equality in family and society maintaining a humanistic view of women and implications for further research originalityvalue this research study has maintained its originality and it has also got great value the delimitation of this study is that it concerns the discrimination and domestic violence against women in families and societies

introduction with the arrival of information age a large amount of information is flooding our city life and the digital form of social innovation has appeared digital social innovation has become a hotspot for policymakers entrepreneurs researchers and startups it presents us with a brand new vision previous research like nestas research on dsi 1 has pioneered the field of dsi from both research questions and methods and created many cases that laid the foundation for our research nowadays for academic institutions like parsons desis lab 2 dsi has become their new thematic group and its work provided the theoretical basis for our study and reference their focus on digital technologies and platforms are considered as the organization tool for connecting community to individuals based on the assumptions of the previous research we believe that digital technology is a dominant and pivotal new way to support people customers and communities to collaborate and cocreate a wide range of social needs consisting of a group of desis laboratories and partners dsi group is currently exploring a different approach focusing on the literal aspect of digital technology which is more technical and academic the purpose is to investigate not only the cases and trends in social innovation but also the corresponding design research issues and strategies in the digital social and ubiquitous network context from the perspective of design the definition and features of dsi need to be concerned what is more important is how to apply dsi to real social practice scenarios in a standardized and processoriented way in order to make the project closer to reality we worked with ngos charities and social enterprises to develop interdisciplinary cooperation among governments organizations and research institutions to find new possibilities during the exploration process also following the trend of globalization we actively cooperated with urban studies program at stanford university and formed crossregional crosscultural and interdisciplinary teams to test and practice dsi we found that urban design is not only about physical infrastructure but it is also about the services and amenities where infrastructure inhabits in addition we use four pillars of sustainability social equity environmental quality cultural continuity and economic vitality as the framework to guide the direction of the project 3 the four pillars have significant referential meaning to the summarized features and evaluation standard of dsi society background according to our previous research 4 the initial prototype of the city is formed by aggregation of population and commodity exchange a real sense of a city is to make its citizens live well with support of urban infrastructure and energy food water transportation recreation and finance system etc the intervention of new ict technology changes the built environment to a sensible interactive and transferred place where support human activities in all levels and make the citys physical space and intangible networks merge together to form a very complex ecosystem in the current state the smart city is envisioned as wired and ictdriven cities that provide better urban life 5 innovative services 6 new business opportunities 7 efficient governance and sustainable environment development 8 more and more cities are beginning to consider civic participation and regard the smart citizen as a new direction of smart city currently governments around the world are taking actions to cooperate with their citizens in the process of designing and constructing smart cities based on their specific situations and objectives social media is being widely used as a way to get citizens involved participatory sensing which is empowered by the development of ict is also a significant approach to collecting data from citizens some government municipalities also launched urban sensing applications such as the nyc 311 service 9 new york city held its annual city hackathon 2013 with the theme of reinvent green aiming to help build digital tools and applications to support new york in leading greener lives 10 from public benefit to social innovation companies increasingly turn to csr30 11 they will focus on a more sustainable model and revolutionize our understanding on concepts such as product consumption wealth and inventions with new methods ideas and technologies for instance in the intel core world social innovation week 12 technology background digital technologies and the internet play an increasingly important role in how social innovation happens todays urban development is gradually turning to smart city new technologies such as the internet big data cloud computing wearable devices intelligent home artificial intelligence and sns have been applied to social innovation 13 and extend the width and breadth of social innovation from the aspects of the process performance and content increasing its efficiency and reducing its complexity significantly the growth and development of social computing has greatly increased the complexity of the system on the other hand coping with complexity also brings new solutions to social innovation collective intelligence harvested from relationships among designers users and organizations and collective wisdom that acquired from things on internet can generate greater value from the interaction between people and things eventually innovative hopeful and sustainable lifestyle can be created 1415 research questions we hope to offer a set of methods to contribute to dsi research in the urban context and meanwhile to practice it and cooperate with the society from all walks of life in the practice we will offer insights and tools from the angle of schools what is the main participant of dsi in recent decades many philanthropic and charitable organizations have often turned to nonprofit especially nongovernmental organizations to address some of the worlds most intractable social problems with the rise of those groups the number of similar social organizations increases however their projects and solutions are almost homogenous and they are also lacking in new theories or thoughts by carefully retooling these organizations with the latest technology and guiding them with the best innovation practices at our disposal today we can start fresh with a rebooted version of traditional nongovernmental organizations ngo 20 1617 what is the method of dsi with the goal of social innovation we focus on the reflection of culture and social value on the aspects of research methods and design tools focusing on research questions from the community level the more mature mode is the bottom of the pyramid 18 in the design field collective action toolkit developed by frog design company 19 hcd toolkit developed by ideo 20 and the diy innovation toolkit produced by nesta 21 are all tools for inspiring and supporting social innovation methodology our train of thought is first analyzing the real cases second concluding the features of them when referring to designing process then forming the framework of dsi suited to city sustainable background at last testing our conclusion by practicing during the process we used case study and grounded theory as our method and tool case study according to thomas 22 case studies are analyses of persons events decisions periods projects policies institutions or other systems that are studied holistically by one or more method the case that is the subject of the inquiry will be an instance of a class of phenomena that provides an analytical framean objectwithin which the study is conducted and which the case illuminates and explicates we studied many dsi cases in order to find a vision for the common features of dsi grounded theory its a systematic methodology in the social sciences involving the construction of theory through the analysis of data 23 from our case studies we also collected many data after having done the statistical analysis we conclude the statistical meaning of these data and deduce the general framework for dsi contribution this paper focuses on researching and practicing dsi in the urban context and makes following contributions • define dsi in the urban context • summarize and conclude the features and framework of dsi • support the relative research • support innovation teams to take part in dsi practices in the urban context related research social innovation there is a possible future in which services are explicitly designed to tackle social challenges such as climate change and unemployment social innovation is now embraced around the world as legitimate public policy in both economic and social arenas according to the open book of social innovation 24 the three most significant problems of social innovation are intractable social problems rising costs and paradigm there is a growing interest in social innovation among policymakers foundations researchers and academic institutions around the world despite this interest there are no a shared or common definition of social innovation currently there are a large number of different definitions in circulation goldenberg defined social innovation as the development and application of new or improved activities initiatives services processes or products designed to address social and economic challenges faced by individuals and communities 25 in 2003 stanford had defined social innovation as the process of inventing securing support for and implementing novel solutions to social needs and problems five years later stanford redefined and broadened the term the latest approach involves dissolving boundaries and brokering a dialogue between the public private and nonprofit sectors the current stanford definition of social innovation is a novel solution to a social problem that is more effective efficient sustainable or just than existing solutions and for which the value created accrues primarily to society as a whole rather than private individuals it describes that a social innovation can be a product production process or technology but it can also be a principle an idea a piece of legislation a social movement an intervention or some combination of them 26 some define social innovation as a type of innovation more broadly timo hämäläinen outlines five types of innovation technological economic regulative normative and cultural 27 according to a report of tepsie it defines social innovation as new solutions which simultaneously meet a social need and lead to new or improved capabilities relationships and better use of assets and resources 28 tepsie found the eight common features of social innovation which are crosssectorial open and collaborative grassroots and bottomup prosumption and coproduction mutualism creates new roles and relationships better use of assets and resources and develops assets and capabilities 28 robin murray julie cauliergrice and geoff mulgan from the young foundation had identified six stages of social innovation from inception to impact the six stages are 24 prompts inspirations and diagnoses proposals and ideas prototyping and pilots sustaining scaling and diffusion and systemic change in the book they explored each of the stages in depth and listed some of the main methods used for each one case study grounded theory believes that a theoretical framework can only gradually be formed through indepth analysis of data therefore we selected five typical dsi cases in the urban context yibo 29 cocacola hello happiness 30 pugedon 31 yitu 32 and fixmycity 33 as our primary data to analyze yibo provides a novel solution to add advertisements on the internet it collects 404 not found web pages that provide the advertisement service to social organizations now over 200000 websites have joined in yibo to provide noncommercial advertisement the advantage is that it spreads noncommercial advertisements online by fully using resources of internet the whole procedure can be easily recorded and traced pugedon is a welldesigned recycling machine it feeds stray animals when it receives plastic bottles at the same time pugedon recycles plastic materials for environment protection on the other hand it provides a solution to feeding stray animals by combining these two features pugedon motivates people to protect environment and meanwhile care for animals hello happiness is a new video from cocacola in march 2014 coke installed five special phone booths that accepted cocacola bottle caps instead of coins in dubai labor camps in exchange for a 54cent coke bottle cap migrant workers could make a threeminute international call 30 similar with pugedon cocacola hello happiness project is totallyan offline solution it modifies the traditional telephone booth by replacing the coins with coke bottle caps apparently cocacolas innovative solution created a positive impact on the society especially to migrant workers yitu provides a multiplefield and mapbased solution targeting different social problems such as environment society and disaster it is the first multiplelayers social map on which every person can upload and search for different social problems and requirements social organizations can generate corresponding social service maps based on the yitu platform the maps can be imbedded into the web pages to reduce the cost of development fixmycity is a framework for easily building and deploying citizen reporting platforms based on web technologies it enables citizens to report local issues to the responsible local authorities through the combination of fixmycity platform features bidirectional channels are created between citizens on the one side and local governments on the other fixmycity focuses on the extensive support to enduser mobile crossdevice and the tight integration of social media 33 during the research of these five dsi cases we collected keywords in related works such as project introductions news and research papers and summarized the feature descriptions as shown in table based on the 5w2h theory a method in grounded theory for microanalysis which is what when where who why how how much we selected seven corresponding aspects deliverable generation service model object orientation approach and operation to categorize the features we learned from other cases that the content of dsi could also be open data offered by the government or relevant departments and organizations digital social innovation 31 definition dsi is the best solution to city life problems in the era of information science and technology have provided guarantees for many unimaginable and undoable things making efficient and largescale innovations possible today at a time when urban lifestyle is so fast science and technology has become more and more essential as a tool of assisting social innovation dsi is one kind of social innovation that is based on internet or uses digital ways its purposes are to improve the life quality of different groups and help raise different solutions to the same problems in digital way nesta had defined dsi as a type of social and collaborative innovation in which innovators users and communities collaborate using digital technologies to cocreate knowledge and solutions for a wide range of social needs and at a scale that was unimaginable before the rise of the internet 34 in a report of nesta 13 we define dsi in the urban context as a type of social innovation in which all of the society members get involved both physically and digitally through using digital technologies to cocreate and codesign our neighborhood features we have concluded seven features of dsi through research and practice they are from the seven aspects shown in table 1 the seven features corresponding with the seven aspects come out in pairs complement and reinforce each other according to grounded theory the features are the substantive theory that we get from the primary data through practicing and validating they gained great guidance to classify the researches on dsi platformproduct solutions can selfgenerate or be improved by users on the platform and are open to many other users a product is effective professional complete and validated usually due to unprofessional quality or financial problems a product comes out at the situation in which users cannot inefficiently find the solution originalreformed science and technology has changed our behaviors an exited and effective social innovation will become a new dsi after digitally reformed the development of technology has broadened our horizon and motivated social innovation whether social innovation is supported by a completely new technology or a combination of existing technologies its all original dsi onlineoffline the application of internet can be seen in almost every case of dsi online means state of connectivity offline means real activities or events the offline part shortens the distance between innovation result and real life while the online part provides chances for creating new business models and solutions collectiveindividual collective intelligence helps us solve complex human problems crowdsourcing and crowdfunding have already been new modes of generating and incubating innovation collective means the dsi is executed by the whole society such as crowdsourcing and crowdfunding while individual means the dsi is initiated or executed by one person resultprocess resultsoriented dsi emphasizes the final outputa solution or a product while processdsi emphasizes the middle output it can be data or social network between the participants generated or established in the dsi process opencustomized open indicates transparent data selfgeneration low threshold and broad audience while customized stands for dsis that have special requirements targeted audiences and experts lightheavy light operation means less or none cost and manpower resources using freely and operating simply heavy operation means complex development and maintenance design framework based on the set factors 35 which are social economic and technology we categorize the features then we get the formal theory a standard dsi design framework as the guide of our practice to evaluate the sustainability economic benefits and efficiency during the process of studying and practicing dsi cases we summarize them as four evaluation indexes in our dsi design framework based on what we have learned from tim browns design thinking 36 the four evaluations indexes are desirability viability and sustainability and feasibility from the perspective of dsi social desirability is about building the participatory vibrant community to support the humanized innovation social and economic sustainability means its an inclusive ecosystem that can create sustaining social values economic viability means aggregating the physical and digital resources to build the collaborative platform technology feasibility means its an open flexible framework based on the new technologies such as social media big data and crowdsourcing in conclusion the four indexes of dsi are participatory community inclusive ecosystem collaborative platform and open framework project practices to explore the opportunities and services for social innovation and sustainable design patterns in the urban context we cooperate with ngos and public institutions to help the students to build a better concept of society problems and find the real demand and in the same time we apply our framework for generating solutions there are 3 examples from the class below case1 urban walkability and walking experience urban walkability is a problem concentrated on sustainability of future cities from a macro perspective and it can determine the citizens life quality and living cost case2 open air quality platform for government the haze and smog can directly damage human respiratory system on one hand limiting the airborne pollution is an important aspect on the other hand the communication among government enterprises and public has a significant meaning youth hostel is a microcosm of society which has a close relationship with youths attitude and manner toward life it also includes many elements travel making friends and accommodation during our study and practice we did a lot of research on existing related methods and tools that have already been used and practiced thousands of times by combining and recreating them we make our own dsi methods and tools for college students in our courses in order to validate them in real urban context we conducted some projects together with ngos and other society organizations as shown above our projects have standardized process and completed result because of our expertise our results are drawn mostly from design concern after this we still have other valuable things to do • firstly build a dsi sharing platform for the organizations and companies who are planning to do dsi the platform will contain large quantities of dsi cases and related data which will be quite helpful for those organizations and companies especially startups of course there will be a committee to supervise the platform and keep it working by certain rules if some groups profit from the platform in return they will share their cases and data on the platform • although dsi has the social attributes we can concern the micro aspect of the whole dsi processthe innovation groups how to make the group more efficient and more creative is the key point we need to discover what tools platforms or specialties influence dsi results and how they influence conclusions starting with the definition of dsi we used case study to conclude the features of dsi and on the basis of these features we developed the dsis framework used on urban context referring to the course practices cooperated with stanford we practice and confirm the relevant method and so that we believe the conclusion have the guiding significance we will continue perfecting and verifying our conclusion and pay attention on development and promotion of creativity of innovation participant also we will develop more distinctive products and services for society

this paper focuses on the research and practice of digital social innovation dsi the rapid progress in the era of information provides many possibilities for social innovation at the meanwhile the development of science and technology has significantly boosted the breadth depth and efficiency of social innovation through years of research and practice we improve the definition and conclude the features of dsi from a large number of case studies then by combining the set factors we develop the general standard framework for dsi at last we use and confirm the righteous and effectiveness of this instruction in practice

introduction in recent years social media platforms have become the main channel for people to share and obtain information xiaohongshu as an emerging social media platform provides a channel for spreading discourse in the context of the new era the concept of equality between men and women in china has gained a kind of legitimacy and the concept of gender equality in society has continued to advance and develop which has laid the foundation for feminisms development as of june 2022 the size of chinas internet users has reached 1051 billion of which 514 are male and 486 are female which is basically consistent with the ratio of men and women in the overall population and to some extent verifies that there is no obvious bias or restriction on internet use by people of different genders internationally scholars have delved into research investigating a variety of social media practices of feminism including feminist blogs 1 popular feminist hashtags 2 3 4 and the use of social networking platforms such as whatsapp instagram youtube and tumblr to convey feminist messages images and identities 56 and how the discussions affect feministrelated movement like metoo 78 in china more and more scholars have also begun to look at the media practices and roles of feminist discourse in the new media landscape some studies have shown that feminist discourse discussions on media platforms can influence the thoughts and behaviours of media users eg the attention attitudes and discussion of feminist online discourse actions among female college student groups have a positive effect on the willingness to speak out 9 besides research on womens topics based on the xiaohongshu platform has also begun to appear such as feminism research 10 womens media image research 11 womens image construction 12 and selfpresentation 13 and female body image anxiety phenomenon 14 and female identity 15 previous research has focused on the role of online feminist discourses on young womens groups dai found that female university students attention attitudes and discussion of feminist online discursive actions had a positive effect on willingness to speak out 9 nevertheless there is a lack of research on how online feminist discourse influences audience behaviour offline besides in a study by analysing data on girls participation in feminist activism on social media like twitter facebook and tumblr in the united states canada and the united kingdom found that girls strategic choices shape the types of feminism seen on various social media platforms these distinctive discourses may be related to the platforms language culture and social interaction styles the findings raise the need for further attention to be paid to whether the expression and shaping of feminist sentiment on social media platforms is influenced by specific platform structures and characteristics 6 feminism is often used as an important framework for exploring issues such as gender equality womens rights diversity of female roles and empowerment in the film industry in existing research in recent years the barbie brand has gradually introduced some storylines related to womens rights and diversity the barbie movie attempts to reflect on traditional gender roles and stereotypes by portraying female characters as ambitious intelligent and versatile movies can help eliminate stereotypes about women and encourage girls to pursue various interests and professions however the barbie movie has also sparked some controversy and many feminists have criticized the barbie movie and related toys believing that their appearance standards body proportions and other factors still strengthen the unhealthy body image to a certain extent thereby affecting womens selfesteem and image confidence currently academic discussions about the movie are mostly focused on the economic and educational fields in the field of mass communication it is still in an absent state at present the academic research on new media platforms mainly focuses on such platforms as facebook twitter instagram weibo tiktok while the research on the media presentation and discourse communication of xiaohongshu is relatively scarce however it is against this backdrop that xiaohongshu as a vibrant social media platform has gradually emerged among chinese users in recent years there is currently a lack of indepth exploration of the platforms communication effectiveness and audience resonance in the past research only focused on the image of female media and the analysis of female user behavior there was a lack of indepth analysis of male users as well as a survey of female offline behavior and its impact on feminism in society the research significance of exploring the xiaohongshu platform cannot be underestimated especially in terms of media practice this study lies in filling the academic gap in the dissemination of feminist discourse on the xiaohongshu platform based on the mentioned research background innovative points and previous practical support the researcher aims to conduct an indepth research on the dissemination of feminist discourse and public resonance of the barbie movie on the xiaohongshu platform to reveal the association between the movie and feminist views to analyze the dissemination mode and expression of views of the discourse to parse the publics emotional attitudes and ultimately to reveal the impact of these discourses on the development of feminist discourse in society given the xiaohongshus significance for highlighting the pervasiveness of feminism this study aims to answer the following research questions 1 how socially engaged is the feminist conversation about the barbie movie on the xiaohongshu what are the main topics and keywords in the posts that relate to feminism 2 what contexts and emotional colors are used by posters on xiaohongshu when discussing feminist topics are the emotions expressed positive negative or neutral 3 what are the attitudes and emotions of the audience towards these feminist topics are these related to the audiences personal background 4 will the audience change their behaviors or thoughts in real life as a result of engaging in discussions on feminist topics on xiaohongshu methodology based on the nature of the platform and sample categories to be studied in this article a combination of manual and software assistance will be used to collect and analyze samples data collection this paper collected the posts and their comments related to the feminist topics under barbie barbiemovie in xiaohongshu the data set for content analysis is from the bazhuayu website wenjuanxin is used to collect questionnaires from xiaohongshu or wechat users 133 posts and 9337 firstlevel comments in xiaohongshu are collected from 21 july 2023 to 4 august 2023 needed to be stated the data were manually cleaned to remove the invalid micro blogs with tags only deleted original texts and repeated postings in order to ensure the quality of the data a total of 226 questionnaires with 0917 cronbach alpha coefficient are distributed from 23 august 2023 to 30 august 2023 after remove invalid samples besides the researcher conduct semistructured interviews involved obtaining information from 5 xiaohongshu users whose posts are hot in order to gain insight into xiaohongshus users attitudes towards the development of feminism in barbie film data analysis data analysis involves three stages in the first phase text mining is performed to determine the semantic insights of the posts and comments and the feminismrelated topics are categorized to help us do further research in the second stage sentiment analyses are used to determine xiaohongshu usersopinions about feminismrelated discussion about barbie movie in the third step context analysis are used to determine the impact of feminist topics related to barbie movie on xiaohongshu on its users through the information obtained from semistructured interviews and questionnaires results and discussion data description figure 1 shows that 8578 per cent of the respondents to the questionnaire were female and 1422 per cent were male respondents the age distribution shows a decreasing distribution centred on the age stage of 1824 years old and the demographic characteristics basically conform to the overall characteristics of the core user group of xiaohongshu the overall overview and basic information of this sample questionnaire is given below the educational level of undergraduate education is the main group of people accounting for 7244 of the total followed by masters degree and doctoral degree accounted for 267 only text mining results feminist relevant topics in the barbie movie this study summarizes the keywords and content of feminismrelated xiaohongshus posts about the barbie movie eleven categories are classified gender consciousness and selfperception gender equality and affirmative action gender discrimination gender violence gender roles body perception and selfconfidence gender image gender economics female autonomy female bonds and friendship and the others gender awareness and selfawareness this classification mainly deals with womens awareness of gender differences in society culture and product design and how these differences have affected their lives and experiences the female situation the shackles compliance training for women in society and the gender value constraints calls for women to accept themselves to know and love themselves gender equality and affirmative action this category is mainly about protecting womens basic rights and interests encouraging female students to speak up share their experiences discuss and criticize and other related content and other related content in this study the participation of xiaohongshu in the discussion of political topics or public issues will also be categorized into this classification encouraging the construction of a nonpatriarchal nonmatriarchal and egalitarian society gender discrimination this classification is mainly focuses on several major topics such as employment discrimination unfair gender distribution of educational r e s o u r c e s a n d f e m a l e c h a s t i t y d i s c r i m i n a t i o n gender violence this classification is genderbased violence including but not limited to sexual assault sexual harassment domestic violence male coagulation female competition under the discipline of patriarchy etc in the content analysis of the xiaohongshu there are also emerging issues such as cyber harassment covered 3 above is a visual display of the words mentioned most frequently in users posts and comments figure 14 feminist word frequency chart of barbie movie in xiaohongshu users attach importance to feminismrelated words such as female patriarchy feminism perfect these keywords cover 10 categories of topics related to feminism in barbies movie by xiaohongshus users sentiment analysis the sentiment of posts and comments extracted by baidu nlp api for the feminismrelated discussion on xiaohongshu results are shown in figure 3 with the following observations it was found that the sentiment tendencies of xiaohongshu users towards feminismrelated discussion were skewed positive and neutral sentiments were less expressed besides most of the respondents of questionnaire was show their positive attitude some of them believe that xiaohongshu has a positive effect on the dissemination of feminist view and affirms that feminist discourses related to film on xiaohongshu will have some degree of influence on the discussion of feminism in society figure 15 emotional attributes of posts and emotional tendency of comments for barbie movie in xiaohongshu however the results of the questionnaire showed that excluding those who expressed positive attitudes the rest were neutral whereas for the content analysis of the posts and comments about onethird of them have a negative attitude towards feminismrelated discussion figure 15 questionnaire respondents emotional tendencies toward topics related to barbie movie feminism more than 90 per cent of xiaohongshu users who have seen barbies film and posted about it said that the emotional words they used to express their attitudes in the discussion were encourage and support and about a third of the users attitudes in their posts were humor angry and concern in order the following are typical positive evaluations this film can be used as a feminist primer or a feminist universal values propaganda filmthis film is not just for women its to tell the society that everyone is an individual you are not dependent on anyone and it has nothing to do with gender the value of life should be to try to be everything you want to be the point that particularly struck me after watching barbie was the fact that women have always given their all to create a world for women negative comments on the films feministrelated topics are not negligible the following are typical negative evaluations this film create a situation where men and women are pitted against each other theres also too little shown of the difficult parts of realworld womenthe shortlived patriarchal kingdom of ken in barbie world is a childish even infantilised male compared to realitythe film seems to have been deliberately dumbed down the role of social media for feminist communication in the analysis of questionnaire more than 91 believed that social media platforms such as xiaohongshu had a positive effect on the dissemination of feminist views 3 believed that it did not and 5 said they were not sure these respondents believe that feminist discourse on xiaohongshu has increased attention to feminist issues raised public awareness of feminism facilitated social discussions on gender equality and triggered reflections on sexism the social medias big data push mechanism divides the audience groups of feminist topics resulting in a stratified phenomenon of feminism conveyed by social media with both deep and shallow while barbie is marketed to the public users with different depths and shades of feminist interpretations watch a feministcolored movie at the same time and this context is one of the reasons for the mixed reviews of barbie on xiaohongshu in the interview five respondents add detailed views womens rights have been emphasized nowadays but it does not mean that some women can use womens rights as womens fists to play on the theme women do have the right to be treated the same as men but at the same time they should not discriminate against all men and call for people not to fall in love and not to get married there are many different kinds of men and women so we need to be more discerning and there are not a few of them who want to just have a bite of the hot meal but very few people talk about how to talk about feminism heterosexuality how to enter into marriage how to procreate gender antagonism counts a little bit yet when i worked on the korean feminist theme i read some interesting quotes men feel vulnerable in the process of being disempowered and patriarchy doesnt seem to be as good as it once promised there is some influence but the audience is limited and the social media has a lot to say about it medias big data push mechanism divides the audience groups of feminist topics resulting in a layered phenomenon of feminism conveyed by social media with deep and shallow while barbie is marketed to the public users with different depths and shades of feminist interpretations watch a feministcolored movie at the same time and this context is one of the reasons for the mixed reviews of barbie on xiaohongshu the majority of the respondents believed that the feminismrelated discussions had an impact on their opinions or behaviors they believe that these discussions have to varying degrees made them more aware of gender equality inspired a desire for selffulfillment increased awareness of gender stereotypes triggered thinking about the image of women in the media and deepened their support for womens rights and interests in order in the interview two respondents explained their changes in other aspects it has made me realize that as a women we have a lot of autonomy and that they can give value to themselves instead of being restricted and limited by patriarchy it has made me understand that women are a situation that being female is a situation at the behavioral level more than 65 believe that the movie has inspired their own social engagement and 4050 believe that it has influenced their philosophy of family education inspired artistic creation and changed their consume attitudes personal context shapes perspectives the study found that users in older age groups appeared to be more conservative about the role of xiaohongshu on the development of feminism in society as opposed to younger people users aged 1825 are relatively optimistic that feminist topics on xiaohongshu have a positive effect on the development of feminism in society with more than 90 of respondents on the contrary more than a quarter of respondents over 35 years old thought that the impact was average as well as small this is also reflected in the fact that nearly 30 of them answered no to the question do these feminist discussions have an impact on opinions or behaviors surprisingly the authors predicted that respondents in developed region would be more knowledgeable about feminism compared to tier 34 or 5 respondents however it turned out that there was no significant difference in the level of knowledge about feminism between these two segments of respondents conclusion social media enables individuals to recognize the importance of feminism the research in this paper focuses on this particular topic emphasizing how users on these platforms share their experiences and respond to the experiences shared by other users this research suggests that the xiaohongshu platform enables individuals to share their personal stories in depth with a tendency to court other users to discover the power of women and increase gender equality awareness disregarding the negativity towards different aspects of these personal experiences the individuals on these platforms are very hopeful that these stories will lead to real change in current society i hope that my work helps to start a discussion between individuals in society as well as researchers and legislators to come up with new laws and regulations to protect females right in society

social media platforms are revolutionizing the way users communicate by increasing the exposure to highly stigmatized issues in the society feminism is one such topic that recently took over social media this paper studies the attributes of xiaohongshu user toward the feminism related topics by content analysis of the online posts via barbie on xiaohongshu a sharing platform the findings show that majority of xiaohongshu user have positive attitudes to feminismrelated topics in barbie movie by analyzing the posts and comments are shared on this platform besides xiaohongshu commentators are mainly focused on eleven topics related to feminism gender consciousness and selfperception gender equality and affirmative action gender discrimination gender violence gender roles body perception and selfconfidence gender image gender economics female autonomy female bonds and friendship and others this research indicated that social media platforms have proven to be fertile ground for movements such as feminism facilitating the dissemination of perspectives and the fostering of dialogue

introduction in the near future in order to be effectively integrated into human environments robots should be able to interact using an adequate level of cognition such cognition should be flexible enough to allow the robots to understand human actions store knowledge efficiently and react accordingly taking into account changes in context among artificial intelligence techniques and machine learning methods a wide variety of techniques are effective under determined conditions for example neural networks can approximate nonlinear functions whereas reinforcement learning can effectively solve game playing and pathfinding problems unsupervised learning on the contrary has the advantage of not needing labelled data for a training set however depending on the specific problem most of these techniques may be inefficient in general the no free lunch theorem applies to machine learning 1 as for each specific problem the most fitting technique is going to be different robots should learn from experience and from interactions with other agents they encounter in their environment in a similar way as animals including humans from the point of view of learning algorithms this setting imposes certain constraints which often do not hold for mainstream machine learning applications such constraints include finite storage and memory and the need to learn incrementally by modifying behavior after each or every few experiences with such conditions online learning is the natural approach for robots 2 objectives of this paper the problem we are addressing involves learning through data extracted from heterogeneous sources such as studies from literature of human sciences in this regard we believe that the quantitative approach has an advantage over purely qualitative descriptions such as symbolic learning techniques because the application of a probabilistic model instead of a deterministic one allows the efficient use of all the information available we therefore refer to statistical learning rather than machine learning a probabilistic approach has been recently attempted in a study by myagmarjav and sridharan 15 where knowledge in humanrobot interaction is acquired through selective active learning using probabilities and queries lepora et al also used the naive bayes classifier in real world tasks on a moving robot with whiskers 1617 our method is close to these works our objectives are the following ‚ formalize empirical social behaviors into a dataset ‚ apply a learning technique to the dataset of correlations of features and actions ‚ make the robot actually learn socially appropriate actions through online adaptation compared to existing research limited in the use of empirical results of social science the main contribution of this paper is to show how through an algorithm based on the naive bayes classifier heterogeneous and incomplete knowledge from social robotics can be used for statistical learning experiments are shown as examples of application to serve as a model in future similar studies in the same field two applications are described the implementation of a greeting selection system for a humanoid robot and the implementation of a behaviour selection system for attracting humans attention in both cases the robot should be able to adapt its action selection to the evolving context learning respectively an appropriate choice of gesture and an appropriate choice of attentionattracting behavior merging empirical datasets that list correlations of features and actions with quantitative experimental data and their subsequent learning behavior is a task that poses several challenges which can be addressed by our method the rest of the paper is organized as follows in section 2 we describe the concept of the algorithm in section 3 we show two possible applications section 4 concludes the paper methods generic model we want to implement a system that enables effective online learning for a robot by using data extracted from literature of human sciences as well as experimental data in figure 1 the concept is described a table is made out of training data features values are given as input and the classifier outputs a chosen class that corresponds to an action to be implemented in the robot the action is performed and evaluated through either questionnaires or experimental measurements the resultant feedback updates the dataset robotics 2016 5 6 3 of 21 classifier in real world tasks on a moving robot with whiskers 1617 our method is close to these works our objectives are the following  formalize empirical social behaviors into a dataset  apply a learning technique to the dataset of correlations of features and actions  make the robot actually learn socially appropriate actions through online adaptation compared to existing research limited in the use of empirical results of social science the main contribution of this paper is to show how through an algorithm based on the naive bayes classifier heterogeneous and incomplete knowledge from social robotics can be used for statistical learning experiments are shown as examples of application to serve as a model in future similar studies in the same field two applications are described the implementation of a greeting selection system for a humanoid robot and the implementation of a behaviour selection system for attracting humans attention in both cases the robot should be able to adapt its action selection to the evolving context learning respectively an appropriate choice of gesture and an appropriate choice of attentionattracting behavior merging empirical datasets that list correlations of features and actions with quantitative experimental data and their subsequent learning behavior is a task that poses several challenges which can be addressed by our method the rest of the paper is organized as follows in section 2 we describe the concept of the algorithm in section 3 we show two possible applications section 4 concludes the paper methods generic model we want to implement a system that enables effective online learning for a robot by using data extracted from literature of human sciences as well as experimental data in figure 1 the concept is described a table is made out of training data features values are given as input and the classifier outputs a chosen class that corresponds to an action to be implemented in the robot the action is performed and evaluated through either questionnaires or experimental measurements the resultant feedback updates the dataset classification of training data characteristics of data in humanrobot interaction and in social robotics it is common to work with quantitative as well as qualitative data extracted from literature of studies of human sciences such as sociology anatomy anthropology and so on from these data we can extract features and classes however there are usually some properties that limit the possible choice of classifying methods classification of training data characteristics of data in humanrobot interaction and in social robotics it is common to work with quantitative as well as qualitative data extracted from literature of studies of human sciences such as sociology anatomy anthropology and so on from these data we can extract features and classes however there are usually some properties that limit the possible choice of classifying methods ‚ heterogeneous data types some features are binary values some other are continuous but can be discretized some others are categorical and not ordinal classes also can be represented in percentages or as absolute values and features may be associated with more than one class to different degrees baynesian networks have been used to synthesize the findings from these separate studies of sociology biology and economics 20 and can be used for representing and predicting social behaviors 21 however they assume parentchild relations between variables while in our problem we are assuming independence between classcondition feature probabilities ‚ incompleteness studies are usually focused on a single or a couple of specific variables whereas our model involves more variables for example a study with gender as a variable may fix some variables while not specifying others which might be of interest missing data can make it difficult to use techniques for classification such as neural networks or to even just represent it in a space with principal component analysis see 22 for a review of the problem from a statistical perspective ‚ set size small datasets limit the choice of training methods data from different sources can be integrated in order to expand the training dataset but this will also cause the incompleteness problem stated above in particular when integrating human studies data with experimental data we receive the data incrementally online learning methods fit this kind of problem small experimental datasets have been used in modelling of complex processes successfully in 23 but the composition of the training datasets becomes critical with designed sets performing better than random ones other learning models were compared for problems with small datasets in 24 where mixed results were found dependent on feature selection and naive bayes and its multinomial variation 25 were reported to outperform the others including support vector machines in many conditions given these properties we believe that the naive bayes classifier is a good choice for dealing with this kind of data naive bayes can easily handle weighted data incomplete data small datasets and categorical variables naive bayes first let us define the sets of features of our problem f f 1 f i and the sets of classes c c 1 c j given i number of features and j number of classes the dataset is composed of k elements f c resulting in equation represents the generic formula of posterior probability for the class c j and the feature f i p cj ˇˇf ˘9p cj ˘ź i p fi ˇˇc j ˘ naive bayes is a simple generative probabilistic classification model which assumes independence between features of the objects to be classified 26 therefore the naive bayes classifier applies bayess theorem with the assumption that the presence or absence of each feature is unrelated to other features its effectiveness in classification has been proven despite its independence assumption 27 moreover naive bayes only requires a small amount of training data to estimate the parameters necessary for classification these characteristics make it appropriate for the features of many problems in social robotics under naive bayes we label object c according to equation c˚ arg max c j p cj ˘ź i p fi ˇˇc j ˘ where p is the prior probability of class c j and p is the likelihood of class c j with respect to feature f i in general these probabilities are estimated from the featureclass cooccurrence count table eg using the maximum likelihood estimates as in equation p fi ˇˇc j ˘ count fi c j count cj ˘ the prior probabilities can be similarly derived from a count table thus these count tables form the sufficient statistics for the naive bayes model count tables can be easily updated online by simply incrementing classfeature counters as each labelled example is processed and the updated model can be immediately used for classifying new objects in fact the naive bayess sufficient statistics form an additive monoid and admit both efficient online training and efficient parallel learning 28 conversion of heterogeneous data into a dataset when handling real data from different sources we should distinguish the types of studies we are using in order to clearly define a semantics of weights w j that can be associated with classes c j and build a count table which will serve as a batch for training data can appear in different types such as a percentage in which all the classes of our problem are considered a percentage in which one or more classes of our problem are not considered a percentage in which one of the classes may include the classes of our problem which are not specifically mentioned absolute values of measurement without a known scale absolute values of measurement between a priori maximum and minimum values likert scales and differential semantic scales fall into this category case is the simplest as percentages are directly turned into weights between 0 and 1 for example in a study in which 55 of the population belongs to class c a its w a will be 055 for case let us now consider the following simple sample data ‚ study 1 when feature 2 is 0 55 of the population belongs to class c a and the rest to class c b whereas when feature 2 is 1 the results change to 39 and 61 ‚ study 2 under different conditions and feature 3 fixed to 0 50 of the population belongs to class c b and the rest to classes c a and c c in table 1 we organized these data marking the field as unknown where variables are not considered in the study when some conditions significantly change between two studies the index of the considered study itself should be considered a feature normalization is then necessary because data refer to different scales in which different classes were involved in this case class c c is not present in the first study therefore assuming a uniform prior estimation for the class c c as 1j where j is the number of classes the weights for c a and c b can be normalized to sum 1 in the above case where w a 039 and w b 061 they will be reduced to 23 becoming w a 026 and w b 041 the way of assuming a prior estimation for the missing class depends on the interpretation of the data and cases and differ from in figure 2 we show an excerpt from three different empirical studies 29 30 31 on asymmetry in facial expressions which provide different data respectively focusing on culture emotion and its background meaning asymmetry gender and emotions and emotional valence gender and asymmetry typically a possible purpose of gathering these data could be making a robot capable of autonomously determining when an asymmetrical facial expression is appropriate the way of assuming a prior estimation for the missing class depends on the interpretation of the data and cases and differ from in figure 2 we show an excerpt from three different empirical studies 29 30 31 on asymmetry in facial expressions which provide different data respectively focusing on culture emotion and its background meaning asymmetry gender and emotions and emotional valence gender and asymmetry typically a possible purpose of gathering these data could be making a robot capable of autonomously determining when an asymmetrical facial expression is appropriate in case it may be desirable to split the remaining part to all the classes not specifically mentioned for example if the data reports 583 class ca 167 class cb 111 class cc and the remaining 139 other supposing that our problem has five classes the latter part can be approximated as the sum of the weights of classes cd and ce filling wd 00695 and we 00695 and adding this data to the dataset will force these weights to be low where a uniform estimation of 025 would be considered too high in case in which as in figure 2 the number of subjects are counted it is enough to apply the same method as assuming a uniform prior estimation for the missing classes as 1j figure 2e shows an example of values measured in pixels therefore having a maximum and minimum value data vary within that scale in this case it may be more reasonable to assign the average value of the scale to unknown classes a further example with simpler data can clarify better the reason of this approach in case in a problem with four classes with two of them unknown a data vector could be 1830 2430 which equals 06 08 fixing a uniform estimate of 025 for wc and wd and then normalizing only wa and wb the weights vector would result in 021 029 025 025 having wc and wd higher than wa may not be reasonable instead assuming data for cc and cd as 1530 adding the resulting wc 05 and wd 05 to the dataset and then normalizing it will force them to be higher the weights vector would be 025 033 021 021 how the relative weight of wa changes compared to unknown classes proves the importance of the semantics in all the above cases after calculating the unknown weights their addition to the dataset is not strictly necessary for the naive bayes classifier to work but it does become necessary depending on the policy described in section 261 in case it may be desirable to split the remaining part to all the classes not specifically mentioned for example if the data reports 583 class c a 167 class c b 111 class c c and the remaining 139 other supposing that our problem has five classes the latter part can be approximated as the sum of the weights of classes c d and c e filling w d 00695 and w e 00695 and adding this data to the dataset will force these weights to be low where a uniform estimation of 025 would be considered too high in case in which as in figure 2 the number of subjects are counted it is enough to apply the same method as assuming a uniform prior estimation for the missing classes as 1j figure 2e shows an example of values measured in pixels therefore having a maximum and minimum value data vary within that scale in this case it may be more reasonable to assign the average value of the scale to unknown classes a further example with simpler data can clarify better the reason of this approach in case in a problem with four classes with two of them unknown a data vector could be 1830 2430 which equals 06 08 fixing a uniform estimate of 025 for w c and w d and then normalizing only w a and w b the weights vector would result in 021 029 025 025 having w c and w d higher than w a may not be reasonable instead assuming data for c c and c d as 1530 adding the resulting w c 05 and w d 05 to the dataset and then normalizing it will force them to be higher the weights vector would be 025 033 021 021 how the relative weight of w a changes compared to unknown classes proves the importance of the semantics in all the above cases after calculating the unknown weights their addition to the dataset is not strictly necessary for the naive bayes classifier to work but it does become necessary depending on the policy described in section 261 customisation of naive bayes formulas in our naive bayes classifier the selection of the class c is done through a formula different from the standard one conditional probability first the standard formula of conditional probability is rewritten in equation taking into account the fact that class membership is based on weights w the probability of f i the ith feature of f being equal to a value v is found through the sum for each kth sample f c in the dataset of the weights that are defined when f i v through a multiplier δ the formula of class priors p is rewritten in the same way in equation p fi v ˇˇc j ˘ k ř k1 ´δpkq pvq ¨wpkq j k ř k1 w pkq j p cj ˘ k ř k1 w pkq j k the best class c is selected through equation c˚ arg max c j p cj ˘i ź i1 p fi v ˇˇc j ˘ in our customized formula we leave class priors p out this additional assumption is made because we do not want to give more weight to more common class a priori so only independent probability distributions are considered c˚ arg max c j i ź i1 p fi v ˇˇc j ˘ leaving out the class priors is equivalent to assuming a uniform probability distribution over the classes class distributions estimated from very small samples are inherently noisy and we believe using a flat prior here is a legitimate choice an example can clarify the need for this modification the typical case is when having a very small dataset like the one in table 2 in which one class appeared more times than the others using the classification formula of equation the mapping of the maximum likelihoods for each possible combination of features would result as in table 3 on the left the bias towards class 2 comes from the priors p which would be 02501 03749 02502 02500 without such bias the mapping will appear as in table 3 on the right extending the concept to a bigger mapping it is easy to predict that priors can unbalance it and penalize less common classes which may never be selected with lass priors f2 0 f3 0 f2 0 f3 1 f2 1 f3 0 f2 1 f3 1 f1 0 c 2 c 3 c 2 c 2 f1 1 c 2 c 2 c 2 c 2 without class priors f2 0 f3 0 f2 0 f3 1 f2 1 f3 0 f2 1 f3 1 f1 0 c 3 c 3 c 2 c 3 f1 1 c 2 c 3 c 2 c 2 242 smoothing technique conditional probabilities p are balanced out through an add smoothing technique namely the use of mestimate 32 which avoids the inconveniences that may happen when the number of total occurrences of a feature under certain conditions equals 0 in generic terms for estimating conditional probabilities in a table of data instead of using the standard formula in equation the formula in equation is used the probability of a given b does not depend only on the joint probability of a and b divided by the probability of b but is balanced out by p and m we need p as a nonzero prior estimate for p which we suppose uniformly distributed and a number m that says how confident we are of this prior estimate p the value m is defined as the equivalent sample size of mestimate formula it can be tuned on a development set usually a small number is convenient for small sets of data in order to balance out probability from training data compared to the weight of p the value p is the uniform prior estimation of the probability it is usually set as 1j where j is the number of classes       b p b a p b a p         m b p p m b a p b a p      as a result the generic formula of the classifier is shown in equation     m w p m w v c v f p k k k j k k k j k j i           1 incomplete data as we may have to deal incomplete data the multiplier  a function introduced for the calculation of the joint probability of a certain feature with a certain class can be customized as well as in equation depending on the quantity of incomplete training data  can be defined arbitrarily it can be 05 or even less in case incomplete data is considered not reliable         otherwise 0 undefined 5 0 1 adaptation through rewards in our model the representation of knowledge has to be adaptive to feedback collected from 242 smoothing technique conditional probabilities p are balanced out through an addε smoothing technique namely the use of mestimate 32 which avoids the inconveniences that may happen when the number of total occurrences of a feature under certain conditions equals 0 in generic terms for estimating conditional probabilities in a table of data instead of using the standard formula in equation the formula in equation is used the probability of a given b does not depend only on the joint probability of a and b divided by the probability of b but is balanced out by p and m we need p as a nonzero prior estimate for p which we suppose uniformly distributed and a number m that says how confident we are of this prior estimate p the value m is defined as the equivalent sample size of mestimate formula it can be tuned on a development set usually a small number is convenient for small sets of data in order to balance out probability from training data compared to the weight of p the value p is the uniform prior estimation of the probability it is usually set as 1j where j is the number of classes p pabq p pa x bq p pbq p pabq p pa x bq m ¨p p pbq m as a result the generic formula of the classifier is shown in equation p fi v ˇˇc j ˘ k ř k1 ´δpkq pvq ¨wpkq j ¯ m ¨p k ř k1 w pkq j m incomplete data as we may have to deal incomplete data the multiplier δ a function introduced for the calculation of the joint probability of a certain feature with a certain class can be customized as well as in equation depending on the quantity of incomplete training data δ can be defined arbitrarily it can be 05 or even less in case incomplete data is considered not reliable δ pkq pvq 1 f pkq i v 05 f pkq i undefined 0 otherwise robotics 2016 5 6 9 of 21 adaptation through rewards in our model the representation of knowledge has to be adaptive to feedback collected from experimental data therefore the model includes rewards or penalties depending on the feedback ideally the algorithm has to adapt quickly as in humanrobot interaction where we are dealing with real world problems rather than abstract ones the desired amount of iterations necessary for a complete adaptation from the initial mapping to another one should be comparable to the number of interactions humans need to understand behavior rules the process should not require hundreds or thousands of steps each time a class is selected and an action is executed by the robot probabilities of the current data sample at step t are considered weights and updated to the new weights at step t 1 through the formula in equation wpt 1q wptq l ¨r ¨d the learning rate l the reward factor r and the value d depend on the specific implementation for instance if the feedback data is obtained from 5point likert scales r could be a value among ´1 ´05 0 05 1 depending on the questionnaire results whereas d could be 1´w or w depending on the questionnaire feedback being 3 or 3 otherwise if feedback is obtained from experimental data such as measurement of participants response of some kind the formula for r could be tailored to be proportional to performance such as the success of an action the number of hits or inversely proportional to negative performance such as delay of response through the combination of these factors a costreward function can be tailored for the experiment the learning rate l can be kept at 1 for assigning equal importance to each step the adapting process can be forcefully led to convergence if l is a decreasing function instead when real world scenario constraints make it necessary rewards are commonly used in reinforcement learning too where transitions from states to other states happen through a range of actions rewards affect good states or actions when the goal is reached in our case rewards modify the weight actions associated to states but there is no transition between one state and another one whole iteration consists in just one state defined by current feature values other policies class selection whenever a new vector of input features f has to be classified the following cases may happen ‚ the set of features f is not present in the dataset in this case naive bayes is calculated ‚ the set of features f is already present in the dataset and the vector is associated with some weights in this case classification can be done either by o using the current weights generically speaking in order for this option to be possible data has to be consistent within all classes for f with missing data previously filled as explained in section 23 o ignoring the current weights and recalculating the probabilities through naive bayes regardless of the vector of the current input features f corresponding to a vector of new probabilities or to a vector of previous weights in either case there are several possible policies for the selection of the output class c ‚ the simplest solution is to get the maximum value as in the standard equation and equation ‚ another possibility which gives more emphasis to exploration is to use a εgreedy policy with 0 ε 1 c is the argmax with ε probability and will be a random selection with 1´ε probability ‚ c can be assigned any of the possible classes with probability proportional to the list of weights for example in a weight vector 04 02 01 03 the first class would be selected with 04 probability stopping conditions the adaptation process can potentially be continuous or can be stopped depending on criteria that are up to the experimenter when stopping conditions are satisfied rewards will no longer apply and the system will be considered fully trained one possible method is to verify the maximum likelihoods for each possible combination of features making a mapping of such values like in table 3 we form a table in which each cell represents a state and is associated with an action represented by the class with maximum likelihood c then stopping conditions can be triggered when changes of c are stabilized this condition is verified when the following two conditions and are true at the same time one condition ensures that all states have been explored once c in which f corresponds to that features vector the other condition checks whether the moving average of c changes during the latest w iterations to decrease below a threshold f dk f pkq f t ř tt´w 1 σ c σ tot w ď θ in equation σ c is the number of states in which c changed σ tot is the total number of states the threshold θ can be set as q σ tot results and discussion in this section we will describe two applications of the algorithm we will not enter into detail of the research behind those experiments but rather show the effectiveness of our method in both applications some details of the algorithm have been customized discussion follows in the last part application 1 greeting interaction purpose of the study as humans we greet each other following sometimes complex or unclear rules which vary by country or even by region nevertheless when exposed to a new culture we are able to adapt to a new set of rules after only a few interactions the purpose of this study was to make a humanoid robot adapt to the german way of greeting while being initially trained with japanese social data about greeting rules culture differences are indeed important for ensuring technology acceptance 34 including more complex machines such as robots in a recent work heenan et al made a state machine model for greetings comprehensive of the approach phase 35 however it does not take cultural factors into consideration which is the focus of this experiment armariii 36 a humanoid robot designed for close cooperation with humans was used in this experiment which took place in the room shown in figure 3 greeting selection system the implementation of the greeting selection system is composed of two parts regarding gesture and speech in figure 4 and in the next paragraph we describe only the part related to gestures the system takes context data as input features and produces the appropriate robot posture for that input robot posture configuration is implemented through a process described in 18 the values of features and classes regarding greeting gestures is summarized in table 4 as the experiment consists of adapting from knowledge extracted from one culture to another culture acts as a discriminant rather than being an input feature in this way for different cultures there will be different mappings mappings are updated using experimental data in the form of questionnaires filled by experiment participants in order to be initialized the only needed training set is the japanese one before beginning the experiment a table made from japanese sociology data and a mapping called m0j was built after interacting with german people the resulting adapted mapping m1 is expected greeting selection system the implementation of the greeting selection system is composed of two parts regarding gesture and speech in figure 4 and in the next paragraph we describe only the part related to gestures greeting selection system the implementation of the greeting selection system is composed of two parts regarding gesture and speech in figure 4 and in the next paragraph we describe only the part related to gestures the system takes context data as input features and produces the appropriate robot posture for that input robot posture configuration is implemented through a process described in 18 the values of features and classes regarding greeting gestures is summarized in table 4 as the experiment consists of adapting from knowledge extracted from one culture to another culture acts as a discriminant rather than being an input feature in this way for different cultures there will be different mappings mappings are updated using experimental data in the form of questionnaires filled by experiment participants in order to be initialized the only needed training set is the japanese one before beginning the experiment a table made from japanese sociology data and a mapping called m0j was built after interacting with german people the resulting adapted mapping m1 is expected the system takes context data as input features and produces the appropriate robot posture for that input robot posture configuration is implemented through a process described in 18 the values of features and classes regarding greeting gestures is summarized in table 4 as the experiment consists of adapting from knowledge extracted from one culture to another culture acts as a discriminant rather than being an input feature in this way for different cultures there will be different mappings mappings are updated using experimental data in the form of questionnaires filled by experiment participants in order to be initialized the only needed training set is the japanese one before beginning the experiment a table made from japanese sociology data and a mapping called m0j was built after interacting with german people the resulting adapted mapping m1 is expected to represent german rules of greeting interaction a mapping m0g made from a table of german sociology data of gestures was built too and only used for validation our hypothesis is that m1 will be closer to m0g than to m0j 5 let us summarize the concept of the algorithm and the way rewards are calculated 1 the dataset is built from training data weights w j corresponds to each vector added 2 whenever a new feature vector f is given as input it is checked whether it is already contained in the dataset or not in the former case the weights are directly read from the dataset and the greeting corresponding to the highest weight is selected in the latter case classification is calculated through naive bayes 3 in the naive bayes classifier the best greeting g chooses the greeting g j that has the highest probability calculated from its weights w i using the addε smoothing technique and a multiplier δ as in equation 4 once the greeting is chosen the resulting probabilities are normalized the stopping condition is then calculated as in equations and if all conditions are satisfied no updating will be performed as the mapping has already been stabilized 5 otherwise the next step consists of getting the evaluation from the participant for the current selected greeting g whether appropriate or not according to the participants culture to the current context f on a scale from 1 to 5 if it is greater than 3 the weight of that greeting for the present context is multiplied by a positive reward if less than 3 is it multiplied by a negative reward if it is exactly 3 nothing is done all vectors f start with a counter s set to 0 and every time one vector is processed its counter increases and makes the learning factor decrease dampening the magnitude of the rewards 6 if the evaluation is less than or equal to 3 the participant is also asked to indicate which greeting type instead would have been appropriate in this context f the weight of that greeting g is boosted 7 the participant is finally asked to indicate for the chosen greeting type g which context f would have sounded appropriate if there is any the weights corresponding to f are updated with a boost for the current greeting otherwise if g is judged inappropriate in any case all the weights receive a negative reward the vector f is added to the dataset if new or updated if already existing 8 all the new weights in the dataset are normalized at this point the algorithm is ready for a new input and goes back to step 1 the next time that the input feature vector is the same as the one just added the weights will be directly used weights receive a negative reward the vector f is added to the dataset if new or updated if already existing 8 all the new weights in the dataset are normalized at this point the algorithm is ready for a new input and goes back to step 1 the next time that the input feature vector is the same as the one just added the weights will be directly used as explained in steps 4 5 and 6 the questionnaire is made up of three questions this means that at the same time the rewards may affect directly three weights in two cells of the mapping making the learning process much faster f i ith feature of f j 5 number of possible greeting choices f kth feature vector in the dataset j 1 … j index of greetings f feature vector selected by the classifier g j jth greeting in g f feature vector suggested by the participant to match g g greeting at the kth element in the dataset v value that can be taken by a feature f i g greeting chosen by the classifier w j learning factor high at the beginning and decreases following the e x curve s stopping conditions as in equations and with w 10 and q 2 tot  1 02 0 multiplier for incomplete data as in equation set empirically low in case of undefined f i due to the high quantity of incomplete training data experiment results and validation in this experiment 18 german people of different ages gender workplace and knowledge of the robot were invited to participate some of them participated in a second interaction at the end all the feature values had the chance to be classified at least once except for location private as explained in steps 4 5 and 6 the questionnaire is made up of three questions this means that at the same time the rewards may affect directly three weights in two cells of the mapping making the learning process much faster s stopping conditions as in equations and with w 10 and q 2σ tot δ 1 02 0 multiplier for incomplete data as in equation set empiricallylow in case of undefined f i due to the high quantity of incomplete training data experiment design the robot nao is placed in a room which is adjusted to the actual manipulated conditions which are the features in table 8 while the participant is concentrated watching tv at random intervals one of the behaviors listed in table 6 will be triggered and nao will try to attract the persons attention until heshe pauses the tv settings of the algorithm the architecture of the algorithm is similar to the one in section 313 it can be summarized as follows 1 the dataset of experience is initially empty whenever a new feature vector is given as input it is checked whether it is already contained in the dataset or not in the former case the classification happens reading the weights directly from the dataset in the latter case they get assigned the values of probabilities calculated through our customized naive bayes of equation the three experiments mainly differ in ‚ features and classes the room conditions and possible behaviors listed in table 8 refer to the first session as all the features are binary the mapping is composed of 16 possible combinations the third experiment had a smaller number of features and four behaviors ‚ measurement in the first two experiments feedback is provided by a questionnaire that is filled out every time the tv is paused it is based on 5point semantic differential scales similar to the experiment in section 31 in the third experiment feedback comes from a costreward function calculated from other measurements such as reaction times head direction delay and a fixed cost of each of the robots behaviors these factors are grouped as reward for action r a which is positive or null cost for the robot c r and cost for the human c h ‚ class selection policy in the third experiment we used leaveoneout crossvalidation introduced in section 261 classification is never taken directly from the current weights but naive bayes probabilities are recalculated every time leaving the current features input out of the calculation settings of the algorithm the architecture of the algorithm is similar to the one in section 313 it can be summarized as follows 1 the dataset of experience is initially empty whenever a new feature vector is given as input it is checked whether it is already contained in the dataset or not in the former case the classification happens reading the weights directly from the dataset in the latter case they get assigned the values of probabilities calculated through our customized naive bayes of equation 2 once the behavior b is chosen and executed we get the evaluation on 5point semantic differential scales from the participant a whether b was effective or not b if the evaluation was lesser or equal than 3 at point a which behavior type b instead would have been appropriate in this context f c if the evaluation was lesser or equal than 3 at point a in which context f the behavior b would have been effective 3 weights are updated through the formula of equation w w l ¨r ¨d where t is the current time step l exp is the learning factor r is the reward factor ´1 ´05 0 05 1 depending on the rating and d is 1´w or w depending on the rating being greaterlesserequal to 3 4 new data obtained from these evaluations are then added to the dataset and normalized as in the previous experiment this way of managing the questionnaire allows data from experience to affect the mapping in up to two different cells at the same time next we report the main differences ‚ unlike in section 31 in which the adaptation process was incremental for all participants here we ran a separate whole set of interactions for each participant this makes it possible to distinguish actual learning regardless of personal differences among participants as for each one we fixed 12 iterations there were no stopping conditions ‚ there is no batch data for training the mapping starts untrained and this brings some complications initializing the first input vector with random values makes learning biased towards the classes that are more likely at the very beginning subsequent positive reward may cause a lack of exploration this problem can be solved using a different policy of class selection as explained in section 261 such as εgreedy andor removing the bias of the class priors as introduced in section 241 a stronger effect can even be obtained if the priors are replaced by another function that actuates a counterbias results each of the 23 participants performed 12 repetitions of the interaction we expected the algorithm to update the mapping and effectively represent participants preferences another 25 participants were used as the control group receiving six randomly chosen actions instead of those generated from the algorithm first we show in table 9 an example of how mapping can evolve in one iteration in the situation of the mapping on the left values have been assigned based on one random input vector the state gets evaluated the subject assigns a low score for the behavior 2 suggesting 1 with maximum score and suggests the state as appropriate for waving the resulting mapping on the right shows how other states were affected by the high rating of behavior 1 and 2 for respectively the second and fourth and for the first and third row how due to customization of priors in the equation less likely behaviors may appear again in order to assess the effectiveness of learning the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared a correlation test was conducted and we found a positive correlation proving that the preferences of the participants were learned figures 7 and8 show the variation of average ratings and respective probability distributions for every action this essentially means that the robot has learned to adapt its attentionattracting behavior selection to the evolving context discussion about this approach the term machine learning was not used in this paper to refer to our solution which is more appropriately referred to as statistical learning we believe the advantages of our approach are its feasibleness and its potential to be used by other researchers tuning it according to their needs especially if the datasets are made of heterogeneous or incomplete knowledge and if the goal is to adapt through experimental data other in order to assess the effectiveness of learning the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared a correlation test was conducted and we found a positive correlation proving that the preferences of the participants were learned figures 7 and8 show the variation of average ratings and respective probability distributions for every action this essentially means that the robot has learned to adapt its attentionattracting behavior selection to the evolving context in order to assess the effectiveness of learning the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared a correlation test was conducted and we found a positive correlation proving that the preferences of the participants were learned figures 7 and8 show the variation of average ratings and respective probability distributions for every action this essentially means that the robot has learned to adapt its attentionattracting behavior selection to the evolving context discussion about this approach the term machine learning was not used in this paper to refer to our solution which is more appropriately referred to as statistical learning we believe the advantages of our approach are its feasibleness and its potential to be used by other researchers tuning it according to their needs especially if the datasets are made of heterogeneous or incomplete knowledge and if the goal is to adapt through experimental data other in order to assess the effectiveness of learning the final probability matrix distribution and the average rating distribution of every behavior in the questionnaires were compared a correlation test was conducted and we found a positive correlation proving that the preferences of the participants were learned figures 7 and8 show the variation of average ratings and respective probability distributions for every action this essentially means that the robot has learned to adapt its attentionattracting behavior selection to the evolving context discussion about this approach the term machine learning was not used in this paper to refer to our solution which is more appropriately referred to as statistical learning we believe the advantages of our approach are its feasibleness and its potential to be used by other researchers tuning it according to their needs especially if the datasets are made of heterogeneous or incomplete knowledge and if the goal is to adapt through experimental data other discussion about this approach the term machine learning was not used in this paper to refer to our solution which is more appropriately referred to as statistical learning we believe the advantages of our approach are its feasibleness and its potential to be used by other researchers tuning it according to their needs especially if the datasets are made of heterogeneous or incomplete knowledge and if the goal is to adapt through experimental data other more refined machine learning solutions are more appropriate for other kinds of studies in which the focus is not on interaction and the learning problem is more complex this solution has also the advantage of being independent from the implementation and of not being robotspecific its limitation is the consequence of such an advantage if the algorithm is implemented separately its integration with the robots environment is also necessary every time customization the method we proposed can be customized and extended in the applications described the following variations were attempted ‚ class priors left out of the probability formula alternative solutions are possible such as a function that biases towards low probability classes using the inverse of the priors or towards the classes that have been selected fewer times conclusions an adequate level of cognition is necessary to employ a robot in a human environment there is a need of representing knowledge which can be incomplete and heterogeneous in an effective and efficient way adaptation to changing environments can be carried out through different learning techniques which can be more or less effective depending on the specific problem this work introduces a quick and effective way of handling this kind of problem adaptation based on statistical learning specifically on naive bayes the method we proposed was applied to two different experiments of humanrobot interaction in the first the humanoid robot armariiib adapted its greeting behavior from the japanese to german style using japanese sociology data as training in the second the robot nao learned different ways of attracting human users attention depending on different contexts in both cases the adaptation process was successful the proposed method can be customized and readapted to be used on other robots future works include comparison with other machine learning techniques experiment results and validation in this experiment 18 german people of different ages gender workplace and knowledge of the robot were invited to participate some of them participated in a second interaction at the end all the feature values had the chance to be classified at least once except for location private the number of interactions including repetitions was 30 it was determined by the stopping condition of the algorithm each time a state determined by a combination of feature values had its weights modified during the feedback after each interaction it is counted as visited the count of how many times states have been visited is shown in table 5 the new mapping of gestures was verified through an objective function v described in the generic equation which measures the difference between two different mappings m1 and m2 v the function calculates the sum of the variance between the weights w in the same features vector f in two different mappings m1 and m2 each variance in the weights is calculated not only by comparing the greeting with maximum likelihood but also considering the sum of the variances for each greeting j the function applied to m0j and m1 gives 0636 as the result conversely comparing m1 with m0g 0324 is obtained the ttest of the variances for each f proves the difference to be significant validating the hypothesis that m1 would become closer to m0g than to m0j this result supports the evolution of mapping m1 from m0j towards m0g assuming that m0g represents german rules correctly the robot learned a gesture for each social context that is close to the german and more appropriate than the japanese one how weights evolve is shown in tables 6 and7 where on the left the tables are at the starting condition on the right variances decrease in table 6 and increase in table 7 application 2 attracting attention purpose of the study socially assistive robots 37 are a category of robots that can actively assist humans thanks to their ability of navigation and their multimodal communication capabilities however in order to communicate with a human partner the robot needs to attract humans attention different modalities of communication have been evaluated 38 and compared with multimodal communication cues 39 the purpose of the present experiment is to explore strategies for successfully initiating communication with humans in a changing environment making a robot learn which communication channel is more effective for each condition of the room where the interaction occurs the social robot nao 40 was used for this application which was divided in three separate experiments with different conditions among them we will examine in detail only the first one author contributions all authors contributed significantly to the described work

as societies move towards integration of robots it is important to study how robots can use their cognition in order to choose effectively their actions in a human environment and possibly adapt to new contexts when modelling these contextual data it is common in social robotics to work with data extracted from human sciences such as sociology anatomy or anthropology these heterogeneous data need to be efficiently used in order to make the robot adapt quickly its actions in this paper we describe a methodology for the use of heterogeneous and incomplete knowledge through an algorithm based on naive bayes classifier the model was successfully applied to two different experiments of humanrobot interaction

‫والدراسات‬ ‫للبحوث‬ ‫ميالف‬ ‫جملة‬ ‫ق‬ ‫عطية‬ ‫اجمللد‬ 6 ‫العدد‬ 2 47 cultural and economic reflection on the manifestations of traditional social lifestyles of individuals and groups and their quest to rebuild value models in their new social relationships as a temporary response to the mechanisms of urbanization and integration this dynamic process that actors in the urban space of the oasis it opens the door to many questions that we must quickly answer based on the approaches of urban anthropology and symbolic interactive which has established a deeper dimension in our analysis of the discourse of actors and researchers with different ethnic affiliations and multiethnic ideological backgrounds due to the complex strategies of the modern urban fabric practiced by social groups in their possession of desert spaces in many different central intersections of both local and urban bedouins through their cultural and field discourses keywords

the totality of the transformations taking place in the city of ouargla through its implicit manifestations and cultural ramifications has a clear impact on the structure of extended families as an inevitable product of urban behavior and its

introduction the ravages of covid19 are reflected in the increasing number of daily deaths and infections and in the distortion of residents mental health which has become a global public health issue that needs to be intervened in the postcovid19 era previous studies have confirmed the negative influence of covid19 on residents mental health for instance chen et al surveyed 18171 people from 35 countriessocieties and found that about 266 of the residents had moderate to extreme depressive symptoms 282 of the residents had moderate to severe anxiety symptoms and 183 of the residents had moderate to extreme stress symptoms due to the spread of covid19 later a followup study of 1161 americans found that the prevalence of severe depressive symptoms increased from 278 in march 2020 to 328 in april 2021 and the increase was even more significant among lowincome groups moreover from the end of january to the middle of april 2020 the detection rates of anxiety and depression in chinese samples were 296 and 325 respectively both significantly higher than the levels of preepidemic epidemiological surveys similarly other studies see rufus et al ramos et al and dyer et al found that the covid19 epidemic has significantly increased the rate of mental health disorders especially among residents in areas with poor economic conditions besides other studies also analyzed the impact of covid19 on the mental health of special groups such as doctors students older people and lowincome groups it is also revealed that the mental health costs of covid19 are huge the large number of mental health cases has strained medical resources treatment costs and financial burdens in the era of covid19 additionally inefficient work or reduced productivity due to mental health problems created new groups of poor that inhibited the sustainable growth of gdp thus it is found that covid19 and its ramifications have caused stress anxiety and depression worldwide in the postpandemic era alleviating residents mental health is significant for coping with new global public health problems and boosting economic and social development moreover much of the literature explored why covid19 affects mental health firstly covid19 control policies such as wearing masks restricting travel keeping social distance and quarantine policies have changed the way residents live which may directly impact the mental health of residents through difficulties in breathing fresh air increase in lonely time and decrease of human interaction as well as fear of isolation policy secondly residents especially those with serious underlying diseases are worried and afraid that the covid19 epidemic is highly contagious and has ambiguous sequelae no vaccine can prevent 100 of people from getting infected thirdly job insecurity or economic uncertainty due to covid19 lockdown and quarantine policies increases residents stress and anxiety fourthly residents fear is aggravated by the shortage of medical resources and the concern of crossinfection in the hospitals finally public discrimination against people infected with covid19 in employment or social communication is also an essential reason for residents depression consequently government and social organizations have taken targeted intervention measures such as providing psychological services supporting the development of the internet economy promoting flexible employment of residents and timely disclosure of covid19 infection information in addition several studies have focused on exploring the phenomenon by taking samples of respondents such as doctors workers in quarantine hotels airports and customs inspectors who are more vulnerable to covid19 and are more likely to have serious mental health issues therefore although the influence mechanism of covid19 on residents mental health is more complex there is a clear causal relationship between them further will this causality break down as covid19 containment policies are lifted previous empirical studies have not given a clear answer so to answer more clearly the current research will contribute innovatively to the existing body of knowledge it is further believed that the covid19 pandemic has dampened the tourism industry and family tourism consumption due to travel restrictions quarantine policies for suspected infections and social distancing the crash in international tourism due to the coronavirus pandemic also caused a considerable loss of more than 4 trillion to the global gdp for 2020 and 2021 according to a unctad report published on 30 june likewise the study of martin et al using the dynamic cge modeling framework also revealed a sharp decline in number of tourists for the year 2020 the study showed that the value of tourism in tanzania decreased by more than 13 and total labor demand for tourism and related industries also declined by more than 33 percent in 2021 moreover covid19 has prompted residents to adopt a cautious travel attitude reduce public transportation use reduce travel time lessen international tourism and prefer outdoor or shortdistance travel accordingly the covid19 pandemic has significantly reduced the number of tourists and the output value of the tourism industry and related industrial chains moreover it also significantly decreased the ability to absorb employment and severely impacted the development of the tertiary industry and the job market in many countries especially those that rely on tourism income of course covid19 has also accelerated the adjustment of the tourism industry and the market competition pattern such as digital tourism innovation in tourism products and the improvement of tourism services these changes also provide a good opportunity to recover the tourism industry and consumption after the covid19 epidemic although the tourism industry is a sunrise industry driven by the spiritual pursuit of residents some scholars hold that longdistance travel requires a variety of individuals skills such as physical fitness concentration understanding decisionmaking and confidence and that mental health can affect the acquisition of these skills which can affect tourists sense of experience satisfaction and happiness however other studies have confirmed the unique role of residents travel consumption in relieving stress anxiety or depression tourism consumption can improve residents mental health by contacting the beautiful nature accepting the improvement of culture relaxing the body and forgetting their troubles similarly liu et al evaluated the mental health of 89 anxious and 72 depressed tourists and stated that tourism consumption significantly reduces the anxiety of tourists based on the literature analysis cheng et al found that tourism consumption can significantly reduce the sense of burnout and pressure of tourists and improve their sleep and mental health in addition sun et al also argued that tourism consumption has a significant inhibitory effect on family members negative emotions or mental illness besides some scholars hold a neutral attitude and argue that the causal relationship between tourism and mental health should be interpreted cautiously as reverse causality may lead to endogenous issues however existing studies have not yet considered the role of tourism consumption in the influence of the rcc on residents mental health in summary previous studies have not empirically tested the causal relationship between rrc and residents mental health moreover the mediating mechanism of family tourism consumption has not been studied previously to make up for the research gaps the studys main objects is to innovatively explore the effect of the rcc on residents mental health and the mediating effect of family tourism consumption furtherly the main contribution include the following first we employed the differencesindifferences method to explore the impact of the rcc on residents mental health using micropanel data from shaanxi province china second considering age and urbanrural differences this paper explored the heterogeneity of the effects of the rcc third the mediating effect model was used to test the role of family tourism consumption concerning the impact of the rcc on residents mental health finally the study provides valuable experience for other countries or governments to improve the mental health of residents in the postepidemic era literature review and hypotheses development 21 conservation of resources theory psychologists generally hold that individuals would continuously pursue happiness and success individuals are more likely to succeed if they can establish and maintain the personal characteristics and social status that can lead them to higher incomes and protect them from losses further hobfoll proposed the cor theory which mainly described the role of resources in the interaction between individuals and the social environment cor theory limits the concept of resources to material resources conditional resources personality traits and energy resources the core notion behind this theory is that individuals strive to acquire maintain and protect resources they deem valuable suppose these resources are at risk of loss because of a stressful event in that case individuals prefer to adopt appropriate strategies such as collective action social support and optimal allocation of resources to minimize the damage therefore the conservation of resources loss of resources and the actions taken result from the individuals stress response in recent years cor theory has been used to test stress response and individual coping strategies under the influence of crisis in the past 3 years the covid19 epidemic and control policies have become the biggest external shocks that individuals face which may directly reduce resource access opportunities valueadded and resource allocation efficiency and exacerbates the severity of an individuals mental health furthermore if covid19 control policies are relaxed residents mental health can improve besides the formation of an individuals mental health is not shortterm but the result of the longterm action of underlying risk factors individuals would inevitably adopt appropriate family strategies such as family travel consumption to adjust family resource allocation and alleviate longterm mental health problems therefore this paper incorporated the rcc residents mental health and family tourism consumption into the cor theoretical analysis framework rcc and residents mental health according to cor theory individuals experience emotional feedback when they perceive the threat of losing resources or experience the actual loss of resources welfare economics holds that the most essential resources in the market are the welfare resources owned by individuals and families previous studies have described welfare resources mainly from the perspective of family economy social security social network and psychological conditions if covid19 control policies are relaxed welfare resources can be protected and increase in value and mental health problems such as stress anxiety or depression caused by residents fear of resource loss will gradually be lessened the rcc is suitable for raising residents family income in the postepidemic era residents can obtain more job opportunities and wage income growth can become an essential guarantee for improving residents mental health meanwhile compared to the pandemic the market potential of household fixed assets preservation and appreciation was better the rcc can help to enhance the social security of the residents the stress anxiety and depression of residents are mainly due to concerns about social insecurity such as the epidemics infection rate and death rate as well as loneliness due to isolation control and social discrimination against infected people third the rcc could enhance the relationship network of residents removing social distancing and isolation policies can lessen the density and intensity of residents relationship networks many studies have further confirmed that the relationship network is crucial for improving mental health concerns the rcc has significantly enhanced the psychological conditions of residents good psychological conditions such as being respected and confident about the future are essential to improve residents mental health besides studies also found that the psychological resilience of older adults with underlying diseases is very weak and it is difficult for them to get rid of anxiety and depression quickly meanwhile compared with rural areas cities showed higher population density and frequent mobility with a higher risk of covid19 infection the epidemic affected residents economic status and mental health more accordingly the rcc affected urban residents more than those in rural areas therefore we propose the following hypothesis h1 the rcc could significantly improve the mental health of residents h1a compared to nonolder adults the rcc had a weak effect on improving mental health in the older adults h1b compared with rural residents the rcc had a stronger effect on improving the mental health of urban residents the mediating effect of family tourism consumption concerning the impact of the rcc on residents mental health cor theory holds that individuals are not passive in coping with resource loss and psychological stress but can adjust their strategies according to the resource situation family tourism consumption is an essential strategy to optimize the allocation of family resources by improving residents sense of experience freedom and happiness which can relieve residents stress anxiety and depression caused by covid19 specifically first the rcc enhanced the financial support for family tourism consumption by increasing employment opportunities unblocking employment channels and directly improving family income second the rcc abandoned control measures such as social distancing home restrictions and hotel isolation to ensure the time and space required for family travel which became an essential policy condition for developing the tourism industry after the epidemic finally the rcc has stimulated residents pursuit of a better and more enjoyable life in the past 3 years tourism is known as a pastime enjoyment and relaxation activity especially outdoor natural scenery tourism which could help to improve longterm residents depressed psychology and negative emotions besides to avoid the causal debate between tourism and mental health the tourism value theory holds that leisure is the primary function of residents tourism consumption to get rid of the hustle and bustle of the city busy work and tedious family affairs residents travel experience is to change their way of life and experience another kind of beauty in real life therefore we infer that the rcc affected residents mental health by stimulating family tourism consumption and proposes the following hypothesis h2 family tourism consumption had an intermediary effect concerning the rccs influence on residents tourism consumption materials and methods study sites sampling and participants the study included the panel data for the two periods april 1 to 7 2021 and april 1 to 7 2023 respectively through a largescale online survey of residents from shaanxi province china the main reasons for the selection of sample areas are as follows shaanxi province is in the west of china the income gap between urban and rural residents is large and the differentiation of urban and rural sample areas is obvious moreover the research group won the cooperation with china mobile shaanxi co ltd to carry out online questionnaire survey specially firstly the mobile shaanxi co ltd randomly informed residents of the purpose main content and rewards for phone calls through mobile phone messages secondly if the respondent agreed the interviewer contacted them by phone to complete the questionnaire finally the research group protected the transferees mobile phone number information and collected panel data the questionnaires main contents included the respondents characteristics the characteristics of their families their cognitive status their employment and income and mental health excluding 42 respondents who were unwilling to answer during the second survey the questionnaire survey obtained data from 735 residents among which 421 belonged to urban areas while 314 were from rural areas besides since the questionnaire adopted the principle of random sampling and the mobile phone coverage rate of urban and rural residents in shaanxi exceeded 90 sample selection bias was minimized variable selection 321 dependent variable in this study the dependent variable is the residents mental health previous literature has characterized the residents mental health mainly from stress anxiety and depression referring to relevant studies such as zhou et al and huang et al and the timesaving requirements of online questionnaire survey we selected some representative indicators such as quality of sleep feeling sad concentration at work to measure residents press cranky tachycardia and fidget to characterize residents anxiety hard to do anything with no hope for life and suicidal thoughts in head to depict residents depression the severity of the mental health issue of the residents was obtained by averaging nine indicators cronbach s alpha was 082 signifying these indicators has good reliability additionally sleep quality and concentration at work were positive indicators so we conducted a reversecoding calculation to maintain the same standard measurement as other indicators table 1 provides a descriptive statistical analysis of the mental health of the residents independent variable the independent variable is the relaxation of covid19 control policy categorized by the dummy variable in december 2022 china relaxed its prevention and control measures and lowered the epidemic from a to b meanwhile the novel coronavirus pneumonia was renamed novel coronavirus infection therefore we assigned a value 1 to samples collected before december 31 2022 and 0 to samples collected after that date control variables referring to the studies of xiong et al and albikawi the study also included control variables such as sex age education level risk preference awareness of covid19 the proportion of the older adults and children job satisfaction disposable income per capita time to pay attention to covid19 chronic diseases relationship network urban or rural areas additionally considering that other policy factors might directly influence the residents mental health the study added the influence of government mental health counseling on 2 it is found that there is a significant difference in residents mental health before and after the rcc overall the mental health level of residents increased by 0611 the differences in stress anxiety and depression between the different groups are0990 0482 and0362 respectively indicating that the mental health of the residents improved significantly after rcc in addition some other control variables also differed considerably between the sample groups compared with residents under covid19 control after the covid19 control was relaxed residents had a more precise awareness of covid19 and they could not only realize the harm of covid19 but also treat the selflimiting disease objectively and rationally residents job satisfaction is also higher and per capita disposable income has increased significantly moreover residents have a more robust network of relationships further they have substantially less time to pay attention to covid19 and are less likely to receive mental health counseling from the government empirical methods differenceindifference method since the outbreak of covid19 in december 2019 the chinese government has adopted the class a management strategy for class b infectious diseases and implemented various control measures such as maintaining social distancing wearing masks and shutting down the infected areas until december 2022 the 3year epidemic has seriously affected the mental health of residents as the omicron virus became less virulent the chinese government has adjusted and relaxed covid19 control an issue worth studying is whether the mental health of residents is restored after the relaxation of the covid19 control policy what are the possible mediating mechanisms to this end first using the did model two periods of panel data from residents of shaanxi china were used to empirically analyze the influence of the rcc on residents health levels the model is constructed as follows y r cc x it it it i i it α α γ µ ν ε 0 1 σ where y it signifies residents mental health including stress anxiety and depression i and t meant county and year rcc signifies relaxation of covid19 control x it indicates control variables and σγ is the effect of control variables on residents mental health α 0 is the constant term and α 1 is the effect of the rcc on residents mental health i µ and ν i are locality and timefixed effect respectively ε it signifies the random error term in addition since twoterm panel data was used and interviewee were the same individuals at different times so we fixed regional and temporal differences but not individual heterogeneity mediating effect model based on model verification tourism consumption is further added to empirically test that the rcc could significantly improve residents mental health by improving family tourism consumption the mediating variable tourism consumption is selected mainly given the following considerations after the deregulation of covid19 control the tourism industry showed retaliatory recovery and development meanwhile travel is also a core mean to improve residents mental health consequently the study employed the mediating effect model to analyze the mediating effect of tourism consumption the hierarchical regression is constructed as follows y r cc x m r cc x it it it i i it it it it i i α α γ µ ν ε ϕ ϕ γ µ ν ε 0 1 0 1 σ σ i it it it it it i i it y r cc m x η η η γ µ ν ε 0 1 2 σ 2 where m signifies mediating variable tourism consumption ϕ 0 and η 0 are constant terms and ϕ 1 η 1 and η 2 are coefficients to be estimated the meanings of other variables are the same as in formula the specific testing process of mediating effect is the same as si et al results influence of the rcc on the mental health of residents according to table 3 it is apparent that the rcc could significantly improve residents mental health and reduce the severity of mental health issues by 0602 in particular the rcc holds a negative inhibitory effect on residents stress anxiety and depression and the severity of stress anxiety and depression decreased by 0805 0406 and 0315 respectively hence the rcc has shown the strongest negative effect on residents anxiety followed by anxiety and depression thus hypothesis h1 is confirmed additionally it is believed that the mental health of the residents is also affected by certain other factors for instance the gender of the residents the awareness of covid19 and job satisfaction are also likely to significantly and negatively influence the mental health of the residents if the residents surveyed were men their mental health severity would decrease by 0206 if residents realized the harmfulness of covid19 and the selflimiting nature of the virus their mental health severity would decrease by 0406 if the residents job satisfaction increased by 1 unit the severity of the residents mental health would decrease by 0505 meanwhile per capita disposable income relationship networks and mental health counseling also negatively influenced residents mental health if per capita disposable income is increased by 1 unit their mental health severity would decrease by 0206 if the relationship network is increased by 1 unit their mental health severity would decrease by 0208 furthermore if residents received mental health counseling from the government the severity of their mental health would be reduced by 0031 additionally some other factors could exacerbate residents mental health seriousness if the proportion of the older adults and children and the time to pay attention to covid19 increases by 1 unit the severity of the mental health of the residents would increase by 0291 and 0038 respectively the did method required that there was no significant difference in residents mental health before december 31 2022 between the treatment group and the control group according to figure 1 it is found that there is no significant difference in residents mental health before december 31 2022 while the severity of residents mental health decreased significantly during januarymarch 2023 which further verifies the positive promotion effect of the rcc on improving residents mental health placebo test further exploring whether the estimation results of the did method are biased or not due to missing variables this paper conducted a placebo test through a randomized selection of treatment groups since the newly generated treatment group was random and would not affect the explained variable its estimated coefficient should be around 0 this paper repeated the random generation process 1000 times and reported the estimated coefficient of the random treatment group and its pvalue distribution in figure 2 the results showed that the average estimation coefficient of the randomly generated treatment group is00003 which is near 0 and far away from0602 in table 3 indicating that there is no obvious model estimation bias issue 45 showed the influence of the rcc on the mental health of residents of different ages and regions respectively specifically on the one hand the rcc did not significantly influence the mental health of residents over the age of 60 that is the mental health of residents over the age of 60 has not improved considerably after the rcc however the rcc showed a linear significant effect on the mental health of residents under 60 years that is with the gradual increase of age the rcc holds a stronger inhibitory effect on the severity of the mental health of residents thus hypothesis h1a is confirmed on the other hand the rcc also showed significant effects on the mental health of residents belonging to urban and rural areas still its improvement effect on the severity of the mental health of urban residents is greater than that of rural residents thus hypothesis h1 b is also confirmed testing the mediating effect of tourism consumption this study also used the mediating effect model to verify the mediating mechanism of tourism consumption related to the rcc that influences the mental health of residents the study selected amount of family tourism consumption in the first quarter to measure mediating variable tourism consumption using the hierarchical regression model the results showed that the rcc positively affects tourism consumption meanwhile the rcc and tourism consumption significantly influenced residents mental health the intermediary effect of tourism consumption is 01492 and its proportion in the total effect is 02458 therefore 2458 of the inhibitory effect of the rcc on residents mental health severity is found to be contributed by family tourism consumption thus hypothesis h2 is also endorsed discussion in infectious disease prevention and control humanity has experienced the longest largest and most damaging covid19 outbreak against climate change financial turmoil food crisis and public health crisis the covid19 pandemic has exacerbated negative impacts on industrial development international trade labor employment and mental health this paper focuses mainly on answering the previous discussion in academia that is since the covid19 epidemic has caused severe damage to residents mental health will residents mental health improve after relaxing the control policy of the covid19 epidemic meanwhile we discuss the possible mechanism or reason from the perspective of family tourism consumption unlike many previous studies that only studied the influence of covid19 on one aspect such as the enterprise supply chain food import and export household production decisions and the mental health of residents however the current study explores the link between rcc family tourism consumption and the mental health of residents which could provide a more plausible explanation for the knockon effects of covid19 unlike the study of wilding et al razali et al and hecker et al studies which focused on the direct causal relationship between covid19 and residents mental health our research innovatively and empirically confirms the promotion role of the rcc in improving residents mental health firstly the rcc has canceled the home restriction and isolation control policy so that residents can have free activities and seek the best comfortable environment second the rcc accelerates the resumption of business and production provides adequate employment opportunities and eases the pressure and anxiety of increased family life security and income third the protective antibodies produced by the vaccine and the indepth understanding of the novel coronavirus have made residents less fearful and reduced their worries and depression about infection and fear of death finally the rcc significantly improves the residents facetoface communication enhances the strength of the relationship network and relieves residents anxiety and depression in addition considering the differences in the ages and regions of the residents we further analyzed the heterogeneity of the impact of the rcc on the mental health of residents although many previous studies have confirmed a causal relationship between the covid19 pandemic and mental health in the older adults people our study reported insignificant improvement in the severity of mental health in residents over 60 years old after the covid19 pandemic was relaxed oldage residents are vulnerable to covid19 accounting for a high proportion of severe cases and deaths meanwhile they also suffer from underlying diseases such as diabetes asthma heart or brain infarction etc therefore given the alternate peaks of covid19 the previous mental states of stress anxiety and depression are not changed moreover our study confirmed the negative linear inhibitory effect of the rcc on the mental health severity of residents this is mainly due to easing employment pressure and increasing household income after the covid19 control was eliminated besides we also find that the rcc improved the mental health of urban residents more than rural residents rural residents have apparent advantages over urban residents in terms of the impact of covid19 on labor transfer living security and epidemic prevention pressure thus they have lower levels of mental health test results of equilibrium trend we also explored the impact of other factors on the mental health of residents consistent with the studies of xiong et al and wall and dempsey our study also confirmed that womens mental health is more serious than mens the rcc has a stronger effect on the mental health of male residents awareness of covid19 helps improve residents behavioral decisions about vaccination and production investment but also affects residents mental health our study also showed that the higher the awareness of covid19 the lower the severity of stress and anxiety furthermore our findings are supported by abdellatif et al and cheng and kao who hold that covid19 has changed job opportunities employment environment income and decreased residents job satisfaction significantly furthermore such negative satisfaction directly aggravates residents mental health severity in addition it is also found that other factors also exacerbate the seriousness of the mental health of residents the older adults and children are vulnerable to covid19 because they have weak immunity if the older adults and children account for a relatively high proportion of the family population the stronger the residents attention to their health the more serious the negative emotions of stress and anxiety of course residents mental health issues are also closely related to their daily life habits for example the longer they pay attention to covid19 the more they may become too sensitive to the novel coronavirus and selfprotection eventually aggravating their mental health finally consistent with the studies of gilbert and abdullah chen et al and dillette et al we also find the mediating effect of tourism consumption on improving residents mental health influenced by rcc firstly the rcc has changed travel restrictions or quarantine policies due to covid19 providing the necessary conditions for the recovery of the tourism industry secondly tourism consumption improves residents sense of experience and happiness which can significantly improve the stress anxiety and depression caused by covid19 thirdly tourism consumption improves residents social interaction and relationship networks opens channels for residents to express their emotions and objects to express their emotions and can reduce mental health problems caused by covid19 finally studies also confirmed that tourism consumption could repair the longterm impact of covid19 on residents mental health by adjusting their lifestyles improving their environment and communicating with nature of course our research still has some shortcomings for example the rcc data was only available for 3 months and the study only explored the shortterm effects of the rcc on the mental health of the residents therefore the longterm effect of the rcc on residents mental health needs further investigation moreover some unobserved factors may also affect both the rcc and the mental health of residents thus generating endogenous issues which need to be further solved by obtaining survey variables and data besides due to using the panel data of two periods for shaanxi province china we do not have enough data points to test whether there was a pretrend before the rcc lift conclusion and policy implications in the postepidemic era in addition to tracking the mutation of the novel coronavirus designing targeted vaccines and developing effective drugs the residents mental health also deserves the international communitys attention the rcc will inevitably lead to economic and social development recovery but the residents mental health resilience is very weak whether mental health can recover effectively from rcc also needs theoretical and empirical exploration in this paper the panel data of shaanxi china were used to analyze the effects of the rcc on residents mental health and the intermediary mechanism of tourism consumption respectively by employing the did method and the mediating effect model the following conclusions are drawn firstly the rcc significantly inhibited the mental health severity of residents and the mental health severity decreased by 0602 in particular the rcc has a negative and significant influence on residents stress anxiety and depression and the severity of stress anxiety and depression decreases by 08050406 and 0315 respectively hence the rcc has the strongest negative effect on residents stress followed by anxiety and depression secondly the gender of the residents awareness of covid19 job satisfaction per capita disposable income relationship network and mental health counseling also significantly and negatively influence the seriousness of mental health however the proportion of older adults and children and the time to pay attention to covid19 can exacerbate the severity of mental health thirdly the rccs effects on residents mental health are heterogeneous the rcc had a linear significant effect on the mental health of residents under 60 years while it does not significantly influence the mental health of residents over 60 years meanwhile the rccs improvement effect on the mental health severity of urban residents is greater than that of rural residents finally tourism consumption plays a mediating role in the rccs influence on residents mental health the intermediary effect of tourism consumption is 01492 and its proportion in the total effect is 02458 in the postepidemic era it is necessary to strengthen mental health interventions firstly the government should strengthen residents mental health identification and treatment community and public hospitals should increase the number of mental health clinics expand the scope of identifying residents mental health issues and initiate early intervention strategies meanwhile the government should also improve access to mental health counseling through online consultation platforms provide mental health relief and selfhelp information to residents and help them improve their stress anxiety data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

objective covid19 has negatively influenced industrial development family consumption and residents mental health unfortunately it has not yet been studied whether this adverse situation can be alleviated after the relaxation of the covid19 control policy rcc therefore this study aimed to analyze the effect of the rcc on the residents mental health and the mediating effect of family tourism consumption methods by using the psm and mediating effetc model to research the panel data of two periods april 2021 and april 2023 for shaanxi province chinathe rcc negatively inhibited the mental health severity of residents and the mental health severity decreased by 0602 in particular the rcc showed the most substantial negative effect on residents stress followed by anxiety and depression meanwhile it is found that the impact of the rcc on the mental health of residents is highly heterogeneous the rcc indicates a linear significant effect on the mental health of residents under 60 years of age while the results were found insignificant for residents above 60 years of age meanwhile the rccs improvement effect on urban residents mental health is greater than that of rural residents in addition mechanism analysis showed that tourism consumption plays a mediating role in the influence of the rcc on the mental health of residents and the mediating effect accounted for 2458 of the total effectbased on the findings the study proposes that government and policymakers should strengthen mental health intervention improve access to mental health counseling stimulate economic development expand the employment of residents and track the mutation of the novel coronavirus

introduction with the intensification of global climate change and geophysical movements since the beginning of the 21st century earthquakes tsunamis landslides mudslides and other disasters have occurred frequently profoundly influencing global economic and social development of these disasters earthquakes are the most catastrophic and thus disasterrisk management for earthquakes has become a hot spot in academic and political circles 12 according to emergency events database from 2000 to 2018 87877 people were killed and 8303867 people were affected by earthquakes worldwide 3 china is a mountainous country with frequent earthquake disasters 4 5 6 7 according to statistics from 2000 to 2017 there were 179 earthquakes with a magnitude of 5 or above in china resulting in 488437 casualties and direct economic losses of 11334249 million yuan 8 as the worlds most famous earthquake province sichuan is the province with the most serious earthquake disasters in china from 2000 to 2017 there were 18 earthquakes with a magnitude of 5 or above in sichuan leading to 459993 casualties and direct economic losses of 93871093 million yuan among them the 5•12 wenchuan earthquake in 2008 the 4•20 lushan earthquake in 2013 and the 8•8 jiuzhaigou earthquake in 2017 were great earthquakes with a magnitude of 7 or above causing 459863 casualties and direct economic losses of 93200543 million yuan 8 the construction of a resilient disasterprevention system in earthquakeprone residential areas has become a focus for government and academic circles in general however academic studies of earthquake disasterrisk management are concentrated in developed countries with insufficient attention given to the disasterrisk management of residents in earthquakeprone areas in china in particular studies of the disasterrisk management of rural households in mountainous settlements where earthquakes are extremely serious are relatively few in china due to the influence of geology and resource endowment the settlements in mountain areas are not only disasterprone areas but also poverty concentrated areas it is of great significance to pay attention to the disaster risk management of such groups especially the risk response to the earthquake additionally in the few researches on disaster risk management in earthquakestricken areas in china scholars pay attention to different contents due to different perspectives for example cui et al 13 mainly explores the construction of resilience and disaster prevention system at the community scale han et al 14 mainly focuses on the impact of households with or without disabled members on their disaster preparedness in general few studies have focused on the correlation between financial preparedness and disaster risk perception from the perspective of rural household financial preparedness therefore there is an urgent need to carry out such research 215 many empirical studies have shown that residents disaster preparedness is key to their coping with the impact of disasters 16 17 18 19 however the existing academic research mostly measures residents disaster preparedness from the perspective of ensuring the physical safety of residents for example residents are asked whether they have emergency supplies whether they have an escape plan and whether they have purchased disasterrelated insurance however in the face of earthquakes which are highly catastrophic such simple disaster preparedness as the preparation of an emergency kit can only guarantee the safety of residents to a certain extent and is of limited help in restoring and reconstructing communities after the devastation of an earthquake in the face of earthquake disasters national relief social assistance and catastrophe insurance can help residents carry out postdisaster reconstruction to some extent however from the three earthquakes with a magnitude of 7 or above in sichuan in recent years it can be seen that compared with the direct losses caused by the disasters external financial assistance was limited 15 and catastrophe insurance was not implemented thus in the case of limited external relief funds the postdisaster reconstruction of residents in earthquakestricken areas had to rely on their own coping abilitynamely their financial preparation despite this fact few academic quantitative studies have measured and explored the size and characteristics of residents financial preparation in earthquakeprone areas thus it is urgent to carry out this research 15 although the study on the characteristics of residents financial preparation in a small area has no obvious correlation with the residents financial preparation in the earthquake threatened area under other social and cultural backgrounds however the measure of financial preparation of rural households in earthquakestricken areas in this study can provide useful enlightenment for disaster risk management in earthquakethreatened areas under other cultural backgrounds and even make a comparative study of crossregional and crosscultural backgrounds meanwhile china is a large earthquake country and the earthquake sample region selected in this study is its typical representative region understanding the characteristics of rural households financial preparation in this region can provide certain reference basis for the implementation of financial preparation policies of rural households in other areas threatened by earthquake disasters in china facing the threat of earthquake disasters rural households will take corresponding actions only when they perceive the risks 621 therefore the disasterrisk perception of residents in disasterprone areas and the influencing factors have always been the focus of academic research the research by lindell 18 bubeck et al 22 huang et al 23 lindell and perry 24 and solberg et al 25 has systematically reviewed residents disasterrisk perception and the driving factors as well as the correlations between disasterrisk perception and disasteravoidance decisions in the existing research residents individual and family socioeconomic characteristics and disaster experiences are commonly used indicators however due to the differences in disaster types and regional socioeconomic culture the results of the correlations between these factors and residents disasterrisk perception are not uniform 2224 for instance lawrence et al 26 have found that flood disaster experience can improve residents disasterrisk perception and xu et al 21 have discovered that landslide disaster experience can enhance residents perception of the possibility of disaster occurrence but has no significant influence on the perception of threat and controllability of disaster occurrence for earthquakes which are especially serious as soon as they occur how do residents socioeconomic characteristics and disaster experience affect their disasterrisk perception what are the correlations between financial preparation which is an effective means for residents to cope with the impact of earthquake disasters and disasterrisk perception in the above context this study takes as its object rural households from areas stricken by the 5•12 wenchuan earthquake and the 4•20 lushan earthquake in sichuan province and explores the construction of an index system for rural households financial preparation from the perspective of the internaland externalcoping abilities of these households moreover it uses statistical models to explore the correlations between rural households financial preparation or earthquake disaster experience and disasterrisk perception this study intends to solve the following two scientific problems what are the characteristics of the financial preparation disaster experience and disasterrisk perception of rural households in earthquakeprone areas what are the correlations between rural households financial preparation or disaster experience and disasterrisk perception in earthquakeprone areas theoretical development the disasterrisk perception of residents in disasterprone areas and the influencing factors have always been the focus of academic research scholars have conducted a lot of explorations on the correlations between residents individual and family socioeconomic characteristics disaster experience or disaster preparedness and disasterrisk perception in different threat areas of different disasters obtaining inconsistent results 27 this study focuses on the correlations between residents financial preparation disaster experience and disasterrisk perception in earthquakestricken areas in sichuan rural households financial preparation and disaster risk perception according to existing studies residents in disasterstricken areas may experience the phenomenon of survivor bias which means families with good financial preparation may underestimate the probability or impact of a disaster 1522 therefore families with financial preparation such as residents with a high income diversity index high income high asset availability deposits and commercial insurance generally believe that even if a major earthquake were to occur they can reduce the impact of the disaster on their family by relying on the internalcoping ability of their family for this reason their perception of the severity of disaster occurrence is relatively low for example lo and cheung 15 have found that residents who purchase insurance have a relatively low perception of the severity of earthquakes miceli et al 20 have discovered that residents disasterpreparedness behavior is not significantly correlated with the probability of their risk perception of flood disaster occurrence but it is significantly positively related to the severity of flood disaster occurrence xu et al 19 have realized that residents insurance purchase behavior is significantly positively correlated with the threat and possibility of landslide disasters helweglarsen 28 paton and johnston 29 have found that individuals with disaster preparedness perceive a lower need for additional preparedness than other people meanwhile many empirical studies on disaster risk management show that the strength of residents social network also has an important impact on their risk perception and disaster preparedness 30 31 32 among them in the face of the earthquake disaster whether residents can smoothly borrow money from friends and relatives and borrow money from banks is an important sign of their social network according to relevant researches in the field of sustainable livelihood rural households are faced with strong external shocks when their internalcoping capacity is insufficient to cope with the losses caused by the earthquake to their families externalcoping capacity will come into play therefore for families with different social networks their disaster risk perception may present different states for example lo and cheung 15 have found that access to commercial credit is significantly positively correlated with the possibility of disaster occurrence however generally speaking the maintenance of social network needs costs thus rural households will not easily use social network rural households only use them when they feel a strong threat and their internalcoping capacity is insufficient to cope with the threat therefore the occurrence of severity perception and social network may be positively correlated based on this research hypothesis h1 was proposed hypothesis 1 rural households financial preparation is significantly correlated with disasterrisk perception specifically hypothesis 1a rural households internalcoping ability is significantly positively related to the possibility of disaster occurrence and is significantly negatively related to the severity of disaster occurrence hypothesis 1b rural households externalcoping ability is significantly negatively correlated with the possibility of disaster occurrence and is significantly positively correlated with the severity of disaster occurrence residents disaster experience and risk perception residents disaster experience is often regarded as one of the important factors affecting risk perception although the measurement of residents disaster experience is not uniform 3334 most empirical research results show that residents disaster experience is positively significantly correlated with their disaster risk perception for example xu et al 619 have used whether residents have landslide disaster experience to carry out the measurement and have found that there are positive correlations between disaster experience and the possibility and severity of disasters lo and cheung 15 have adopted the severity of residents disaster experience to carry out the measurement and have found similar results based on this research hypothesis h2 was proposed hypothesis 2 rural households disasterexperience severity is significantly correlated with disasterrisk perception specifically hypothesis 2a rural households disasterexperience severity is significantly positively related to the possibility of disaster occurrence hypothesis 2b rural households disasterexperience severity is significantly positively related to the severity of disaster occurrence data and methods data source the data used in this study are mainly from the questionnaire survey conducted by the research team in the areas stricken by the wenchuan earthquake and the lushan earthquake in july 2019 and the survey method is a oneonone facetoface interview the contents of the survey mainly include rural households sustainable livelihoods residents disasterrisk perception residents disasteravoidance behavior the construction of a resilient disasterprevention system in villages etc the time for each questionnaire was about one and a half hours some objective indicators such as rural households income were mainly adopted to inquire about the family situation of rural households by the end of 2018 whereas some subjective indicators such as residents disasterrisk perception were primarily used to ask about the status of respondents when they were surveyed in order to ensure the typicality and representativeness of the selected samples this study chiefly adopted the stratified sampling method which is a probability sampling technique to determine the survey samples the specific operation process was as follows firstly with regard to the selection of sample counties this study was mainly based on the following two aspects 1 the four sample counties should be from the areas stricken by the wenchuan earthquake and the lushan earthquake 2 there are significant differences in economic development level between the two sample counties selected for each of the two major earthquakes based on the above considerations this study selected as sample counties beichuan county and pengzhou city from 10 counties stricken by the wenchuan earthquake and baoxing county and lushan county from six areas stricken by the lushan earthquake secondly after sample counties were selected two sample townships were randomly selected from each sample county according to differences in the level of economic development within the counties and the distance from the county center and the seriousdisaster situation especially the number of threatened people a total of eight townships were obtained thirdly after the sample townships were determined the villages in each sample township were divided into two types in accordance with the number of threatened people in the villages the differences in the level of economic development the distance from the township center and other indicators one village was randomly selected from each type of village as the sample village in this way a total of 16 villages were obtained fourthly concerning the determination of sample rural households after the sample villages were determined the frontline team members obtained the roster of rural households in the sample villages from village cadres and 2023 rural households were randomly selected from each sample village as sample rural households according to the preset random numerical tables finally in order to obtain high quality survey data unify the questionnaire answer standard and teach the basic etiquette and skills of interview research the teachers of the research group systematically trained 13 researchers who participated in the survey within one day then 13 researchers who received strict training conducted oneonone facetoface interviews in the homes of rural households under the guidance of village cadres and a total of 327 valid questionnaires were obtained from 16 villages of eight townships in four counties methods selection and definition of model variables the objective of this study was to probe the correlations between rural households financial preparation disaster experience and disasterrisk perception rural households disasterrisk perception was the dependent variable of this study with regard to the measurement of disasterrisk perception in academic circles there are two main schools namely the cultural theory school and the psychological measurement paradigm consistent with the research by xu et al 2 armas 9 xu et al 21 solberg et al 25 lindell and whitney 35 lo 36 slovic 37 and sun and han 38 this study argued that disasterrisk perception is a measurable multidimensional concept based on this this study mainly designed entries from the two dimensions of possibility and severity of earthquake disaster occurrence to measure disasterrisk perception and the specific measurement entries are detailed in table 1 before the measurement an internal consistency test was carried out on the entries characterizing residents disasterrisk perception cronbach α values corresponding to the probability of disaster occurrence the severity of disaster occurrence and the perception of disaster risks were 070 064 and 072 respectively which are all greater than 060 indicating that the entries designed by this study had good internal consistency subsequently this study used factor analysis to reduce the dimensionality of the entry of disasterrisk perception so as to obtain the two dimensions of the probability and severity of disaster occurrence the value of kaisermeyerolkin corresponding to factor analysis is 074 and the cumulative variance contribution rate of the two dimensions is 6192 which indicates that the results of the factor analysis are reasonable rural households financial preparation is one of the two core independent variables of this study it relates to rural households income family assets or borrowing capacity based on this referring to the setting of residents financial preparation in the research by armas 9 becker et al 10 lo and cheung 15 bubeck et al 22 keil et al 39 le dang et al 40 and paul and bhuiyan 41 this study mainly measured rural households financial preparation from two dimensions which are the internalcoping ability and externalcoping ability rural households internalcoping ability is characterized by total family cash income income diversity whether rural households have deposits current asset diversity and whether rural households purchase commercial insurance rural households externalcoping ability is characterized by whether rural households can borrow sufficient money from formal institutions and whether they can successfully borrow money from informal channels when a catastrophe such as an earthquake occurs income diversity is measured by dividing the main income source channels of rural households by the total channels of income sources the total channels of income sources mainly consist of five aspects agricultural income wage income business income income from relatives and friends and transfer payment income and the main income source channels of rural households are generally one or more of these five aspects current asset diversity is measured by dividing the present value of current assets by the present value of total family assets the present value of current assets refers to the present value of valuable fixed assets owned by rural households other than houses while the present value of total family assets represent the present value of current assets as well as the present value of rural households housing assets rural households disaster experience is the other core independent variable of this study mainly referring to the setting in the research by lo and cheung 15 this study adopts the severity of rural households earthquake disaster experience to measure rural households disaster experience in order to minimize the impact on the independent variables of missing important variables this study with reference to the research by xu et al 21 bubeck et al 22 lindell and perry 24 lo 42 lindell and hwang 43 sun and sun 27 yu et al 44 lindell and perry 45 lazo et al 46 and peng et al 4748 also includes some variables that may affect residents disasterrisk perception as control variables mainly each respondents age gender years of education occupation residence time nationality etc the models since the probability of disaster occurrence and the severity of disaster occurrence which are the dependent variables of this study are interval variables this study used ordinary least square to estimate the models when exploring the correlations between rural households financial preparation or disaster experience and disasterrisk perception the simple expression of the model is as follows y i α 0 β 1i × fp i β 2i × experience i β 3i × control i ε i where y i refers to the dependent variable of the model which can be decomposed into two indicators namely possibility and severity fp i experience i and control i represent rural households financial preparation disaster experience severity and control variable respectively α 0 β 1i β 2i and β 3i represent the model parameters to be estimated respectively and ε i represents the residual term stata 110 was adopted in the whole model implementation process results descriptive statistics of the variables table 3 shows descriptive statistics of the variables in the model as for financial preparation in terms of rural households internalcoping ability rural households income diversity index was 05 on average indicating that rural households have an average of 23 main income sources the average annual family cash income is 6623894 yuan which showed great fluctuation among 327 sample rural households 46 of them had deposits and 28 of them had purchased commercial insurance lastly rural households asset diversity index was 015 on average indicating that rural households family assets were more allocated to real estate with regard to rural households externalcoping ability whenever there was a catastrophe such as an earthquake 69 and 75 of rural households could borrow money from banks and borrow money from friends and relatives respectively concerning the severity of residents disaster experience 8960 of rural households believed that their disaster experience was serious regarding control variables 46 of the respondents were women the average age of the respondents was 5344 the average years of education was 629 the average residence time at home was 4171 years 82 of the respondents were han people and 57 of rural households were farmers model results tables 4 and5 show the correlation coefficient matrix and regression analysis results of model variables respectively as shown in table 4 the correlation coefficients among all variables of the models are below 08 which indicates that there is no serious multicollinearity between the independent variables of the models as shown in table 5 model 1 model 2 and model 3 are the results when the probability of disaster occurrence is taken as the dependent variable model 1 is the result of only including rural households financial preparation and model 2 is the result of only including the severity of disaster experience while model 3 is the result of including control variables based on model 1 and model 2 the results of model 4 model 5 and model 6 are similar to those of model 1 model 2 and model 3 except that the dependent variable of the models is the severity of disaster occurrence from all the model test statistics it is seen that the results of all models except model 2 are significant at the level of 01 and above and rsquared values corresponding to model 3 and model 6 are 0113 and 0107 respectively suggesting that independent variables can respectively explain 113 and 107 of the probability of disaster occurrence as for the correlations between financial preparation and possibility in model 1 and model 3 rural households total family cash income asset diversity and whether rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake were significantly negatively correlated with the probability of disaster occurrence in other words if rural households total family cash income is more the proportion of the present value of current fixed assets in the present value of total family assets is larger and rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake rural households will believe that the probability of an earthquake will be smaller specifically when other conditions remain unchanged with every one unit increase in the logarithm of rural households total cash income rural households perception of the probability of a disaster will decrease on average by 0113 units furthermore with every one unit increase in the proportion of the present value of current fixed assets in the present value of total family assets rural households perception of the probability of disaster occurrence will decrease on average by 0908 units lastly compared with rural households who cannot borrow money from relatives and friends whenever there is a catastrophe such as an earthquake rural households who can borrow money from relatives and friends in those circumstances will believe that the probability of a disaster will decrease on average by 0292 units meanwhile it is noted that among the seven indicators of rural households financial preparation four indicators were not significantly related to the possibility of disaster occurrence the correlation coefficient between the severity of residents disaster experience and the possibility of a disaster is positive but not remarkable in addition all control variables were not significantly correlated with the probability of disaster occurrence as for the correlations between financial preparation and severity in model 4 and model 6 asset diversity and whether rural households can borrow money from banks whenever there is a catastrophe such as an earthquake were significantly positively related to the severity of the disaster in other words if the proportion of the present value of rural households current fixed assets in the present value of total family assets was larger and rural households can borrow money from banks whenever there is a catastrophe such as an earthquake rural households will believe that the severity of the earthquake will be stronger to be specific when other conditions remain unchanged with every one unit increase in the proportion of the present value of rural households current fixed assets in the present value of total family assets rural households perception of the severity of disaster occurrence will increase on average by 0918 units compared with rural households who cannot borrow money from banks whenever there is a catastrophe such as an earthquake rural households who can borrow money from banks in those circumstances will believe that the severity of the disaster will increase on average by 0245 units it is noted that among the seven indicators of rural households financial preparation five indicators are not significantly correlated with the severity of the disaster if rural households earthquake disaster experience is more severe their perception of the severity of the disaster will be stronger specifically when other conditions remain unchanged with every one unit increase in the severity of rural households earthquake disaster experience rural households perception of the severity of the disaster will increase on average by 0306 units additionally all control variables were not significantly related to the severity of the disaster note p 001 p 005 p 01 114 respectively represent an income diversityoccupation among them 15 belong to internalcoping ability while 6 and 7 belong to externalcoping ability discussion rural households disaster preparedness is an important part of the construction of a regionally resilient disasterprevention system and financial preparation is the most important part of disaster preparedness directly relating to the extent to which rural households can carry out postdisaster reconstruction however few studies have focused on the financial preparation of rural households in disaster preparedness the measurement and characteristics of financial preparation of rural households in earthquakestricken areas and the correlation between financial preparation and disaster risk perception the marginal contribution of this study was to make up for the above deficiencies specifically this study constructed an index system for rural households financial preparation from the perspective of rural households internalcoping ability and externalcoping ability using survey data of rural households in the areas stricken by the wenchuan earthquake and the lushan earthquake this study empirically analyzes the correlations between rural households financial preparation or disasterexperience severity and disasterrisk perception the construction of a financial preparation index system and the results of the empirical research in this study can provide enlightenment for the construction of a resilient disasterprevention system in earthquakeprone areas meanwhile the measurement of financial preparation in this study can also provide useful enlightenment for other similar researches the internalcoping ability of rural households is an important factor affecting their disaster risk perception inconsistent with hypothesis h1a this study found that income diversity total cash income whether rural households had deposits and whether rural households purchased commercial insurance were not significantly correlated with residents disaster risk perception at the same time it is interesting that the correlation between asset diversity and the probability and severity of disasters turned out to be the opposite of research hypothesis h1a the possible reasons for the results are as follows the research area of this study is mostly hilly influenced by geographical location and natural resource endowment rural households agricultural income or business income is not high at the same time with limited years of education and few skills most migrant workers are engaged in construction and service industries and their wages are relatively low in the face of the impact of education medical treatment of serious diseases human relations and other large expenditures rural households annual cash income is not much therefore deposits are relatively limited and are generally insufficient to deal with the impact of earthquakes and other catastrophes on families meanwhile there is no earthquake catastrophe insurance in the study area while many rural households have purchased commercial insurance this insurance is mostly used for oldage care or medical treatment for serious diseases and thus has little impact on rural households resistance to earthquakes in addition due to the expense of childrens marriages or competition with others in the village who are also on a relatively low income many rural residents in china generally invest the money they have saved over the years in fixed assets especially housing 5 therefore in this study the asset diversity index is markedly correlated with residents disasterrisk perception it is also noted that although many studies on sustainable livelihoods of rural households have shown that rural households can sell their fixed household assets to withstand external shocks however earthquake shock is different from other risk shocks if the earthquake shock is strong it will directly threaten the lives and fixed assets of rural households in this case it will be difficult for rural households to sell their fixed assets to withstand the earthquake at this time rural households may have more survivor bias 1522 for the safety of life and assets they will underestimate the possibility of disasters and overestimate the severity of disasters therefore in this study asset diversity is negatively significantly correlated with the probability of disaster occurrence and positively significantly correlated with the severity of disaster occurrence in the face of external risk impact when the internalcoping capacity of rural households is insufficient their externalcoping capacity will play a crucial role therefore rural households externalcoping capacity is also an important factor affecting their disaster risk perception and behavioral decisionmaking inconsistent with the hypothesis h1b this study found that in the event of a major disaster such as an earthquake the ability to borrow money from friends and family is negatively significantly correlated with the probability of disaster occurrence but not significantly correlated with the severity of disaster occurrence at the same time in the event of major disasters such as earthquakes the success of lending money to banks is positively significantly correlated with the severity of disaster occurrence but not significantly correlated with the probability of disaster occurrence the possible reasons for the results are as follows the severity of the damage caused by earthquakes makes rural households more inclined to seek external help from relatives friends or banks when they are affected by disasters when rural households are facing the serious impact of earthquake disasters they cannot carry out recovery or reconstruction by only relying on their internalcoping ability thus they rely more on external support however the social networks of rural households are basically in the same county and some are even concentrated in the same township or the same village in the face of earthquake disasters the relatives and friends of rural households may be affected as well thus concerning the possibility of disaster occurrence rural households are more inclined to seek help from relatives and friends when the internalcoping ability is insufficient whereas with regards to the severity of disaster occurrence rural households are more inclined to borrow money from banks when the internalcoping ability is insufficient residents disasterrisk experience is another important factor affecting their disasterrisk perception however consistent with h2b but inconsistent with h2a this study finds that the severity of residents disaster experience is significantly positively correlated with the severity of disaster occurrence but is not significantly related to the possibility of disaster occurrence the results are different from the findings of lo and cheung 15 their research has found that residents disaster experience is significantly positively correlated with the possibility and severity of disaster occurrence the possible reason is that the damage caused by these two major earthquakes is too serious and residents in earthquakestricken areas have a particularly deep memory of the severity of earthquake damage therefore the severity of residents disaster experience is significantly positively related to the severity of disasterrisk perception at the same time earthquakes are lowfrequency disasters that may occur only once in several decades although people are worried about the damage caused by earthquakes they still believe that the possibility of recurrence in the next 10 years is relatively small thus in the research area the severity of sample residents disaster experience is not significantly correlated with the possibility of disaster occurrence additionally the differences between our study and lo and cheung 15 may also be due to the differences in sample areas and disaster risk perception measures lo and cheungs 15 disaster risk perception is measured by a single index while this study uses factor analysis to reduce dimensions of multiple indexes in the revised manuscript we have also explained this situation in addition interestingly this study indicates that respondents gender age education level nationality job and residence time are not significantly related to disasterrisk perception the possible reason is that devastating earthquakes such as the wenchuan earthquake or the lushan earthquake have a great impact on people and the people who have experienced the disaster have an extremely deep memory of the earthquake thus there are no remarkable differences in earthquake disasterrisk perception among gender age education level and other personal characteristics conclusions and implications based on the survey data of 327 rural households from four counties stricken by the wenchuan earthquake and the lushan earthquake in sichuan province this study analyzes the characteristics of rural households financial preparation disasterexperience severity and disasterrisk perception meanwhile it constructs ols models to probe the correlations between rural households financial preparation or disasterexperience severity and the perception of the possibility and severity of disaster occurrence three main conclusions are drawn as for financial preparation among 327 sample rural households rural households income diversity index and asset diversity index are both less than 05 about one third rural households purchase commercial insurance and less than half rural households have deposits whenever there is a catastrophe such as an earthquake about three quarters of rural households can borrow money from banks and can borrow money from friends and relatives as for the correlations between financial preparation and disaster risk perception the higher the rural households total family cash income the higher the asset diversity and when rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake the lower their perception of the possibility of disaster occurrence the higher the asset diversity when rural households can borrow money from banks whenever there is a catastrophe such as an earthquake the stronger their perception of the severity of disaster occurrence as for the correlation between experience and possible disasterrisk perception the more severe the disaster experience the stronger their perception of the severity of disaster occurrence meanwhile the severity of residents disaster experience is not significantly correlated with the probability of disaster occurrence based on the above analysis this study can also derive some useful policy implications for instance although this study found that many indicators of rural households internalcapacity are not significantly correlated with their disaster risk perception they are also an important means for rural households to resist external risk impact this study found that the internalcapacity of rural households is not strong on the whole the implication for the government is that the government should give more support to rural households such as helping them find jobs and increasing family income through employment training trying to implement earthquake catastrophe insurance to help rural households withstand the impact of earthquakes in addition this study indicates that rural households borrowing networks are significantly correlated with their disasterrisk perception while the total cash income income diversity whether rural households have deposits and whether rural households purchase commercial insurance and have financial preparation are not significantly related to disasterrisk perception this reflects the importance of rural households social networks for postdisaster reconstruction the message to the government is that it is necessary to pay attention to the construction of formal financial institutions and rural households borrowing networks and offer loan services for rural households in earthquakestricken areas to help them carry out postdisaster reconstruction at the same time through reasonable guidance there is a need to make full use of the support role of rural households social networks in their postdisaster recovery despite its theoretical and practical significance this study has some limitations which can be improved upon in future research for example many empirical studies have shown that residents disasterrisk perception is significantly related to their disasteravoidance behavior however this study only focused on the correlations between rural households financial preparation or disasterexperience severity and disasterrisk perception and did not explore rural households disasteravoidance decisions future research for example can explore the correlations between rural households financial preparation or disaster experience and evacuationrelocation behavior decisionintention for another example in different empirical studies the measurement criteria for disasterrisk experience are different and this study uses the severity of residents disasterrisk experience a relatively subjective indicator to carry out the measurement hence future research can consider using some objective and quantitative indicators to carry out the measurement and explore the influence of disasterrisk experience on residents disasterrisk perception or disasteravoidance behavior author contributions conceptualization dx and xd formal analysis zy funding acquisition dx investigation zy yl kh wz and zm methodology dx supervision dx writingoriginal draft dx zy xd yl kh wz and zm writingreview editing dx

sichuan is a province in southwest china that is famous worldwide for its earthquakes however few quantitative studies in china have probed the correlations between rural households financial preparation disaster experience and disasterrisk perception using survey data of 327 rural households from four areas stricken by the wenchuan earthquake and lushan earthquake in sichuan the ordinary least square ols method was used to quantitatively explore the correlations between these three factors the results show that rural households total family cash income asset diversity and whether rural households can borrow money from relatives and friends whenever there is a catastrophe such as an earthquake are significantly negatively correlated with the probability of disaster occurrence asset diversity and whether rural households can borrow money from banks whenever there is a catastrophe such as an earthquake are significantly positively related to the severity of disaster occurrence the severity of residents disaster experience is not significantly correlated with the probability of disaster occurrence but is significantly positively related to the severity of the disaster the research results can provide useful enlightenment for the improvement of financial preparedness and disaster risk management for rural households in earthquakestricken areas

introduction family and marriage issues are an important part of all societies in our society this issue is given importance at the level of state policy because tomorrows successors will grow up in the familypresident mirziyoyev shm also expressed the following comments on this issue constantly paying attention to the health of mothers and children providing employment taking into account the living conditions of women their place and influence in our social and political life we consider ourselves to be the most important task to continue the state policy on increasing 1 based on this in todays rapidly changing world it is important to study family and marriage relations which are an important part of our national mentality in this article we focused on the attitude of todays youth to the family and the analysis of their thoughts about the ideal family the term ideal is the highest example perfection of something event and phenomenon in general this term is understood differently in different fields in particular morally ideal perfect human qualities human relations aesthetic appearance character description mature in all aspects ideal is a real existence the highest manifestation of beauty it consists of our perfect completely subjective concepts of life 2 based on this what characteristics should an ideal family have the characteristics of an ideal family differ in different periods and regions there is no clear criterion for what an ideal family should look like because as many people as there are on earth their views on the ideal family will be different depending on their nature and outlook a type of family that is considered ideal for one person may not be ideal for another this varies depending on their age group literature review volume03 issue11 doi pages 2327 family and marriage issues have always been one of the topics in the focus of researchers in various fields in particularar lemekhova analyzed the relationships between girls and boys and touched upon the characteristics of ideality in these relationships and lp ilarionova studied the aspects of interpersonal adaptation in family relationships 3 the works of va sukhomlinsky should be mentioned separately he expressed his thoughts about the formation of ideal family ideas in teenagers based on the family he is growing up in norotkov nz kordon si rogova ia family everything starts with love most of this work is written on the basis of sociological surveys of russian teenagers 4 in addition vi we can cite barsky marriage harmony va baltsevich sn burova dk arapbayeva research methodology the article is written based on the methods of ethnology ethnographic field research observation and the comparative analysis of the results of questionnaires received by the youth of jizzakh region analysis and results as mentioned above peoples views on the ideal family are different in terms of age for example 1720yearolds ideas about the ideal family are more likely to be love love which is connected with their emotional feelings people of this age idealize their partners and relationships in this place lets look at ar lemekhovas analysis of the relationship between girls and boys he examines the relationship between girls and boys and describes it in three ways 1 harmonious type in this type girls and boys have enough moral concepts and have a developed emotional culture that is they can control their feelings they look at love the opposite sex and family life somewhat clearly and correctly assess the situation 2 family romantic type on the contrary feelings play a leading role love relations between the sexes are taken away from life they are extremely idealized and when they collide with the existing existence in life all their imaginations are shattered and they become mentally depressed too idealized feelings disappear 3 spiritually poor type young people misunderstand love in love they cannot see the spiritual closeness the importance of the spiritual factor and as a result they encounter many obstacles 5 adolescents ideas about the ideal family have something in common with the second type of attitude above 2425yearolds and older people have different opinions about the ideal family as a proof of ideas we will analyze the ideas of some young people about the ideal family one of the middleaged respondents said that an ideal family means a family in which a couple understands each other correctly solves problems with good words calmly and where love always reigns in the family another informant said that in an ideal family both husband and wife should be responsible for the stability of the family the man should be the head of the family and be determined and in any situation family problems should be solved mutually he also mentioned that parents should always make time for the family in comparison 2325yearolds and middleaged adults are more intellectual than emotional in their ideas about the ideal family 6 modern young people include the need to have their own budget and nuclear family among the features of their ideal family in our society twogeneration families are the main form of family however in foreign countries we rarely meet the twosyllable family type nevertheless they have a lot of family disputes and divorces at this point we will mention the opinions of foreign youth about the ideal family this is mainly the opinion of german youth over 18 about the ideal family • in an ideal family first of all all family members believe in the same religion parents are married good communication is established between all family members and both men and women have permanent jobs it is noted that he should be able to spend time with his children and raise them well • according to another respondent in an ideal family everyone should understand each other establish good communication and healthy relationship between family members solve all problems together and in general everyone should feel happy in the family • first of all everyone in the family should be able to express their opinion freely if they support each other there should also be respect for the decisions of others mutual trust and open communication most importantly in an ideal family each member of the family should play an important role and take responsibility in the family only then did he express his opinion that this family would be an ideal family the above ideas are the ideas and thoughts of young people who have not yet started a family about an ideal family these thoughts of theirs may have been formed based on the environment in the family where he lived that is they are satisfied with the relationship of their parents and have made it their ideal or they are dissatisfied with the environment in the family so they do not want to build a similar family in the future in 197879 russian researchers conducted surveys of several russian families on this very issue according to him three out of four teenagers want to be like their parents 413 of girls and 349 of boys want to be like their mother according to the results of interviews with class leaders mothers set a more positive example for their children than fathers because in 969 of cases mothers do not have negative manifestations in their behavior while this indicator is only 752 of fathers among schoolchildren in the group of delinquents fathers have more and more often negative deviations in their behavior than in other surveyed families they drink and quarrel 7 as va sukhomlinsky said where the father educates himself children will educate themselves if the father does not have a clear example any words about the childs selfeducation will remain mere words 8 so how the ideas of the ideal family of young people who have not yet started a family are formed depends on their own family it also depends on the environment now we will analyze the opinions of foreign young people who have started a family about the ideal family • in order to be an ideal family there should be certain rules in the family and everyone should follow them fully • finding a solution to the problem together doing some kind of exercise together at least once a week the couple understanding each other having trust • a 27yearold german married woman informant described the ideal family with words such as a house a good husband children work and health 9 if we look at the ideas of german youth about the ideal family there is a lot of emphasis on the fact that each member of the family has a place and their opinions are taken into account they also want to be married have many children and have a family gathering at least once a week to do something together through these thoughts we can find out what kind of families they have therefore young people in germany are often not married and rarely do family members get together and spend time with children these features are characteristic not only of germany but also of many western countries this can be explained by the fact that the tendency against detocentrism appeared in the second half of the 20th century the sociopolitical emancipation of women and their involvement in more social production activities has made womens family roles including motherhood less important for some modern western women do not want to be only faithful husband wife loving mother and cannot be anymore womens selfrespect now includes other bases besides motherhood not only because of professional achievement social independence the fact that they touched the earth but also the social position they have achieved some traditional tasks of mothers functions related to child care and education are now taken over by other specialists pediatricians nurses educators special social institutions ie kindergartens this does not eliminate the value of maternal love and the need for it but it changes the nature of maternal behavior 10 as a result of such factors specific family characteristics have been formed in western countries unfortunately such features are visible in some uzbek families in particular children are left to fend for themselves as a result of the constant employment of parents also the fact that many parents leave their children to work abroad also leads to the formation of dysfunctional families the concept of a dysfunctional family is the exact opposite of an ideal family conclusion and recommendations summarizing the above information the characteristics of the ideal family are a concept that changes according to space and time also each persons views on the ideal family differ depending on the environment worldview age and status it gains commonality in some aspects only when it is taken at the level of a certain nation for the uzbek people the ideal family is built on the basis of mutual love and respect trust mutual support understanding in different situations and moving in the same direction dreams goals and interests years total

this article analyzes the opinions of todays youth about the ideal family also the views of foreign youth on the ideal family were analyzed in comparison with the views of uzbek youth on this issue

introduction the curious case of rightwing human rights activism when it comes to human rights struggles a longstanding picture of civil society vs the state emerged with the former depicted as defenders and reformers and the latter as major transgressors and antagonists many have theoretically contested and empirically disproven the idea that civil society organisations are necessarily progressive pluralist and democratic yet the assumption that csos are generally for liberal and progressive notions of human rights still lingers as they are organisationally distinct and institutionally separated from political society many assume that csos favour an expanded protected and autonomous civil space to maintain a competitive edge visàvis the state and other pressure groups to advance their respective causes and interests this reading seeps into scholarly treatments of religious csos too even though their relationship with notions of universal human rights is complicated if not contentious for example in his influential book casanova describes a public or deprivatised religion that operates at the level of civil society as consistent with modern universalistic principles and with modern differentiated structures robert hefners pathbreaking study of civil islam in indonesia marries the phenomenon with the broader democratisation agenda that heralded the collapse of the suharto regime he painted civil islam as the majoritys counterbalance to statist islam through its commitment to values of freedom equality and justice however developments in postsuharto indonesia that saw the persecution of gender and religious minorities entrenched moral policing laws a contentious mobilisation campaign against a christian mayor and the empowerment of muslim vigilante groups such as the front pembela islam challenge the idea that civil societys expansion will necessarily boost the human rights agenda 1 this sense of disillusionment is compounded by the fact that numerous actors and agents associated with hefners civil islam enabled many of these occurrences the alarming developments in india myanmar and indonesia that saw the decline of religious freedom and minority rights following the mobilisation of rightwing religious actors reinforced a conceptual binary that divides nonwestern csos into two opposing camps one camp rejects western interpretations of human rights as embedded in the united nations universal declaration of human rights whereas the other generally accepts and champions it heuristically useful as it might be this categorical distinction speaks very little about a new breed of rightwing csos who style themselves explicitly as human rights defenders these csos are willing to work within the international human rights regime but they also engage in a kind of human rights activism that implicitly subverts undercuts and reformulates the agenda to move it away from a normative commitment to protect minority rights social equality and religious freedom specifically this paper sheds light on the appropriation of human rightism 2 by rightwing islamist actors in malaysia the picture painted here complicates the idea that nativist political actors most scoffing at the western human rights regime will always position themselves as rejectionists and outsiders of the enterprise rather what one witnesses is that the more these actors engage in the politics of human rights as fellow activists and putative insiders the likelier they erode the parameters of what constitutes human rights and the notions of freedom and equality it affords even though the protagonists of this study do not openly identify themselves as islamists their nativist positioning are inextricably linked to islamist ideology grievances and networks i will deal with the nativist and islamist underpinnings of these actors in a later section however discussing the relationship between islam and human rights is necessary scholars have long offered sophisticated treatments on the question of islams compatibility with the ideas of universal human rights and more importantly whether those are the only terms of debate for those seeking a radical vision of global justice and solidarity those are not the grounds this paper wishes to tread it does not debate whether human rights should be universal or particularistic whether its values should be globalised or decolonised or whether its historical praxis comprises good intentions or hypocrisies rather my inquiry scrutinises a more practical concern if we accept that discourses about human rights are inevitably subjected to pluralising pressures what happens when two understandings of human rights coincide and contend in a muslimmajority state do such contestations improve the lives and protections of the socially marginal and disadvantaged in our case what transpires is that a struggle portrayed as dismantling an allegedly hegemonic global western human rights regime actually contributes to reinforcing local hegemonies based on a muslim majoritarian worldview in a world where the nationstate remains the perimeters in which dynamics of exclusion and inclusion play out significantly any local reproduction of majoritarian hegemonies in the name of human rights is undoubtedly a cause for concern müllers account of paradoxical normativities in brunei and malaysia offers one way to visualise the encounter of contending visions of human rights he underlines the paradox in how muslim states janusfacedly complied with the human rights regime by symbolically committing to a transdoctrinal justification of human rights on the diplomatic front and simultaneously enforcing an antipluralist brand of islam on the governing front my departure from müllers approach is that i am less interested in documenting various forms of state hypocrisy and violations on human 1 regarding these incidences see hew connley mohamed osman and waikar syechbubakr 2 the term human rightism highlights a sense of irony here the former prime minister of malaysia najib razak first coined it to denigrate humanism secularism and liberalism as threats to islam the fact that rightwing islamist actors appropriated the human rights discourse a few years later to pursue conservative causes associated with sexual morality antiminority stances and political authoritarianism is an ironic twist indeed rights issues that journalists and groups like human rights watch have meticulously accomplished instead i argue that we must focus on how nonstate actors who position themselves as active defenders of human rights capitalise on the liminal space these paradoxical normativities offer when they appropriate the human rights vocabulary and reframe it to justify exclusivist majoritarian social political and religious causes these articulations are impactful reinventions of the human right discourse because they shed any moral commitment to protecting minorities and the socially marginalised altogether as such my account builds on similar observations scholars have made when examining rightwing politics in places such as israel and europe that saw a sweeping acculturation of the universal human rights discourse to legitimise the racist and chauvinistic agendas of actors whose ideological predecessors might have scorned such symbolic associations previously whereas these studies focus on actors who adopt an antimuslim position this papers empirical contribution comes from examining those who advance a muslim nativist and majoritarian agenda rightwing nonstate actors active appropriation of the human rights agenda deserves greater scholarly attention for three reasons first such appropriation sustains the appearance of compliance and cooperation in the eyes of external observers rendering invisible the fact that these actors are working to undermine the human rights agenda significantly in issues concerning the protection of gender sexual racial and religious minorities second because they leverage through a nativist framing these actors often enjoy the sympathy if not the tacit support of political and bureaucratic actors and agents who hold the levers of power in malaysias increasing islamicallyoriented ethnocratic regime due to a shared scepticism of human rights as a western conspiracy with other state actors these rightwing activists lobbying efforts unlike their liberal counterparts can easily translate into concrete policy action contrary to their grievous positioning as underdogs having to contend with a hegemonic and foreign human rights regime these rightwing csos work with power holders and brokers not against them 3 third despite the human rights packaging the positions held by these csos overlap with many social conservatives on morality sexuality and family values enabling them to command a sizable local support as we shall see this aspect afforded these activistsmany of whom are newcomers to the human rights scenethe social capital to leverage populist pressures to undermine other established local human rights agencies and activists legitimacy by labelling them as prowestern liberal and even treasonous on social media by advancing a promajoritarian version of human rights they inject ethnoreligious and exclusivist elements not to mention potentially transand homophobic ideas into local discourses about human rights the result reshapes public expectations of the role of human rights defenders and overturns the axis of victimhood to portray the majority as the victim of an oppressive western human rights regime in short this paper examines the cosharing of the human rights rhetorical and institutional space where a globally situated proceduralcentric human rights regime came up against nativist selfproclaimed human rights entrepreneurs who infiltrated its mechanisms and reconfigured its norms while posing as cooperative local partners it depicts a scenario where semantically recognising an overarching ideal of human rights protection does not necessarily safeguard it against normative and institutional erosion it shows that csos can maintain the human rights façade while acting as cheerleaders of state policies that target police and discriminate against socially marginal groupings such as racial gender sexual and religious minorities methodology and paper structure the empirical focus of this paper lies in two areas of interest the first is the historical and social context in which malaysias rightwing human rights activism arose the second concerns the strategic novelties these rightwing actors introduced which stood apart from rightwing islamist actors more rejectionist 3 this perspective also complicates hurds point about the transformative influence of transnational authorities in defining the terms of religious conflict and coexistence in malaysia it is local conservative actors who wield such influence given their proximity to political power their appropriation of the human rights discourse further justifies authoritarian exercises of power as they repackage statesanctioned religious interventions as protecting ones rights to religion and hostile treatment of the human rights agenda before the 2010s it draws heavily from primary sources such as media writings social media postings interviews reports and publications it uses a combination of actor tracing and discourse analysis to illustrate the phenomenon the paper is structured as follows the first section traces the development of a kind of human rights activism in malaysia that involves two nongovernmental organisations the centre of human rights research advocacy and the malaysian alliance of civil society organisations in the upr process that emerged in the late2010s 4 i argue that these movements are distinctive in their explicit tactical and discursive focus on human rights unlike other islamist movements these islamist ngos steered clear of party politics they spent considerable effort positioning themselves as legitimate stakeholders in malaysias human rights agenda such as participating in the united nations human rights councils universal periodic review and maintaining an active media presence to argue for a more cultural relativist understanding of human rights despite their proclaimed human rights niche i argue that we must understand these groups activism within the networked effects of other rightwing islamist affiliates that are also promoting an agenda of muslim majoritarianism and islamic cultural supremacy even as each lobbied in different tones and on different fronts the second and third sections provide an account of the two main strategies employed by centhra and macsa which i examine under the rubric of getting in and pushing out respectively the former refers to how the two groups position themselves as key stakeholders of the malaysian human rights agenda through vigorous participation in institutional processes and active appropriation of the human rights lexicon and iconography the latter depicts an aggressive strategy of exposé shaming and critique of local human rights agencies and activists particularly malaysias national human rights institution the human rights commission of malaysia for pandering to western understandings of human rights i argue that these activities aimed to erode the legitimacy of many established human rights actors in the eyes of malaysians at the same time they hollow out the human rights agenda of its norms and commitments especially concerning the protection of religious and sexual minorities through these empiricallygrounded observations this paper denotes how active participation in the human rights agenda on the procedural and rhetorical front does not necessarily entail its consolidation rather the human rights regime in malaysia appears particularly vulnerable to this twopronged strategy that saw rightwing actors infiltrating to earn insider credentials on the one hand and mobilising external pressures to drive the agenda towards majoritarian and chauvinist ends on the other setting the scene the historical context of malaysias rightwing activism identifying what constitutes malaysias rightwing activism is challenging because communitarianism is central to the postcolonial nations social political and cultural fabric the majority of malaysias mainstream political parties are racebased with many defining memberships in explicitly racial terms 5 for the first 60 years of the nations history a malaydominated consociational coalition the barisan nasional led a government that carefully balanced communal interests with maintaining malaymuslim hegemony in both politicoeconomic and sociocultural spheres the idea of ketuanan melayu further legitimised this notion of malay dominance under the stewardship of the malay nationalist party the united malays national organisation which several factors consolidated and institutionalised 6they include constitutional provisions that recognise the special positions of the malays7 the political dominance of umno visàvis the other component parties in bn and the mainstreaming 4 this paper uses ngos interchangeably with csos giving preference to the former as it comes with less normative baggage 5 for example the membership for the united malays national organisation the malaysian chinese association and the malaysian indian congress admits members only from the titular races although the umno later expanded its membership to include nonmalay bumiputeras to make its way into sabahan politics even the religiously denominated panmalaysian islamic party is defined by an overwhelmingly malaymuslim membership of malaypreferential affirmative action aimed at reducing sinomalay inequalities in the 1970s however the latter has since morphed into a political economy that weaved together statist capitalism clientelism and a burgeoning malay middle class further complicating this picture is that the notion of ketuanan melayu has gradually taken on the rhetoric of ketuanan islam since the 1980s 8 juxtaposed onto the idea of malay political dominance is a line of islamist reasoning that conflated a narrative of social justice for the malayswho were seen as economically backward when compared to the chinesewith an idea of cultural justice that demanded the public sphere be transformed and regulated based on islamic understandings of public morality halal consumption and personal decency one sees this transformation in the incremental implementation of sociocultural policies that outlawed extramarital sex alcohol and nonheteronormative relationships among muslims nonetheless such effects bled into nonmuslim lives due to the cosharing of public spaces as the constantly bumbling discord about liquor sales control evinces nativist arguments supported these conservative yet authoritarian policy positions with proponents claiming that islamic values must permeate the social and political space because islam was the original law of the land prior to the advent of colonialism i call it nativism because it reflects highams classic definition that based it on an intense opposition to an internal minority on the ground of its foreign…connections this nativist streak in malaysias rightwing islamism is most recently seen in campaigns such as the bmf movement launched in 2018 which coopted malay nationalist sentiments to function as an unstated boycott of nonmuslim or mainly ethnic chinese produced goods islams increased saliency is arguably inexorable given the interlocking of the malay identity with the religion and the fact that many interpret malaynonmalay divisions in malaysia though not always neatly as a muslimnonmuslim partition 9 the trend was also intensified by dynamics of topdown islamisation as a result of umnos competition with its islamist rival the panmalaysian islamic party on the one hand and bottomup islamisation that was following global patterns advanced by muslim dakwah movements that peppered the urban landscape since the 1970s on the other in short a conservative ecosystem has long acclimatised malay politics especially after the demise of an inchoate leftist streak following state oppression it is a form of conservatism that rewarded racially and increasingly religiously exclusivist discourses and policies that in turn reinforced racial categories and religiocultural hierarchies historically umnos pragmatic leadership circumscribed the parameters of such exclusivism they were careful to not perturb malaysias multicultural peace as it was conducive to the nations political stability and economic growth put differently since the 1980s a malaymuslim majoritarian ideology was increasingly institutionalised and normalised yet simultaneously curtailed by an authoritarian state that maintained the equilibrium 10 if umno was the metaphorical lid to these majoritarian forces its dwindling political strength political strength after the 2008 elections and even more so after the bns historic defeat in the 2018 general elections saw rightwing majoritarian activism take off via numerous malay nongovernmental organisations 11 rightwing populist groups such as the malay nationalist pertubuhan pribumi perkasa language is the national language see moustafa for the historical context under which the constitution drafted the idea of the malays special position see fernando 8 i have revised the translation of ketuanan from overlordship to supremacy to signify the changing meaning of the term the discourse of powersharing premised on the recognition of malay indigeneity has now shifted towards one of majoritarian identity politics in which islam functions as a symbolic resource to justify and perpetuate a hegemonic and exclusivist religious discourse 9 a malay is defined as someone who professes the religion of islam habitually speaks the malay language and conforms to malay custom in article 160 of the constitution nagata perceptively observed that as language and custom faded away as distinctive identity markers of malayness due to cultural integration islam became the last bastion of malay identity 10 for example the existence of the internal security act sedition act and the printing presses and publication act has limited the parameters of free speech often in the name of maintaining racial harmony nonetheless the weight of the law more frequently impacts those questioning umnos rule instead of those who spewed antiminority hate speeches 11 abdul hamid and ismails tracing of how a more assertive form of conservative islamism has risen during abdullah badawis leadership provides a genealogy of said developments whereby the mutual reinforcement of weakening malaysia and the islamist ikatan muslimin malaysia painted umnos demise as a result of nonmalays and nonmuslims colluding to overturn the longestablished malay political order 12 their messaging often signalled the malaysian chinese as the main culprit we may consider these groups populist as their activism frames their struggle as elite vs masses however their underlying worldview is nativist wherein corrupted malay elites have forsaken the indigenous malay masses by selling out to chinese interests whom they see as pendatangs 13 this penchant for populist politics is why social media is so central to their strategies the platforms aggregating strength allows these rightwing groups to mobilise populist opinion against minorityfriendly groups and agendas they oppose as we shall see later i categorise these groups as rightwing because they shift a conservative malaymuslim nationalist discourse to extreme positions these groups did so via fiery rhetoric such as perkasas threat to burn bibles advocating for an extraparliamentary rule such as ismas proposal for semidemocratic rule to preserve malaymuslim hegemony 14 and championing a form of racial exclusivism to replace the old model of malaydominated consociationalism with a malaymuslimonly government isma in particular has spearheaded aggressive online campaigns and electoral strategies to dislodge nonmalay parties from the ruling coalitions of the bn and later the perikatan nasional 15 moreover it is telling that a party with strong connections to connections to isma berjasa have joined a coalition called gerakan tanah air which fielded no nonmuslim candidates in the 2022 general elections longtime observers will not find ismas total political exclusion of nonmuslims surprising given that it has been their longterm goal what is more concerning is the gradual mainstreaming of these views in the 2022 general elections pn which won the second highest number of parliamentary seats fielded a paltry number of nonmalay and nonmuslim candidates far fewer when compared to the umnodominated bn this trajectory of mainstreaming malaymuslim majoritarianism appears to mimic that of the hindu majoritarian bharatiya janata party in india which currently has no muslim representation in parliament and does not seem to care about changing the situation as they continued to field a negligible amount of muslim candidates in elections and propagate an exclusivist rhetoric that clearly targeted the muslim population complicating efforts to call out these actors extreme rightwing positions is their mainstream social existence even though academic writings have addressed them as worrying trends these actors were rarely subjected them to the social stigma that befell farright groups in the west for example they could still meet or share platforms with ministers and senior civil servants hold columns in mainstream newspapers and join umbrella organisations with other more moderate malay leadership and umnos diminished electoral fortunes served as the backdrop to the rising influence of rightwing ethnoreligious populists 12 on perkasa and ismas rightwing activism see hamayotsu hew pusat komas malaysiakini 13 on populist ideology see mudde and kaltwasser on a sample of writing by the president of isma that belied such elite disillusionment see ismaweb 14 the article uses the pandemic and malaysias political instability to justify its advovacy for semidemocratic rule in that besides the prime minister all ministers and governmentlinked companies appointees cannot be parliamentarians but rather technocrats and civil servants to be fair such calls to nullify parliamentary rule during the pandemic were not exclusive to isma but proponents were mostly politicians as most csos in malaysia favoured parliamentary oversight instead of doing away with it the articles claim that the political chaos has led to malaymuslim interests being pawned when coupled with its call for extraparliamentary rule reveal its fascistic undertones 15 the two prongs of ismas strategy is as follows the first is to set up a facebook page called gerakan pengundi sedar that urged voters to vote for credible muslim candidates of all the candidates they endorse none of them were from the pakatan harapan coalition that advocated for a more multiethic model of politics second during the 14 th general election in 2018 when bn or pas did not send a muslim candidate in a malaymajority area isma under the banner of berjasa would send their own muslim candidates to contest against the nonmalay candidates aiming to break the longterm compromise in malaysia that candidates do not always have to reflect the majority race of a constituency so that ethnic minorities can still gain meaningful representation see abdul hamid andche mohd razali hew malaymuslim csos with little to no pushback 16 this situation is appalling if one considers that according to muddes definition we should regard these groups as the far right due to their hostility to liberal democracy characterised by extreme exclusivist attitudes towards minorities including calling them invaders at one point nevertheless calling out their ideological positions is fraught with risks especially if the messenger is based in malaysia an academic who called isma extreme rightwing in an article saw it withdrawn from its singaporebased platform after one of the individuals named in the article threatened a lawsuit the social acceptance of what may look to many as discriminatory if not extreme positions further insulate some of these actors from critique enabling them to infiltrate a traditionally liberal domain such as human rights majoritarianism as human rights the centring of human rights in malaysias rightwing islamist activism the emergence of rightwing ngos that position themselves as human rights organisations is connected to the developments above the gradual weakening of umno that resulted in its ouster from government in 2018 and the pervasiveness of what hew calls liquid islamism emerging from the overlapping between pious urbane muslim middleclass aspirations and an increasingly syariahminded political consciousness resulted in the mushrooming of numerous muslim pressure groups in areas ranging from consumerist interests to womens issues as a social movement these muslim ngos are comprised of urban middleclass activists seeking to actualise their ideas of islamic rule in malaysia through nonelectoral means such as ideas propagation public pressuring and stakeholder lobbying due to their conservative outlooks they tend to differ and at times clash with the more progressive ngos on issues of sexual morality censorship religious freedom and social inequalities in malaysia to be sure malaymuslim groups also inhabit the progressive parts of malaysias ngo ecosystem as in the cases of the sisters in islam the islamic renaissance front and komuniti muslim universal malaysia their efforts to advance a more humanistic and feminist reinterpretation of islamic orthodoxies inform their activism however by virtue of their professed malaymuslim identity the state and religious establishment significantly censured and ostracised these groups for example sis was labelled deviant in a fatwa irfs book was banned and kmu activists were doxed and harassed forcing some to seek temporary asylum abroad the harsh treatment of these liberal muslim ngos often cheered on by their rightwing counterparts shows how the contestation of norms and rights has expanded from a statecsos axis to a culture war between the csos tamir moustafas work traces this war back to a rightsversusrites binary that saw controversial court cases manufactured into public spectacles that in turn drew public opinion and competing activists into skirmishes that sought to settle the question of malaysias secularislamic identity in a zerosum and highstakes manner these battles increased stakes eventually leaked into the upr process in which malaysia has participated since 2008 to summarise briefly the upr is a process that enables the hrc to review the human rights record of a country every five years the process involves assessing reports from governments independent experts and national stakeholders such as nhris and ngos after the review states receive recommendations to improve their human rights condition which they can accept or simply note the upr initially attracted many ngos from the liberal end of the value spectrum who organised themselves as the coalition of malaysian ngos in the upr process however by its third round of review in 2018 the participants had diversified with groups such as centhra and macsa emerging as a conservative islamist bloc centhra and macsa arose as the successor to a coalition of muslim ngos muslimupro that came into the scene during malaysias second upr in 2013 muslimupro argued that the malaysian governments proposals in response to the upr process must 16 isma for example is a member of the allied coordinating committee of islamic ngos in accin they share a platform with other more moderate islamist csos like the muslim youth movement of malaysia and pertubuhan ikram malaysia be properly based on syariah laws and the federal constitution when compared to its successors muslimupro was more confrontational and disagreeable in 2013 it attacked comango as foreignfunded and successfully pushed for it to be banned they also polemically claimed that unqualified persons represented muslimmajority nations while drafting international human rights conventions nonetheless they had dropped these aggressive stances by the time of centhras and macsas establishment they even obscured the muslim aspect of their identities by eliminating the term muslim from their names at this point a brief introduction of the two groups is due azril mohd amin who once headed muslimupro founded centhra in 2014 it calls itself a research and advocacy organisation that …provide s an alternative to the global human rights perspective in order to offer a more balanced view that is respectful particularly of the muslim faith and tradition and in general the abrahamic tradition 17 nonetheless the true successor to muslimupro is macsa established in 2018 it claims to represent 52 ngos with most if not all being muslim ngos many of these ngos were involved in muslimupro including the muslim youth movement of malaysia and isma 18 cochaired by azril mohd amin and a university sains islam malaysia lecturer in physiology rafidah hanim mokhtar during its founding macsa also proclaimed strengthening human rights as its agenda although it was couched in an islamistand nativistinflected language we can understand the entry of muslimupro and later centhra and macsa into the human rights scene in malaysia as an act to counterbalance the perceived preponderance of liberal csos such as suhakam and the various groups within comango in the upr process yet unlike many islamist actors who viewed human rights as an outright western import not worth engaging in centhra and macsa have fronted human rights activism as their raison detre they call themselves human rights defenders explicitly and have positioned themselves as informed stakeholders who should be consulted in the upr process they have done so by meeting with the ministry of foreign affairs to discuss the upr submitting a stakeholders report to the hrc for review celebrating international human rights day on their social media page and even sending delegates to participate in the upr process as observers in geneva key personalities and ideological affiliations even as it played down such associations macsas islamist and nativist leanings are noticeable in three aspects its internal composition rightwing ideological affiliations and issue positions 19 firstly the groups that came under the coalition are mainly islamist organisations including the allied coordinating committee of islamic ngos one of the largest islamist umbrella organisations in the country one of the oldest islamist ngos in malaysia abim founded by the prominent politician and sitting prime minister anwar ibrahim is one of macsas members as well 20secondly the group overlaps with the aforementioned rightwing islamist group isma in terms of its personnel and public position thus it is hardly surprising that macsas most prominent activists have taken some relatively hardline positions on issues concerning politics identity gender and religion for instance the cochairperson of macsa dr rafidah was the information chief of the womens wing 17 who we are at centhraorgwhoweare 18 macsa in upr 2018 wafiqmy 30 october 2018 available at 19 the confluence of islamism and nativism can be seen in vedi hadizs study of islamic populism see hadiz i hesitate to use the term populism to discuss macsa and centhra because they were not involved in the kind of popular mobilisation embarked by populist movements nor were they enjoying sizeable popular support as groups like the front pembela islam in indonesia has of isma which according to abdul hamid and che mohd razali maintains an anachronistically xenophobic and ethnocentric worldview back in 2014 dr rafidah was herself involved in ismas push to get comango banned for challenging the position of islam in malaysia and spreading liberalism teachings backed by western powers she claimed that the sacrosanctity of islam is at stake because comango was pushing for the flourishing of lgbt culture the other cochairperson of macsa since 2019 lukman sheriff alias is a lawyer involved in opposing the malaysian governments ratification of the international convention on the elimination of all forms of racial discrimination 21 isma also took a vehemently antiicerd stance engineering a massive protest by galvanising malaymuslim political parties and ngos 22 lukman was reportedly part of a conservative islamist faction trying to gain hold of malaysias relatively liberal bar council and a key proponent of legal reforms that would elevate the power of syariah courts in malaysias parallel court system 23 the former cochairperson of macsa and current chief executive of centhra azril was once caught in a controversy for reportedly calling for a ban on christian evangelicalism claiming that a high number of muslims were leaving the faith 24 isma similarly propagated a moral panic through an conspiracy of christians infiltrating putrajaya thirdly macsa primarily directed its human rights advocacy at issues of most interest to proponents of islamism on the domestic front these focused on conceptions of moral sins such as the lgbt issue extramarital sex 25 and alcohol consumption their human rights worldview is linked to their push for increased syariahisation of malaysian laws which they believe to be a solution to such social ills for example macsa activists supported a bill called ruu 355 that would have removed the constitutional barrier for the state government of kelantan to implement hudud laws that criminalise adultery with punishments that included stoning to death or 40 to 80 lashes for any muslim caught drinking intoxicating substances macsa also criticised many nonmuslim politicians who questioned the bill as politicising islamophobia these macsa activists justified their religioconservative positions through either revisionist legal arguments that claim the constitution underscores islams supremacy as the religion of the federation in article 3 26 or nativist majoritarian reasoning that the national identity must be based on the indigenous culture of the nation with malay civilisation and culture as well as islam being the main and important component on the international front issues of muslim persecution such as the rohingyan refugee crisis the palestinian issue and the xinjiang problem remains the mainstay if not the sole focus of their advocacy with much energy spent on highlighting the hypocrisy of the western liberal order to summarise we can view macsa and centhra as islamists because they demonstrate notable features of political islaminaction their activism sought to impose doctrinal purity in public spaces and muslim private lives relied on victimhood discourses to create a sense of empowerment and championed increased syariahisation as a bulwark against secularism however as newcomers to the human rights scene macsa and centhra made little effort to combine the universalistic aspiration in the conventional human rights tradition with islamic teachings 27 instead they have focused on championing an islamist agenda reframed in nativist and cultural 21 icerd was ratified by 55 out of the 57 organisation of islamic cooperation nations so malaysia is not the norm but an exception 22 on the fracas about icerd in malaysian politics see jayasooria 23 on malaysias parallel legal system see tew 24 nonetheless all demographic projections have shown that the muslim population in malaysia is bound to increase to 72 per cent in 2050 from 64 per cent in 2010 see malay mail online 25 see for example dr rafidahs position that malaysias education system should teach students that sexual intimacy should only exist within a legal marriage at mokhtar relativist terms their ideological worldview also made their human rights agenda exclusionary to the religious sexual racial and gender minorities that historically and today remain the usual target of human rights abuses in malaysia although centhra has highlighted issues of statelessness concerning malaysian indians and the orang asli discursive framings and strategies there is nothing inherently problematic or unique about conservative religiopolitical activism which one can trace historically to the asian values debate in southeast asia and geographically to conservative evangelical politics in the united states however case studies in israel where a human rights vocabulary is used to justify a rightwing discourse of settler justice or in europe where generation identitys rights to identity ultimately championed a xenophobic cause should warn us from taking these human rights turns at face value in malaysia rightwing actors appropriation of the human rights agenda is a concerning development for two reasons first these campaigns redefine the language of human rights to limit its parameters of protection and undercut its potential for emancipation thereby justifying extending state authoritarianism and the continued marginalisation of disadvantaged and stigmatised minorities second their discourse subverts the content of human rights traditionally aimed at securing the rights of marginalised minorities living under majoritarian pressures rightwing human rights narratives flip the discourse by reinventing the majority as the persecuted group going squarely against academic and activist findings of malaysias narrowing religious and cultural space due to statebacked islamisation pressures one uncovers macsas subversion of the human rights agenda in three aspects of its framing first macsas stated agenda dilutes the human rights agenda by situating the udhr within the triple confines of cultural relativism doctrinal supremacy and statist exceptionalism these elements emerge in macsas message concerning human rights improvement measures undertaken following the upr …in addition to upholding international human rights instruments such as the universal declaration of human rights 1948 the cairo declaration on human rights in islam 1990 and the asean human rights declaration 2012 they must also be in tandem with malaysias own laws and customs particularly with the federal constitution and the constitutions and positions of the states existing within the federation 28 there is no question that the human rights agenda has always struggled between universalistic ideals and particularistic contexts including in western settings however by ringfencing the discourse of human rights within the cdhri ahrd and national laws29 macsa narrows the usual scope of protection that the human rights project affords by conflating higher and humanistic ideals with a meshwork of declarations and national exceptionalisms that preponderantly skew towards protecting preexisting patriarchal and regimeaffirming hierarchies its version of human rights risks eroding whatever checks and balances against state and majoritarian excesses the project promiseseven if only as moral supportto victims of oppression and discrimination second the discourse that macsa employs obscures and subverts human rights guarantees of freedom and choice with euphemisms such as religious and health rights of lgbt personsthe language it used in its stakeholders report to the upr process these euphemisms diverted the lgbt rights discourse in two directions the first was a medicalised discourse that depicted lgbt communities as public health issues culpable for the transmission of hiv and other highrisk 28 macsa formed to strengthen human rights in malaysia november 16 2017 at one should note that the legislation behind the founding of suhakam only mentioned the udhr and the federal constitution as its reference of the human rights commission of malaysia act 1997 which has been a bugbear for rightwing islamist activists behaviours 30 macsa activists also condemned the phenomenon as a lifestyle stemming from a liberal fascist ideology that goes against the prevailing sentiments and religious concerns of the general public they actively pushed for state intervention to protect the muslim public against immoral and indecent acts 31 with a handful of christian representatives macsa activists also invoked the idea that the lgbt lifestyle is against all religious traditions and the principles of courtesy and morality within malaysias rukun negara 32 the second direction was a religious rights discourse that stressed the lgbt communities right to religious input and education 33 what these narratives concealed was their support of controversial statesponsored religious programmes one example is the mukhayyam programme that claims to inculcate spiritual awareness through a religious approach to face the challenges of life and abandon the practice of unnatural sex which led to comparisons with conversion therapies in the west human rights watch even describes these programmes as manipulating lgbt people into believing they are deviant although macsa insisted these programmes are voluntary 34 the hrws research disputed that notion by demonstrating that participants received inducements to participate macsas preoccupation with defending these controversial programmes from criticisms contrasts against its silence on malaysias criminalisation of homosexuality and transgender people through penal code and syariah enactments put differently rather than addressing legal and religiousmoral stigmatisation of lgbt communities macsa shifts the problem to their alleged deprivation of religious and spiritual care which it never substantiated empirically third macsas appropriation of the human rights agenda aims to strengthen a majoritariannativist agenda through the creative engineering of majoritarian victimhood the majoritariancentricity of macsas human rights discourses appears in its founding statement it argued that the term indigenous people in human rights discourse must include the malay majority 35 in reality however the term occurs specifically in human rights discourses to refer to the aboriginal orang asli who face severe social and economic marginalisation given their small population approximately 07 per cent of the peninsulas population this specific term sets the orang asli apart from the malay community in malaysia who constitute the majority and are politically economically and socially dominant 36 even though many of the orang asli were not muslims macsa still advocates for their assimilation through educational and islamic outreach to encourage them to adopt malay language and to assimilate to malay culture and customs 37 the irony is certainly not lost here that despite their prouyghur positions macsa is adopting a vernacular that could easily be construed as entering cultural genocide territory macsas many statements and articles also propagated a victimhood narrative that pictures the majority malaymuslim community as systematically subjected to islamophobia the rukun negara was drafted as a national philosophy after malaysias devastating racial riots in 1969 its five principles are belief in god loyalty to king and country supremacy of the constitution rule of law and courtesy and morality the principles themselves are not legally binding and remain a source of contention and semantical acrobatics for proponents of various forms of politics whether secular or religious 33 uphold religious and spiritual values on sexual morality and family unit july 23 2020 at upholdreligiousandspiritualvaluesonsexualmoralityandfamilyunit 34 mukhayyam honour the religious rights of lgbtq people august 5 2020 at 35 macsa formed to strengthen human rights in malaysia november 16 2017 at 36 international work group for indigenous affairs malaysia at textas 20of 202017 2c 20the 20indigenouscollectively 20known 20as 20orang 20asal 37 macsa formed to strengthen human rights in malaysia november 16 2017 at alias and mokhtar 2021 for example referencing a case where the court ruled that the consent of both parents is needed before a child can be converted to islam the stakeholders report macsa submitted calls it the discrimination against parental rights of muslim reverts effectively invoking the idea of muslim supremacy in what is supposedly an issue of coparenthood 38 echoing the use of hinduphobia to stymie dissent by hindu nationalists macsa also published a report on islamophobia that condemned perceived negative media depictions of islam as well as any criticisms of malaysias muslimdominated government as islamophobic by citing scholarly critiques of islamophobia meant to highlight the plight of muslim minorities subjected to majoritarian treatment the report appropriates the moral indignation behind the term to justify its narrative of majoritarian victimhood 39 unsurprisingly it is utterly silent about legitimate minority fears of assimilative pressures and the continuous erosion of their political economic and cultural rights in malaysia it is also worth noting that macsas majoritarian and revisionist interpretation of the human rights agenda did not refer at all to pressing issues that needed international pressure to overcome state inaction such as two wellreported cases of enforced disappearances in malaysia 40 instead of targeting the socially and politically marginalised the human rights agenda that groups like macsa advance merely reproduces the political mainstream that saw minority interests tossed aside when the competition in malaysia for malaymuslim votes intensified from the late 2000s in other words such majoritarian appropriation and derailing of the human rights agenda does not broaden the terms of debate but constricts and narrows the circle of victimhood to favour the status quo and all its attendant power imbalances worse it portrays the many racial sexual and religious minorities as victors and persecutors effectively gaslighting minority woes and individual experiences of injustice amidst the rising currents of muslim majoritarianism in malaysia this section has thus far laid out the broader political context the social ecosystem and the ideological worldview that sparked the infiltration of a kind of rightwing islamist activism into the human rights domain the following section will focus on two aspects of human rights politics that groups such as centhra and macsa undertook to mainstream their religious majoritarian version of human rights they include institutional and discursive strategies of getting in that help rightwing actors gain legitimacy in formal human rights processes and aggressive strategies of pushing out that ostracise liberal rivals and status quo gatekeepers through tactics of exposé and public shaming getting in gaining legitimacy as a human rights defender despite their efforts to reformulate and resist what they see as foreign human rights norms actors from macsa and centhra actively position themselves as insiders to the cause their nativist positions notwithstanding these groups often resort to english as their primary medium of communication this strategy dovetails with the fact that english remains the working language for human rights advocacy in malaysia and internationally echoing generation identitys appropriation of symbols associated with amnesty international macsas full name the malaysian alliance of civil society organisations in the upr process bears a striking resemblance to comangos notably both use a similar blue hue in their logos most tellingly when comango raised concerns about macsa having an almost identical name yet adopting abjectly contradictory stands on issues of female genital mutilation or cutting whipping polygamy and womens and girls unequal 38 note the use of the term muslim revert in the report which is the preferred terminology of some dakwah movements implying a return to an original state the term contrasts with convert that highlights change which arguably speaks better to a scenario that necessitates readjustments from all parties such as in the case of a childs religious upbringing when one parent converted 39 notwithstanding the empirical fact that malaysias head of state all its prime ministers and deputy prime ministers all senior ministers in the pn government its head of police and military and more than 80 percent of the civil service are malay muslims inheritance macsa fired back at comango for their unprovoked malicious attacks on their fellow human rights defenders 41 this effort to build insider credentials as a human rights defender benefitted from macsas active participation in the upr process such as submitting their stakeholders report and sending a delegate to the upr sessions in geneva the group also provided training for those wishing to participate in future upr processes a move aimed at breaking the hold of liberal human rights actors on these mechanisms this newfound proclivity towards technocratic activism that departs from the kind of protest and mobilisational politics in muslimupro days helps sharpen macsas image as a civil and legitimate stakeholder within the human rights agenda despite their synergistic origins and alignment in ideological positions macsas leaders have softly distanced themselves from ultraconservative groups such as isma to focus on their human rights activism 42 this decision in turn enhances macsas appeal to the middleclass malaymuslim bourgeoisie that prefers a more intellectual outlook in ones activism this strategy of getting in appears to be astonishingly successful given that despite being a newcomer to the scene macsa was one of the few human rights bodies the ministry of foreign affairs consulted in 2018 when formulating a new foreign policy framework mofa cemented their legitimacy as human rights defenders by engaging macsa as the putative islamic bloc alongside other human rights stakeholders such as suhakam and comango during the upr process in 2018 astoundingly this event happened during phs administration logically ph should have been less friendly to actors with putative ties to rightwing muslim ngos like isma as they led a vehement oppositional campaign against the ph government they deemed antimalay and antiislam interestingly media reports had labelled macsa as human rights defenders even as one journalist acknowledged comangos and macsas clashing interpretations of human rights not to mention the latters smear campaign against the former a few years earlier by 2021 macsa and centhra gained column spaces in malay and english mainstream newspapers such as new straits times berita harian and utusan malaysia where their activists frequently wrote about human rights issues nevertheless successfully getting in was not unexpected as macsa activists already enjoyed considerable insider access for a start the groups conservative islamist take on human rights issues has always enjoyed some degree of sympathy and support from many within malaysias civil service particularly the islamic bureaucracy the federal department of islamic development of malaysia has collaborated with various islamist ngos including isma to counter liberal causes in malaysia the majlis agama islam wilayah persekutuan reportedly sponsored macsas delegation to geneva 43 moreover azril mohd amin the head of centhra was a special officer to malaysias 8 th prime minister muhyiddin yassin giving him insider access due to the social and islamic affairs clusters he oversaw after muhyiddins resignation azril was appointed chief executive officer of the institute masa depan malaysia a think tank linked to muhyiddins party the malaysian united indigenous party 44 dr rafidah on the other hand is a public university professor who as of this writing serves as a member of the womens council of the yayasan dakwah islamiah malaysia a statefunded body coordinating the dakwah activities of muslim ngos 45 she is also the president of the international womens 41 macsa comango attack of fellow human rights defenders smacks of diversion and desperation 28 june 2018 available at 42 for example muslimupros push for comango to be banned in 2013 was complemented by ismas campaign to collect one million signatures in support of the call see human rights in asean 43 macsa formed to strengthen human rights in malaysia 16 november 2017 available at 44 institut masa depan malaysia buat kajian mendalam hala tuju parti orang melayu institut masa dean malaysia to research about the future of the party and the malays berita harian december 30 2018 at beritapolitik201812514530institutmasadepanmalaysiabuatkajianmendalamhalatujuparti 45 presidents biography at alliance for family institution and quality education also part of macsaworking with the religious authorities in malaysia in their mukhayyam programmes that claim to serve those who have repented from their lgbt lifestyles 46 put differently despite their polemics that human rights is merely a playground for the liberal detached elites the prime movers of this conservative nativist and islamist version of human rights activism in malaysia are very much a part of the upper social classes too pushing out networked assault on suhakam and human rights activists centhras and macsas strategy of positioning themselves as competent human rights insiders also generated substantial pressure for many established human rights organisations such as comango and suhakam acting as dedicated human rights observers these groups often resorted to critiques and exposés to push liberal human rights organisations into public attention to invite state intervention or public backlash i have already discussed efforts to get comango banned in the early 2010s above recently these groups have directed efforts of pushing out at suhakam admittedly the most important party to malaysias upr processes given its status as the nhri at this point it is worth briefly surveying suhakams role which has been a matter of fierce debate established in 2000 under the human rights commission of malaysia act 1999 suhakam is a statutory body that enjoys an international mandate established by the paris principles which guarantees it some measure of financial personal and institutional autonomy from the government in practice however suhakam is still dependent on state funding and appointments and plays more of an advisory and educational role in mediating between international norms and local contexts to advance human rights agendas by having an investigative mandate that allows the agency to examine and report on allegations of human rights abuse suhakam often finds itself in an unenviable position where human rights ngos accuse it as being toothless and the government sees it as a nuisance 37 a fair assessment of suhakam would be that it helps with the popularization of human rights even if the agency maintains strict nogo zones on issues of race and religion directly contradicting the paris principles special emphasis on combatting racial discrimination 47 even as suhakams silence on many racial and religious discrimination issues exasperated critics human rights ngos have thus far been able to count on suhakam as a distant ally to uphold human rights standards that are at least nominally antiauthoritarian and committed to protecting minority rights however that could change as rightwing human rights activists have astutely targeted suhakam itself as a site for contention infiltration and subversion although it has maintained a working relationship with suhakam on selected issues such as child rights and the convention against torture 48 macsa has resolutely disagreed with suhakam on topics such as abolishing the death penalty and sedition act child marriage and tackling discrimination towards ethnic gender and sexual minorities concerning these issues macsa hewed to the position of the conservative promalay proorthodox islam establishment whereas suhakam took more progressive positions 49 as noted above macsas vision of empowerment for the orang asli aspires to assimilate them as muslims whereas suhakam has criticised covert efforts to convert the orang asli 24 macsa couched its disagreement with suhakam in cultural relativist arguments it accused suhakams positions as primarily based on the udhr and not the cdhri and ahrd that better reflected the regions and malaysias religiocultural context because the human rights commission of malaysia act 1999 did not include the two declarations macsa also pushed for its amendment demonstrating its appetite for institutional reforms that went beyond the aggressive protest politics of the past in any case any sign of collegial disagreement between suhakam and macsa all but disappeared when news about the agency researching the feasibility of having legislation of the recognition of a third gender in malaysia leaked in june 2021 accusing the agency of being against all faiths in an englishlanguage article dr rafidah lambasted it for having exposed their own lack of independence and blind deference to whatever external pressures that are being wielded upon them to promote this immoral agenda in another malaylanguage article she argued that for muslims secular principles of human rights were not harmonious with religion and especially singled out the muslim commissioners for adhering to the paris principles rigidly to the extent they went against islamic teachings and the constitution 50 this line of critique and worse its backsliding to ad hominem attacks was taken up by isma and later the pertubuhanpertubuhan pembela islam then headed by a former president of isma aminuddin yahaya 51 on one of the facebook pages that isma managed a posted image contained the faces of suhakams commissioners under the title those responsible for the maliciousness of suhakam the post called out suhakam for its five sins striving to recognise the third gender legalising prostitution pushing the government to provide special facilities to the transgender community normalising the idea of nonbinary gender by including it in their report and opposing the criminalisation of muslim apostasy in malaysia three days later a macsa facebook post again featured the nine suhakam commissioners with their photos displayed alongside a message protesting suhakam for allegedly trying to recognise a third gender aminuddin went further by listing the names of the four muslim commissioners and rhetorically asking what were their functions in the agency if not to protect islam 52 one of the commissioners professor nik salida an islamic law lecturer was also singled out figure 3 shows an image posted on facebook where her face paired with a purported statement of hers claiming all gender identities and sexual orientation should not be discriminated was laid next to the then minister of islamic affairs claim that malaysia rejects lgbt and will not recognise the third gender outing the muslim commissioners in this way helped polemicise the issue through the lens of religious identity soon netizens left comments claiming that the problem with suhakam was that the majority of the commissioners were nonmuslims aminuddin also called for action against suhakam including changing the lineup of its commissioner to include more islamic scholars 53 doxxing attacks also befell a suhakam staff member whose face was appended on articles that called him out for saying that stateenacted syariah laws can be criticised because they are ultimately manmade 54 these naming and shaming tactics were effective because they exploited suhakams precarity and exposure to state manipulation on the one hand and populist anger on the other notwithstanding its stature as malaysias nhri that comes with certain safeguards of institutional autonomy the government often subjects suhakam to its pressure and influence for example in 2016 suhakam had to endure a 50 per cent funding cut from the najib administration that had proclaimed human rightism as its enemy 50 the article is muted however in explaining how exploring the issue of nonbinary genders in research infringes the malaysian constitution 51 pembela started out as an abimled movement agitating over controversial court cases involving muslim converts and apostasy see abdul hamid in october 2022 aminuddin yahaya left his post as pembelas president to run as an election candidate of gta which ismas affiliate berjasa was also part of in malaysias 15 th general elections despite claiming to be nonpartisan like isma pembelas facebook page kept echoing gtas ultranationalist narratives of the malays and islam under threat 52 rupanya suhakam diterajui profesor syariah tokoh maal hijrah ahli majlis agamatapi mana mereka so suhakam is led by islamic law professor prominent islamic figure and member of the islamic councilbut where are they beritamelayukini 18 october 2021 available at available at even the elected ph government that was more amenable to the human rights agenda had continued the opaque practice of appointing suhakam commissioners without any parliamentary oversight suhakams porosity to state intervention renders it more vulnerable to media campaigns and institutional capture mounted by conservative and rightwing elements moreover significant quarters within the statewhether politicians academics or civil servantshave long considered the agency too prowestern and antiislam such scepticism of the human rights agenda is evident in a paper coauthored by the secretarygeneral of the ministry of home affairs that counts fanatical human rights groups as one form of violent extremism thus pushing out the commissioners who owed their appointment to a government that contained an islamist partner 57 achieved two motives exposing the commissioners to public shaming and shoring up public expectations for the appointment of more islamicallycompliant commissioners in the future without the state showing support or making any guarantees of protection these pressure and intimidation tactics even if mainly on social media appeared to have worked 58 on 15 december 2021 to the shock of many human rights activists suhakam released a statement clarifying its stance on religious rights and the lgbt issue conceding vaguely to the islamists and cultural relativists positions for example the statement asserts that enactments against muslim apostasy are legitimate in malaysia when this article was written pas was still part of the bnpn government that ruled malaysia from february 2020 to october 2022 however after the general elections on 19 november 2022 where no coalition managed to achieve a simple majority the new phled government has as of writing not incorporated pas however the political situation remains fluid and pas may very well return to government if the current government collapses under statelevel syariah laws contravening suhakams longstanding position on religious freedom the statement also claims that even as the federal constitution guarantees fundamental rights for the lgbt community such rights… …are not amenable to them practicing a lifestyle that is contrary to the cultural and religious norms of this nation besides individual rights human rights law should also protect collective rights and be balanced with the imperative to safeguard malaysias multicultural peace 60 additionally suhakams commissioner lineup has tilted towards the conservatives the new chairperson appointed in mid2022 has argued against malaysia joining the rome statute and icerd one of the new commissioners was a former directorgeneral of jakim an agency that often butted heads with human rights ngos because it accused the agenda of being antiislam it would appear that in return for their activism to push out the more liberal commissioners rightwing islamists were rewarded with appointments more sympathetic to their conservative islamist cause given the aggressive lobbying and personal attacks it is difficult to take this concession as simply an outcome of civil debate between particularistic and universalist proponents of human rights which the normative literature on human rights tends to assume the tussle was hardly ever framed in theoretical or philosophical terms nor did one treat the other as a worthy equal dialogue partner suhakams precarious position as an nhri holding relatively liberal positions within a conservative malay ethnonationalist regime that included an islamist governing partner rendered it almost defenceless in the face of these attacks more so when the political parties in the opposition were hesitant to support the agency for fear of a conservative backlash the harnessing of social medias galvanising potential also helped these rightwing actors penetrate the insular and bureaucratic world suhakam usually operates in forcing the agency and its leadership out of their comfort zone to face semblances of majoritarian pressure as these rightwing activists claimed to be speaking for the silent conservative malaymuslim majority they mounted these networked and seemingly coordinated attacks against suhakam across multiple platforms creating a wave of populist anger suhakam alone seemed illequipped to respond most notably these interlocutors kept questioning suhakams legitimacy in representing the interest of the majority malaymuslim community as a statefunded body blithely dismissing suhakams mandate as human rights agency and not a communitarian one 61 conclusion this papers objective lies in identifying novel strategies of human rights activism that turned human rights discourse into a cover for undermining it these strategies include appropriating human rights rhetoric to soften elements that belie ethnoreligious supremacist thinking tapping into ones proclaimed status as a human rights defender to deflect criticisms for advancing positions that violate human rights and maintaining a technocratic sheen to convey legitimacy for ones activism by strategically promoting revisionist and majoritarianfriendly interpretations of human rights rightwing actors further undermined the precarious legitimacy and limited autonomous space that malaysias embattled human rights activists and the nhri occupy put another way they attenuated the enormous challenges already faced by these human rights activists in their struggle to advance civil liberties and to preserve the nations multicultural social fabric 2019 this article has opted for a twostep analysis to untangle these developments first i discussed its historical context namely the rise of rightwing ethnoreligious forces in the face of increasing political instability in malaysia second i highlighted two tactics rightwing ngos employed to position themselves as legitimate human rights defenders for heuristic purposes i name them strategies of getting in and pushing out the former entails institutional participation and social media campaigns that position centhra and macsa as bona fide human rights stakeholders and experts the latter refers to aggressive and networked campaigns of outing that name and shame suhakam and other established human rights ngos as unislamic overly liberal and uncritically parroting the western agenda these strategies operated in tandem to rally sympathetic opinion from conservative elements within and without the state to pressure suhakam to accept a majoritarian cultural relativist understanding of human right they also gradually excluded proponents who held liberal views from state institutions and engagement what i described in the malaysian case is not unique domestically or globally domestically the rightwing human rights activism i highlighted is not an isolated venture but part of a broader revisionist project rightwing actors undertook to selectively appropriate intellectual currents popularised in the west such as decolonisation to perpetuate majoritarian fears ironically despite its strong antiwest sentiments these rightwing islamistled projects often pantomime farright movements in the west that 61 for example the chairperson of macsa lukman sheriff shared an online panel with pembelas aminuddin yahaya and the head of persatuan pengguna islam malaysia to discuss the relevance of suhakam see the facebook video on demi malaiu 25 june 2021 ppim and aminuddin were the key organisers of a nativist buy muslim first campaign in 2019 that exhibited subtle but certainly notable antichinese sentiments see hew also deploy conspiracy theories such as white genocide and the great displacement to propagate a narrative of victimhood to justify white supremacy and xenophobia whereas malaysias situation is not as worrying as that of europe or the united states outlandish theories such as malay genocide are present in the mainstream if one knows where to look for them 62 in other muslimmajority states similar trends occur too the veiled antichinese sentiments in malaysias rightwing islamist human rights narratives are not unfamiliar to those who have read hadizs account of muslim populism in indonesia which often reimagines the ethnic chinese indonesians as the persecutors of the marginalised ummah centrhas and macsas neoconservative rationality which conceives the heteronormative family as the kernel of social order and its strengthening as the effective remedy for various social problems has surfaced in turkey as well in turkey as in malaysia such neoconservative thoughts emerged as the neoliberal state receded from providing welfare and regulating economic relations alas despite the worsening inequality these rightwing islamists primarily confined their calls for state interventions to the cultural sphere instead of socioeconomic ones rendering them unable to energise an elite vs masses form of populist politics that may lead to greater democratisation and genuinely redistributive outcomes this dragging of malaysias cultural wars into the human rights domains by rightwing actors also sustains three further observations that shed light on the future of human rights politics in the country first the conventional understanding that human rights activism is the monopoly of urbane cosmopolitan and progressive liberals no longer stands true whereas one can undoubtedly use the first two descriptors to characterise the protagonists identified in this paper the seeping of neoconservative ideas into the human rights arena also reflects the rise of a new class of muslim professionals who can capitalise on their resources and access to funds research and lobbying to redefine the ethical grounding and political priorities of the human rights project 63second the mainstreaming of a revisionist and majoritarianfriendly interpretation of human rights also foreshadows more trouble for progressive human rights ngos due to the progressives ideological historical and institutional distance from the state political elites continually desire to replace them with a more regimefriendly set of human rights defenders especially when lobbying efforts from the conservatives are underway malaysias democratisation which has not produced the more liberal civil society political scientists hoped for exacerbates this situation instead the political fragmentation amongst the malaymuslim parties which led to greater uncertainty in their electoral fortunes has produced two outcomes the increased influence of the malaymuslimdominated civil service and politicians willingness to engage with fringe influencers and radical ideologues to widen their appeal as they grapple with the seemingly impossible task of securing a majority from a fragmented malaymuslim vote base these developments led to considerable ideological hardening in state religiocultural policies on alcohol censorship gender and sexuality rights apostasy public decency and intellectual freedom the proximity between these rightwing ngos and those in the corridors of power also raises the prospect that their activism even if largely civil by method will lead to outcomes that are inherently uncivil lastly rightwing actors appropriation of the human rights agenda also underscores the discourses recognition and moral capital including amongst conservative and nativist actors who have long felt alienated from the agendas purported western liberal biases however if this doubleplay of rhetorical approval and content subversion continues by the time these rightwing actors earned their 62 see for example this book published by an ismaaffiliated think tank entitled colonial urbanisation and the elimination of the malay race in malaysia that argues that the malays are facing genocide from first the british and later the ethnic chinese this use of an academic veneer to propagate and buttress racist unethical and academically dubious positions in malaysia is nothing new rahman for example counts up to 119 academic articles published in unscientific questionable andor unaccredited journals in support of conversion therapy and transphobia longyearnedfor status as human rights defenders the human rights agendaone defined by a fierce commitment towards minority protection universal rights and constraining authoritarianismwill look very different from where it started

scholarly treatments of the human rights agenda tend to posit civil society organisations csos as its defender and the state and mainstream political actors as its violators even when raising the problem of an uncivil society the literature labels these csos as reactive and hostile to the human rights agenda they perceive as western and foreign i argue that these treatments of the issue overlook another phenomenon the emergence of csos that adopted the language of human rights and participated in its formal processes yet subtly redefined subverted and undermined the core commitments of the human rights agenda this paper discusses such developments by referencing rightwing nongovernmental organisations ngos in malaysia that redefined the parameters of the human rights agenda to undercut state commitments to protect religious freedom sexuality rights and gender minorities through actor and discourse tracing this paper illustrates how rightwing islamist ngos employed a novel twopronged strategy that no longer openly repudiated the human rights agenda but continued to erode eviscerate and reformulate its contents and principles the first prong involved institutional measures of getting in to gain legitimacy by participating as a stakeholder within local and international human rights processes the second prong encompassed social strategies of pushing out whereby actors and their networks mobilised populist pressure to expose ostracise and subvert established human rights norms institutions and actors

research livelihoods through cottage industries the proportion of the day spent at home may be higher still especially among childminders children the elderly and people with preexisting illhealth conditions 1 the sa city of port elizabeth is located on the coast of eastern cape province port elizabeth houses one of the countrys busiest seaports the deepwater port of ngqura two large industrial areas and several large motor vehicle assembly plants despite the potential for port elizabeth industrial operations to be a source of public exposure to a wide range of associated pollutants there is a dearth of environmental and health information on local communities especially in relatively impoverished port elizabeth neighbourhoods or townships located in close proximity to sites of pollution objectives to investigate the living conditions and health status of communities in two such townships walmer township and wells estate the findings provide important insights into local environmental and health concerns and needs in the two communities and a baseline against which the impacts of ongoing industrial development and emissions as well as any interventions which may be implemented could be measured methods in may 2016 the south african medical research council and nelson mandela university together with the nelson mandela bay municipality embarked on household surveys in two lowincome port elizabeth neighbourhoods namely walmer township and wells estate data from the 2011 sa census indicate that 19 000 people lived in each of the study sites 8 walmer township is one of the oldest townships in port elizabeth and is currently flanked along its southern border by the citys airport wells estate is located 20 km from the centre of the city of port elizabeth and close to two major industrial zones the markman industrial area is the older of the two and houses an abattoir a tannery and cement steel and brick manufacturers among other industries the more recently constructed coega industrial development zone lets space to a range of industries including manufacturers of vehicles wind towers and cement a steel mill aquaculture cold storage and processing of agricultural produce the coega idz also has the infrastructure to support nuclear conventional and renewable energy projects as well as an oil refinery forming part of the coega idz is the deepwater port of ngqura the thirdbusiest container port in sa 9 there are plans in place to expand the portfolio of industrial operations in the coega idz wells estate was established in 2001 when lowcost housing was built for 300 families that had been displaced in order to construct the coega idz and the port of ngqura 1011 ethical approval for the study was obtained from nelson mandela university prior to commencement ref research were ensured by removal of all identifiers such as names of the participants and allocation of a unique study number to each study participant approximately 120 households per site were randomly selected for inclusion in the study using town planning maps in 2016 following written informed consent one household member of at least 18 years of age was interviewed to obtain information on factors including household sociodemographic status perceptions of the living environment and housing conditions and health status responses were entered on site into a handheld digital device preloaded with the study questionnaire the software and services of mobenzi researcher a data management system provided realtime access to uploaded data allowing the study coordinator to monitor data collection activities data were analysed using stata se version 15 categorical data were described using frequencies proportions and percentages continuous data were presented as means medians and measures of spread the outcome variables were upper and lower respiratory tract infections upper respiratory tract infections were defined as a wet or dry cough runny or blocked nose fever and chills chest pain earache headaches rapid breathing sore throat sneezing or tearywatery eyes experienced by participants or household members during the 2week period prior to the interview lower respiratory tract infections were bronchitis and pneumonia univariate analyses for sociodemographic and environmental characteristics and respiratory health outcomes in each site were compared using χ 2 tests the level of significance was taken at p 005 for the multiple regression models new binary variables were created for upper and lower respiratory tract infections participants were considered to have an upper respiratory tract infection if they presented with one or more symptoms participants who had bronchitis or pneumonia diagnosed were recorded as having a lower respiratory tract infection independent variables were included in the regression model if the pvalue was 005 and adjusted odds ratios were calculated results the study response rates in walmer township and wells estate were 68 and 85 respectively lack of an eligible respondent at home at the time of the field visit was the main reason for not being included in the study in walmer township political unrest prevented access to some of the selected study dwellings while the mean age of the head of the household differed significantly the two communities were similar in respect of a range of socioeconomic and demographic factors most household members had been born in the eastern cape the province in which the city of port elizabeth is located the vast majority spoke isixhosa at home low proportions of household heads in both communities had achieved tertiary education more than onethird of adult household members in both communities were unemployed consequently average monthly household incomes were low and there was a high level of reliance on state financial grants access to medical insurance was also low however more households in walmer township relative to wells estate had been able to save money the median dwelling age was relatively high in walmer township compared with wells estate dwellings in both townships had a median of five rooms and households comprised a median of four people electricity was the main fuel used for cooking in both communities and 37 and 38 of households in walmer township and wells estate respectively included someone who smoked to generate additional income 33 of walmer township households operated at least one cottage industry at home of which 44 involved activities potentially associated with toxic metals for example spray painting hairdressing and car repairs the remaining 15 households generated an income through activities such as needlework photography painting and tiling in wells estate 18 of households operated at least one cottage industry of which 50 were metalrelated the remaining households were involved in money lending miscellaneous sales beadwork and laundry services fig 3 shows the topranked monthly household expenditures it can be seen that in both sites the biggest share of household expenditure was on food supplies followed by debt servicing and education in general household expenditure was higher in walmer township than wells estate apart from transportation rentbond payments and medical expenses on which wells estate residents spent more structural conditions of dwellings in walmer township and wells estate as reported by the respondents are shown in fig 4 the presence of cracks in the walls of dwellings predominated in both study sites followed by peeling paint leaking roofs and broken windows table 2 sets out the responses given when interviewees were asked about their perceptions of selected aspects of the local environment as well as selfreported illhealth conditions among household members more respondents in wells estate relative to walmer township reported major problems with indoor dust as well as with odours in the neighbourhood similarly in terms of illhealth symptoms there was a higher level of reports of wet cough rapid breathing sneezing and tearywatery eyes in wells estate relative to walmer township selfreported levels of pneumonia bronchitis and tuberculosis were similar in the two communities the results of univariate analyses to explore relationships between risk factors and health status are set out in table 3 selfreported pneumonia and bronchitis were significantly associated with low income levels 0791 p0056 having a child aged 5 years in the household living in a dwelling with cracks in the walls and overcrowding after adjusting for potential confounding factors having a child aged 5 years in the household remained significantly associated with elevated levels of bronchitis and pneumonia the wide confidence intervals are probably due to the small sample size and this result should be viewed with caution perceptions of dust inside dwellings cracks in walls bad odours in the neighbourhood air pollution in the neighbourhood and overcrowding in the dwelling and neighbourhood as major problems were significant in the univariate analyses however only air pollution in the neighbourhood retained a significant association with upper respiratory infections after adjusting for confounding factors discussion this is the first detailed description of the living conditions and health status of two poor communities in one of sas few coastal industrial cities the results indicate high levels of poverty in research both communities evidenced by high unemployment levels low household incomes heavy reliance on state support low savings capacity and limited affordability of medical aid unemployment levels in walmer township and wells estate were higher than provincial and national unemployment rates 12 a further indicator of the degree of poverty in both walmer township and wells estate was that during the year of fieldwork debt servicing was the secondranked expenditure item which inevitably constitutes a further drain research on already constrained household financial resources the who commission on social determinants of health has described poverty and poor living standards as powerful determinants of ill health overwhelming the health impact of lifestyles and medical care for example 1314 within the home setting the operation of cottage industries associated with pollutant emissions such as spray painting and electrical appliance repairs while contributing to household coffers constitutes an insidious cause for public health concern the risks are highest for young children the elderly and those who are unemployed or have preexisting illhealth conditions who may spend most of their time in the home environment 15 apart from their poverty a second layer of health vulnerability for the two study communities arises from the poor quality of their housing including high levels of damp and fungal infestations cracked walls peeling paint leaking roofs and water pipes poor ventilation overcrowding widespread perceptions of local air pollution and bad odours in the neighbourhood each of which is associated with illhealth conditions in recognition of the powerful role of housing quality in health the who recently updated its guidelines for healthy housing especially in the light of climate change 1 the new who housing and health guidelines build on earlier who guidelines on indoor air and water quality for example as well as on evidence emerging from the who csdh which emphasise the role of living conditions in health status 16 a key question asked by the who csdh was why we keep treating people only to send them back to the conditions that caused their ill health in the first place this question is valid in respect of housing quality in walmer township and wells estate and should be considered by local health housing trade and industry and financial sectors a third layer of preventable environmental health vulnerability in walmer township and wells estate is brought to bear by planning decisions to locate human settlements in close proximity to point sources of pollution in this case the port elizabeth airport and the markman and coega industrial areas while detailed air water and soil quality studies have not yet been undertaken in the study areas significantly elevated perceptions of indoor dust and air pollution in wells estate should be heeded and it is hoped will catalyse a proactive programme of investigation and concomitant intervention proximity to or exposures from sources of pollution are strongly associated with ill health compromised quality of life and shortened life expectancy apart from noise airports research have been associated with the emission of pollutants such as carbon monoxide particulate matter and black carbon 1718 as well as poor scores on assessments of subjective wellbeing among people living beneath the aircraft flight paths 19 an sa study associated living in close proximity to an airport with elevations in hearing thresholds 20 given the very short distance between walmer township and the local airport more comprehensive investigations of the health risks including hearing and cardiac effects associated with air pollution and noise are warranted holistic consideration of the findings of this study point to multiple lost opportunities for the prevention of ill health in terms of housing quality poverty livelihoods and the proximity of human settlements to point sources of pollution together with local health departments nonhealth sectors such as urban planners the human settlement sector trade and industry finance and the housing sector are in powerful positions to prevent ill health in some instances in a more compelling and costeffective manner than the health sector nonhealth sectors need to recognise that they are a health force to be reckoned with and to take ownership of and exploit the opportunities they hold to prevent disease save lives and build healthy communities especially during this era of climate change failure to do so ultimately translates to potential acts of environmental injustice heavy burdens of ill health among the most vulnerable in our unequal society and a dimming of prospects of kickstarting the stagnant sa economy study limitations in this crosssectional study a snapshot has been provided of the situation at the time of fieldwork and causal links between environmental exposuresliving conditions and health status cannot be drawn the sample size was relatively small and the study findings cannot be extrapolated to other settings research conclusions this study highlights the triple threat of socioenvironmental hazards faced by the communities of walmer township and wells estate poverty poor housing quality and the lack of an effective buffer zone between human settlements and point sources of pollution associated with a range of harmful substances these preventable environmental health hazards may be associated with a burden of ill health and mortality that is preventable and in which regard nonhealth sectors such as planners housing departments tradeindustry and finance have a powerful preventive role to play declaration none

healthy housing is a fundamental pillar of good health in terms of its world health organization who definition as a state of complete physical mental and social wellbeing and not just the absence of disease 1 healthy housing is associated with a feeling of home and also refers to the quality and role of the physical structure in enabling health including aspects related to shelter from the elements access to safe sources of energy and healthy indoor and ambient air access to sufficient quantities of safe water thermal comfort absence of dampness and mould and protection from pollutants injury hazards and pests healthy housing also relates to local availability of education and health services green space active public transport options and protection from waste and pollution 2 the location of housing in close proximity to sites of industrial pollution may cause preventable public exposure to pollutants in air soil and water with concomitantly elevated burdens of ill health as indicated by numerous studies conducted in various parts of the world and in varying population groups for example a study undertaken in oman showed that living close to an industrial park was associated with elevated levels of acute respiratory disease asthma conjunctivitis and dermatitis 3 the risks of ill health were highest in older people and those of lower socioeconomic status in spain living 25 km from certain industries has been associated with an excess risk of childhood leukaemia 4 researchers in pueblo colorado usa have also shown that certain pollutant exposures may incur illhealth effects decades after the cessation of industrial activity 5 poorquality housing polluted living environments and poor economic and social conditions such as unemployment uncertain employment and limited education may independently exert detrimental health effects on affected communities 6 in south africa sa economic pressures underpinned by poor economic growth high levels of unemployment increasing consumer prices for energy and food and household dependence on credit are some of the factors driving high levels of poverty in 2015 55 of south africans were living in poverty most of whom were black africans females children those with little or no education and those living in eastern cape or limpopo provinces 7 exposure to toxic substances in and around dwellings is a particular concern given the amount of time spent in the home environment in wellresourced countries people may spend 70 of their time at home in poorly resourced countries where unemployment rates may be high and where relatively large proportions of households generate this openaccess article is distributed under creative commons licence ccbync 40

introduction the covid19 pandemic context brought inequalities to the forefront numerous international studies have measured the extent of inequalities associated with the covid19 pandemic they reveal racial and ethnic socioeconomic or territorial inequalities in mortality associated with covid19 including in france merging with preexisting social inequalities the covid19 pandemic further emphasized the global issue of social inequalities in health given this the covid19 pandemic context could have provided a window of opportunity for acting on sih according to kingdon a window of opportunity is an opportune moment seized by political entrepreneurs particularly during major events such as a pandemic when it is possible to consider the implementation of a solution to tackle a major problem testing and contact tracing have been central interventions in the pandemic response different studies have shown the impact of social deprivation or ethnicity on the testing rate which was except in certain cases higher among socioeconomically privileged populations in france the spring 2020 lockdown policy also caused differential and cumulative effects on certain population groups public health interventions are likely to increase sih if their design does not consider population needs two rapid reviews of the literature demonstrated that the consideration of sih in the design of infectious diseases control interventions is typically rare interventions following the proportionate universalism principle are effective in limiting or reducing sih from an equity perspective the principle of proportionate universalism is that the intervention is implemented universally for all but that certain activities are specifically tailored to the particular needs of subgroups of the population taking into account the social gradient in the distribution of the health problem being addressed to support stakeholders to better take equity into account and in particular implementors the reflexiss tool was developed based on a review of the literature and applications in canada in france testing and contact tracing interventions have been generalized as specific measures to control the epidemic risk by the commission in charge of developing the national strategy for ending lockdown which came into effect on 11 may 2020 summarized by the threestep motto test trace isolate the national strategy was based on testing contact tracing isolation this study aimed to analyze how sih were considered in the design of sarscov2 testing and contact tracing interventions method design we conducted a qualitative case study focusing on a pilot intervention that was part of covid19 response efforts in france we focused on covitct as it was one of the first interventions providing sarscov2 testing and contact tracing as well as isolation assistance to the general population on the îledefrance region initially carried out by the regional public hospital institution the intervention design began in april 2020 and extended over the following weeks the analysis focused on the period corresponding to the first and second waves of covid19 infections from march to december 2020 sampling strategy an exploratory phase consisting of a media articles review gray literature review and analysis of available documents enabled us to identify the key actors of covitcts design using a purposeful sampling strategy we followed the principle of internal and external diversification we reached an internal diversification by targeting a variety of actors involved in the design of covitct in its central and local sites which also reflected a form of diversification through their geographical locations and catchment areas actors from sites a and b were the primary target participants for the study given the focus on sih site c was explored in less depth but included as part of our diversification strategy and also because it was closely linked to the central site of covitct key actors involved in the broader governmental response to the pandemic were also interviewed to provide a better understanding of the general context in which covitct was designed we used a snowball strategy for participant recruitment over the course of the study data collection between november 2020 and may 2021 we collected a variety of press content gray literature and documents between december 2020 and may 2021 the first author conducted semistructured interviews averaging 40 min in length until the point of empirical saturation at times the interviews were conducted with the second and last authors we interviewed 21 women and 15 men of all ages who were mostly health care workers often key actors in the central and local sites we also interviewed public health professionals from diverse public agencies humanitarian professionals members of civil societys organizations among others the interviews were conducted following a conceptual framework providing three planning dimensions with respect to sih reflexiss in an equity perspective this health promotion tool intends to facilitate the consideration of sih in each stage of public health interventions our research focuses on the first stage identified as design of a public health intervention beyond the focus on sih interviews also included an open discussion regarding their trajectory how they perceived their work or their thoughts regarding the pandemic and sih we contacted 53 individuals via email phone or linkedin messages we carried out 33 interviews between the 11 november 2020 and 24 april 2021 19 of whom were involved in the design of covitct due to the pandemic context 23 interviews were conducted remotely and 10 inperson given their active involvement with the pandemic many of them had limited time and mental availability three of the respondents were met with twice as they had to end the first interview due to professional commitments the use of videoconference and phone calls to conduct remote interviews allowed for flexible adjustment to respondents schedules despite the technical challenges and the difficulty of collecting nonverbal data these interviews were audio recorded and fully transcribed analytical strategy the consistency of the findings was checked by data triangulation we applied an inductivedeductive analysis strategy as part of the inductive analysis interview transcriptions were read multiple times and annotated to reflect the words of participants this inductive analysis fostered the emergence of original elements with regards to sociological profile and trajectory of the respondents their discourses and representations as part of the deductive analysis strategy the dataset was processed by maxqda software the themes emerging from the inductive analysis were regrouped around the three dimensions of intervention planning according to reflexiss problems and needs analysis objectives rationale and design of the intervention crosssectoral partnerships and participation of the target population in the next section the results are presented following the deductive structure of our analysis in the order of the three dimensions of intervention planning of reflexiss the titles reflect the main elements that emerged inductively in each of these dimensions results tackling sih in the context of an outbreak emergency and ambivalences sih taking a back seat to the health emergency despite respondents intense workload due to the pandemic response at the time of the interviews they made themselves available and demonstrated concern for sih however sih were rarely mentioned spontaneously by the respondents despite the explicit mention of our questioning and none of the reviewed documents mentioned sih the urgency of the pandemic situation appeared to be the main concern which resulted in narratives of haste and positive tension that seemed to inhibit critical reflection in most of the discussion consideration of sih appeared to be secondary sometimes as inappropriate as if urgency had overshadowed the sih challenges for instance a general practitioner stated that the health crisis context was incompatible with action that was proportionate to the needs of population subgroups behind diverse perceptions of sih the specters of poverty and exclusion the interviews revealed the diverse representations of sih in participants responses migrant populations particularly those living in collective accommodations appeared as the prevailing representation for sih regardless of the actors professional background rather than discussing sih participants more often focused on populations in situations of poverty and or social exclusion they frequently used an interchangeable vocabulary populations in a vulnerable situation in difficulty or in a precarious situation at times some actors asked about the meaning of social inequalities in health suggesting that this topic remained confusing within the medical and humanitarian health fields the actors had different perceptions of sih which appeared to be related with factors such as their domain of expertise location of usual professional activities and epidemic response experience the actors comprehension of sih can be situated on a continuum ranging from a biomedical to a health promotion vision private medicine professionals expressed more a biomedical vision public medicine professionals or humanitarian professionals tended to focus more on a health promotion vision of sih as well as public health professionals regarding the location professionals working in central paris mostly demonstrated a biomedical comprehension of sih while professionals acting in the north suburb of paris and specific popular or priority neighborhoods showed a more health promotion comprehension of sih lastly actors having a significant epidemic response experience expressed a health promotion vision of sih actors that had a little or no experience in the epidemic response focused more on a biomedical understanding of sih a consensus the unequal dimension of the pandemic respondents agreed on the unequal dimension of the covid19 pandemic for several participants this could be linked to a humanitarian sensitivity and experience various participants also expressed a keen interest in public health issues andor their concern for inequities resulting from field experience in covid19 response efforts all respondents agreed that different socioeconomic factors may increase the vulnerability of some populations to the risk of infection of sarscov2 most participants identified different attributes of housing as factors that increase the risk of infection they mentioned the likelihood of increased virus transmission among the household members and barriers to certain control and prevention measures they also pointed out financial insecurity as preventing access to personal protective equipment a few participants mentioned barriers arising from language and health literacy challenges in terms of understanding the purpose and directions of the different control and prevention measures the challenging operationalization of addressing sih during a health crisis biomedical epidemiology framework pragmatism and adaptations in a context of urgency the design of covitct began in april 2020 it took place in a context of scientific uncertainty regarding the virus and its modes of transmission in addition to a scarcity of testing given material and resource constraints anticipating the gradual ending of the lockdown restrictions and increased transmission a hospital physician with specialization in infectious and tropical diseases with extensive humanitarian experience led efforts to organize teams that would visit potential patients homes for testing and counseling it resulted in the transfer of a model previously implemented in haïti for the cholera epidemic the primary objective of the intervention was to break the chains of transmission slideshow presentation partners meeting of 14 april 2020 by implementing a case targeted intervention intended for the general population of the îledefrance region this strategy called for the deployment of the intervention around confirmed and suspected cases of covid19 the first stage detection illustrates the strength of the epidemiological argument and the central position of the virus in the strategy the intervention was based on transmission hotspots when a hotspot was confirmed the intervention of field teams were then deployed for mass testing with the objective of controlling its spread such a detection strategy appeared to be at odds with a sih reduction approach i had put forward proposals as i said about the mobile units to reach the most vulnerable groups in order to reestablish certain inequalities and to reach the groups that were not going to access the system i think my proposal was perhaps a little surprising and then what i understood was that it didnt work like that so they didnt see how it was going to be done it was for them i think my suggestion was a bit abstractcovitct partner aids nonprofit organization yet actors involved in the first stages of covitcts design said their intent was to differ from the criticized topdown uniform and coercive governmental response strategies to the epidemic implemented at the time the proposal was designed as pragmatic trustbased and contextualized covitct included a social component aimed at making this strategy compatible with a diversity of social situations and therefore improving its acceptability mobile teams were rolled out to conduct home visits they were responsible for testing at home delivering a kit consisting of masks and hydroalcoholic gel and fostering a partnership with the covid19 cases to identify and organize their isolation plan based on an assessment of their living environment as it turned out to be necessary in some cases they could resort to humanitarian or local social services to provide some social support during the period of isolation while the medical provision standard of covitct was clearly defined the design of the intervention left room for a significant amount of improvisation this was especially true with regards to the social component which was associated with the ability of the field teams to adapt and improvise which were less discussed and formalized we adapted completely to this family context and with that our team improvised in some ways so they had their baselines for isolation they had their baselines for advice and procedures to follow up on transmission and to make sure that it was cut off as quickly as possible and therefore to isolate this outbreak and so as a result they were improvising according to the contextsproject team member the centralized design of covitct made it possible to provide a general framework that was common across all sites due to the urgency of the situation in terms of time and health risks covitct became active in less than a week after the beginning of its planning the process was refined through the experimentation of different models that was done concurrently during its implementation the local sites developed and experimented with an operational model that was adapted to their context which resulted in important differences between the sites in terms of how sih were considered diversity of attempts and approaches to addressing sih in the intervention there were important differences between the parisian sites and suburban site regarding the way sih were considered in the design of their respective operational models this may be related to the socioeconomic contrast of the territories with the most deprived to the wealthiest initially focused on home visits the local site a opened a testing center in october 2020 although this required a doctors referral until december 2020 after this date the sites team the team bypassed these restrictions and encouraged mass testing of the population before possible holiday gatherings in keeping with a medical vision of caregivercare receiver relationship trust was emphasized as the main factor of adherence to the intervention at this site interestingly it was not always recognized that socioeconomic determinants could be an issue regarding intervention implementation i think that a fairly simple public health intervention model everyone adheres to it and its not because its a person in a more precarious situation that they wont adhere to it what works is that people trust us it makes no difference whether they are in a precarious position or not general physician local site a conversely the former coordinator of local suburban site b outlined the teams real desire to get closer to the people and to reach a population that is particularly vulnerable in comparison with private urban medicine as covid19 cases were frequently refusing home visits the operational model of this site was quickly adapted to foster improved accessibility and acceptability of the intervention a testing and contact tracing alternative was developed in various centers within a municipal health network urban private practices and a local public hospital patients could present without an appointment unlike in sites a and c the actors involved in the design of the model of site b demonstrated a critical reflection on covitct and their own action regarding sih during his interview the initiator of site b pointed out a very clear lack of perception of deprivation in the department among the team that designed covitcts centralized outline he insisted on the need to adapt the intervention model to the socioeconomic local context another team member regretted the nonuse of proportionateuniversalism approaches and stated that basically covitct while having noted and followed a logic that was a little bit different … doesnt replace some 20 to 30 years of history of public health in france general and public health physician local site b crosssectoral partnerships during a health crisis between distrust and collaboration from hypercentralization to the multiplication of actors at the very beginning of the outbreak covitcts design was characterized by its hypercentralization the general approach of the intervention was first designed by a few influencial members of the regional public hospital institution following which a variety of actors from different sectors became gradually involved the implementation of the intervention was made possible by the massive mobilization of volunteers including several hundred students and young professionals most of the volunteers joined the field teams after a theoretical training on interculturality motivational interviewing and nonjudgmental attitude the training was developed by an association dedicated to fighting hivaids with extensive experience in addressing sih the covid19 cases participation in the intervention took the form of a partnership between cases and field teams nurtured by a relationship based on trust case participation remained limited to the interaction with field teams as part of the contact tracing process or organization of isolation with no involvement of the cases in the design of the intervention itself the profiles of the actors varied depending on the sites the influence of the initiator of each site appeared to be instrumental in the mobilization of actors as well as the presence of networks that existed before the pandemic the public hospital doctor who initiated covitct gathered former humanitarian colleagues as well as hospital colleagues over time and following the intention not to adopt a hospitalcentered approach covitct was increasingly taken over by physicians practicing private medicine in urban centers in sites a and c the private general practitioners who initiated the sites mobilized the local multiprofessional health communities as a result both sites relied on the involvement of a majority of private medical and paramedical health professionals the public hospital doctor who initiated site b relied on public municipal and territorial health network in this more deprived territory this network was already mobilized for other infectious diseases consequently the main actors involved were municipal health actors hospital professionals as well as urban private medical professionals who were mobilized via their representative organization a similar expansion dynamic was observed with regards to the organizations known as partners of the intervention local public services as well as csos were involved according to needs the summer of 2020 was also associated with the increase in number and power of key actors involved in the deployment of testing and contact tracing government strategies this dynamic brought together many intersectoral partners including medical ngos and csos municipalities public social andor health services participants appreciated this multiactor and decentralized collaboration as it was considered a valuable opportunity to try an alternative governance structure different to the traditional silos of the health system respondents also emphasized the complexities of bringing crosssectoral partnerships to fruition due to chronic resource shortages power imbalances and persistent misunderstandings between the partners including sih complexities of crosssectoral partnerships respondents mentioned various barriers to mobilizing crosssectoral partners despite their attempts the north paris team was unable to mobilize social workers due to a lack of human resources administrative complexities and fears related to the pandemic situation while other examples of mobilization of crosssectoral collaborations have proven successful the equitable dimension of the collaborations is questionable not all actors held the same position within the intervention professionals from the medical or paramedical fields were predominant in the intervention design on the contrary other actors such as csos and social workers mainly focused on operational aspects and were often excluded in the design or planning stages of the intervention lastly there were important differences in understanding and the vision of sih between different professions for example between private medical practice and public hospital medicine we had set up this local site b as a purely public health operation the financial dimension did not interest me and did not catch my attention and i faced this first thing which was that the private general practitioners … wanted guarantees that their patients would not escape them like it was not normal for patients seen in a private practice to be cared in a municipal health center and i fell off my chair because i thought how can such considerations arise while we are in the middle of a health crisis and people are dropping like flieshospital infectious diseases specialist local site b however these divergences did not prevent valuable collaborations the collaborations experienced between hospital medicine and private urban medicine were regularly mentioned in participants discourse as one of the successes of covitct in contrast they shared more reserved opinions on certain collaborations such as those between the medical and public health sectors in certain respects forms of diffidence and misunderstanding persisted at the expense of addressing sih for instance a general physician of local site a contested the scientific basis and refused to take part in an intervention addressing sih promoted by a regional public health institution the difficulty is that i never knew how the interventions in priority neighborhoods were done was it done on a scientific basis or on a political basis downloaded from by guest on 07 may 2024 because it is a priority district of the city and we see that it is necessary to go and do it there to show that people are not forgotten politicalgeneral physician local site a discussion critical insights on the consideration of sih in designing covitct and covid19 response efforts this case study highlighted some of the challenges of addressing sih in the design of covid19 response efforts in the îledefrance region france findings revealed diverse understanding and visions of sih among covitcts actors as well as the complexities of mobilization and crosssectoral partnerships covitct was rooted in and took place in a context of an organizational crisis of a weak french public health system and a rapidly changing and uncertain covid19 environment our findings emphasized an intervention design relying on the mobilization of existing configurations of actors strategic and operational models a phenomenon widely observed in decisionmaking processes in crisis contexts the urgency to act without delay rushed the design process and led to its initial centralization around medical and paramedical professionals the intervention design was similar to the general dynamics of the pandemic response in france the lack of pandemic preparedness resulted in an overrepresentation of medical elites compared to public health professionals and institutions there was little room for cocreation or the structuring of collective action around the consideration of sih in the design of the intervention the actors faced widespread challenges in the design of public health interventions such as power inequities and difficulties regarding intersectoral action among covitcts actors sih was mostly related to situations of great poverty or exclusion notably migrant populations at the extreme end of the social gradient in health which correlates position in the social hierarchy with health condition of individuals these findings reflect the challenges associated with the historic lack of understanding of social determinants of health and sih within the french healthcare system medical training and the professional culture often overlook these concepts and has previously raised concerns about continued discrimination the analysis of public policies invites us to dwell on the representations of the problem and problematization initially designed and implemented to address a severe medical humanitarian emergency in haiti the intervention was urgently transferred to france to fight against covid19 despite the differences regarding the diseases and national contexts for ridde and guichard the way in which the causes of health inequalities are understood and socially constructed will influence not only the decision to take action but also the methods of action this translocation highlights covitcts links with humanitarian approaches social medicine and social epidemiology all widely developed in southern countries even so centered on the virus and contaminations around the covid19 positive patients the model of covitct participated in producing a predominant clinical framing of the pandemic situation the similar intervention deployed to fight cholera in haiti was considered to have a predominantly biomedical public health approach in covitct when there was consideration for sih it was as an element complementing the clinical epidemiology strategy of the intervention and supporting its problems and needs analysis • despite an important concern for the unequal dimensions of the pandemic inequalities appeared secondary to the pandemic emergency • covitcts actors did not share a consensual understanding of sih which were often equated to poverty and social exclusion objectives rationale and design of the intervention • covitcts design planning was expedited by the health emergency • covitct was based on a biomedical epidemiological approach which prevailed during the intervention design • the social component of the intervention supported its clinical activities by addressing certain inequalities • the approach to address sih took different forms depending on the site of the intervention crosssectoral partnerships and participation of the target population • actors from the medical fields designed covitct despite the focus on paris for this case study these findings echo that of the broader response to the covid19 pandemic globally health promotion and its objective of reducing sih appeared to have been mostly neglected our use of the reflexiss tool and a public policy analysis approach emphasized that while the pandemic was the occasion for a rediscovery of the sih issue it did not constitute a window of opportunity favorable for their consideration our findings have highlighted the need to improve the understanding and working on sih during routine periods it appeared paramount to promote sih consideration in crisis situations when standard operating procedures take precedence recent innovations such as the plan to fight sih adopted by the îledefrance regional health agency show that in the pandemic context sih have become the major priority for action within certain public health institutions the covid19 crisis has not only demonstrated that a collective and formalized fight against sih was crucial but also that it was possible investigating sih consideration in intervention design strengths and limitations our investigation provides methodological and theoretical insights on the use of reflexiss as a research tool in health promotion research in the covid19 pandemic context the use of the reflexiss tool as a basis for data collection made it possible to focus the interviews on elements directly related to covitcts design and on the consideration of sih participants tendency to focus on action narratives not centered on sih suggested that this approach may be preferable in crisis situations however the semistructured interviews based on reflexiss constrained the participants discourse while the pandemic context was not optimal for reflective considerations on the design of emergency interventions it sometimes put respondents in an uncomfortable position by urging them to focus on topics or aspects that appeared difficult to grasp in a health crisis situation also the design and implementation appeared to be intertwined in the context of covid19 outbreak and difficult to distinguish at the operational level from this standpoint the temporality of our investigation also represented a limitation it began in september 2020 to june 2021 several months after the initial design we were investigating the initial design was likely subject to poor recall for various key respondents given the time delay from when they were interviewed to the time period of interest these different points highlight the importance of using an analytical approach with an inductive dimension our hybrid approach to analysis enabled us to complete the deduction based on the reflexiss tool if we had limited ourselves to the components of the reflexiss tool our analysis would have emphasized negative aspects the inductive analysis made it possible to analyze the rich empirical material in the respondents own words and provide more nuance on respondents accounts and understanding of sih for instance it allowed us to perceive the staggering urgency weighing on the actors the clinical framing of the pandemic among the actors or the determinants of the barriers to consideration of sih in the design of the intervention from an epistemic point of view this allowed the reflexiss framework to be mobilized as a conceptual framework versus a normative framework lastly the discussion of these results from public health and political science perspectives fostered a holistic understanding of the design process which is not only the result of individual decisions this approach made it possible to consider the pandemic conjuncture and at a broader scale structural sociopolitical dynamics that influenced covitcts design conclusion our research emphasized the numerous challenges of tackling sih in context of the covid19 pandemic a collective vision and intersectoral action against sih did not occur during the initial design of covitct and instead a biomedical approach prevailed this biomedical approach to public health interventions and the omission of sih in the initial design has been common in france positioning a sih reduction approach as a complement to dominant biomedical strategies can mitigate some of the inequitable effects of an intervention however it will be insufficient to address their systemic and structural nature the experience of the covid19 pandemic highlights the crucial need of promoting and formalizing sih reduction approaches socioenvironmental developments suggest that pandemic events will increase in the coming years from a dual perspective of social justice and epidemiological coherence the covid19 pandemic has highlighted that sih need to be considered as the basis of infectious diseases response regardless of the emergency context conflict of interest the authors declare that they have no conflict of interest regarding the research authorship and publication of this article ethics approval the comité dévaluation de lethique des projets de recherche biomédicale paris nord has reviewed and approved the research project in 2020

the covid19 pandemic highlighted the impact of social inequalities in health sih various studies have shown significant inequalities in mortality and morbidity associated with covid19 and the influence of social determinants of health the objective of this qualitative case study was to analyze the consideration of sih in the design of two key covid19 prevention and control interventions in france testing and contact tracing interviews were conducted with 36 key informants involved in the design of the intervention andor the government response to the pandemic as well as relevant documents n 15 were reviewed we applied data triangulation and a hybrid deductive and inductive analysis to analyze the data findings revealed the divergent understandings and perspectives about sih as well as the challenges associated with consideration for these at the beginning stages of the pandemic despite a shared concern for sih between the participants an epidemiological frame of reference dominated the design of the intervention it resulted in a model in which consideration for sih appeared as a complement with a clinical goal of the intervention breaking the chain of covid19 transmission although the covid19 health crisis highlighted the importance of sih it did not appear to be an opportunity to further their consideration in response efforts this article provides original insights into consideration for sih in the design of testing and contacttracing interventions based upon a qualitative investigation

introduction childbirth and birth are phenomena that undergo modifications according to the society in which they are inserted the current obstetric scenario reflects an institutionalization of practical knowledge associated with childbirth and invasive procedures often unnecessary and potentially iatrogenic resulting in the loss of womens autonomy this process is called medicalization the routine performance of csections causes the isolation of pregnant women and their families negatively interferes in newborn care and puts the maternal and fetal health at risks becoming an abusive procedure and hindering the adoption of humanization conducts in this process women are subject to strict and mechanized routines that are adopted without critical evaluation on a casebycase basis therefore the high number of csections can cause more harm than good to mothers and the fetuses concerning the csections performed in the brazilian unified health system there was an increase from 383 in 2001 to 5515 in 2014 from such index we infer that brazil lives an epidemic of elective csections hence considering the medicalization aspects of the brazilian obstetric care and its development such as high rates of csections and the circulation of collective discourses of risk in the pregnantpuerperal cycle we aim to reflect on the process of medicalization of childbirth and its consequences from a brazilian audiovisual media artifact the documentary o renascimento do parto portrays this period of late modernity in which such practices result in turning women into frail and incapable parturients believing they need aid to achieve the birth of their child denying their own capacity to give birth and decreasing their potential this reflection is justified because vital events such as the birth are based on a model centered in medical technology favoring the emergence of a csection culture in which common symptoms or ordinary factors become the reason for choosing the surgical procedure childbirth assistance in brazil is still characterized by procedural attitudes supported by cultural changes and convenient interventions are imposed to knowledge and practices established by the biomedical field therefore we focus on the formation of social and discursive practices concerning this late modernity in order to contribute to a more complex vision of births objective to reflect on the medicalization process of childbirth and its consequences from a brazilian audiovisual media artifact method this is a reflective and interpretive analysis based on the documentary o renascimento do parto to this end data are presented for the production and construction of our narrative being analyzed its content by two analytical categories giving birth to life from nature to medicalization between perceptions and affections where are the love hormones in such categories were used excerpts from interviews in the documentary that support and illustrate their central ideas this study analyzes discursive practices for establishing identities of the professionals and the pregnant women within the current obstetric scenario the best way to analyze an audiovisual material is choosing a theoretical framework and applying it to the empirical object hence our analysis was based on critical discourse analysis the theoretical and methodological assumptions of cda formulated and presented considering the concepts of the british linguist norman fairclough will be useful to create this framework of statements present in the documentary the following step was selecting a sampling framework which would be the medicalization of childbirth and then creating rules for the transcription of visual and verbal information selecting illustrative citations that would complement the visual analysis to do so were considered three essential elements in discourse analysis production in the case of the documentary highlighting its authors producers and other contributors the text itself and the reception regarding the interpretation by those who watch the documentary for a production to make sense it is not necessary for it to be within the text it can be what has not been said thus it is possible to identify its assumptions the documentary is a brazilian production that addresses as a public accusation the increase of csections in brazil and which stands for the autonomy of women during childbirth the movie lasts 90 minutes and it was directed by eduardo chauvet screenplay by érica de paula photography by rafael morbeck and soundtrack by charles torres and marcello dalla it was released in august 2013 in brazil and features statements ranging from personal experiences to results of scientific research among the interviewees we highlight the participation of michel odent robbie davisfloyd daphne rattner naoli vinaver and the brazilian couple márcio garcia and andréa santa rosa in addition brazilian doctorsobstetricians pediatricians nurses doulas midwives and women with maternal experiences both positive and negative participated in the documentary considering the speeches participants contributed positively reporting the historical process of transformation of this paradigm when the birth art for a long period was classified as an exclusively female function giving birth to life from nature to medicalization the categories were classified as elements since according to cda social life is composed of social practices in constant and unstable articulation thus considering discourse as an element of these practices the first category was described as element 1 in which childbirth was chosen as an example of a material activity during the middle ages labor was perceived as the main role of women and religious decrees forbade the male presence within the giving birth scenario making it an activity exclusively feminine initially parturient women received empirical care from women who were considered to be witches and those who were curious however over time this kind of behavior has been modified by man the male figure appears in the history of childbirth by introducing obstetrics as a science implementing the horizontal delivery and episiotomy from the consolidation of hospital delivery the medicalization of this event resulted in the loss of womens autonomy as bellwether of the givingbirth process leaving this physiological and vital event to be marked by the overuse of invasive practices often unnecessary and potentially iatrogenic these conditions ended up resulting in oppression situations whether due to the medicalization of the female body or the nonrecognition of womens protagonism in this process we cant give birth the way our mothers and grandmothers did we cant do what once was considered normal in such speech the interviewee begins her report in the present tense promoting the idea of womens inability to act when giving birth especially when stating we cant do what once was considered normal this idea along with the phrase we cant give birth the way our mothers and grandmothers did illustrates the order of discourse of change in the obstetric reality and womens appropriation in their own labor the transfer of the birth environment improved health indicators in brazil especially concerning the reduction of maternal and neonatal mortality rates over the past thirty years in ideal conditions the csection is safe and contributes to reducing maternal and perinatal morbidity and mortality hence its value in modern obstetrics however the negative consequence was the increase in the number of interventions at birth without justified medical reasons in this sense the world health organization states that rates above the range of 10 to 15 do not contribute to reducing maternal perinatal or neonatal mortality in the brazilian context in which there is a high rate of alreadyperformed csections the reference rate is estimated around 29 it is noteworthy that the counterproductive feature induced by the elective csection understood as the imbalance between autonomous health actions such as products of the interaction of the individual with the social environment and heteronomous health actions undertake by health professionals and specialists within the institutionalization context results in an illusion of needing more heteronomous actions for correcting undesirable and potentially harmful consequences transforming this reality in a vicious circle women ended up conforming to strict standards established by the medical system according to which they must give birth in a given time and behave in a certain way in the second speech the doctor describes the female resilience mentioning the conformation and consequent adaptation of women to medicalized acts without expecting a justification for such action at the same time in his speech the doctor blames the public system when stating that women must give birth in a given time and behave in a certain way standardization of the labor process is a structural condition of late modernity which equals people and situations in conditions of economic social and cultural inequality therefore a consumption need is produced conditioned by professional interests that culminate in an identification on the part of some women csection ends up being the result of a cultural and social medicalization in this sense the public system itself the reality of the health situation in our country and the obstetric care model contribute to such results there is a cultural logic on top of that … the patient has the idea that the csection is more controlled less risky or with no risk at all and that her baby will be safe the doctor on the other hand despite having learned that natural childbirth is safe that is good for the baby ends up believing in the false fact that csection is safer the expectation of a safe delivery is associated with the tranquility of a csection the doctor describes such attitude when stating that women believe csection is more controlled less risky or with no risk at all thus the last two statements may be representative of the power of medicine and the feeling of nonparticipation of women in an act that once was natural the idea of greater control in the csection is established by elements of the surgical technique which require greater knowledge and professional skill instituting a powerknowledge path in addition there is the possibility of controlling variables such as time which allows increasing productivity however the little time directed to womens care may negatively reverberate to the establishment of the professionalpatient bond such bond is surrounded by affections and these may generate comfort and delight in a counterhegemonic way professionals working in obstetric care especially doctors and nurses who are interest in restoring the vaginal delivery work with evidencebased health practices in order to reduce the trivialization of this type of procedure however it is still a paradigm to be overcome and a challenge since medicalization has been established by diverse strategies using different actors including the state mediation the result was the exclusion of women from their traditional practices an issue that is discussed by the movement of humanization of labor and birth between perceptions and affections where are the love hormones the second category represents the mental phenomena overall they concern feelings beliefs and values for this reason the hormonal cocktail produced by women during labor was chosen to represent the element 2 during labor women are physiologically prepared for the upcoming release of hormones that are programmed to act before during and after the childs birth and that influence the behavior and bond between mother and son which may have an impact even on the ability to love and on peoples potential aggression unnecessary csection prevents the production of the hormonal cocktail which has oxytocin as the main secreted substance during labor such hormone triggers contractions that precede it performing many functions that are beneficial for both the mother and the newborn in addition oxytocin is also produced during sexual activity being responsible for male and female orgasms and when breastfeeding until recently love was the theme of poets philosophers and novelists but today love is also studied by scientists nowadays we understand that the ability to love is largely organized and built during the period comprising the birth the obstetrician michael odent describes this hormonal production as a feeling when he says the ability to love is largely organized and built during the period comprising the birth he narrates the importance of creating the bond between the binomial motherson these hormones produced at childbirth will favor the development of the bond thus avoiding possible complications and making maternal recovery faster in addition to physiological aspects the birth organizes and builds our capacity to love the labor period has potential for achieving this goal as well as it allows developing the female body awareness and relationships with the people that are meaningful which reflects on the strengthening of affective bonds labor is not only a physiological act that begins with contractions and ends with pushing the baby and the placenta out it is above all a true rite of initiation of passage not only for the mother but also for the whole family and the baby that actively participates in this experience and come out of it stronger people think that giving birth is a bodily thing … a physical thing only but over the years that i monitor labor processes i see that it is the soul of the woman expressing itself through the body some doulas also participated in the documentary and their speeches express the subjective side of childbirth one of them evidenced this when saying that giving birth is above all a true rite of initiation of passage making it clear that the experience of this moment makes women more assured of their emotional capacity the givingbirth process provides women the transcendence of boundaries connecting them with their inner i to the extent it promotes the expression of their soul through the body labor as a rite of initiation is based on the premise that with it a mother a child a father and a family are born an event that establishes a multipleimplication relationship that when positively experienced is able to generate happiness and to strengthen the affective and social relations csection radically separates the newborn the placenta and the mother from each other the coldness situation worsens with the absence of love hormones elective csections prevent the labor process and consequently the action of hormones essential for childbirth and for strengthening the creation of the bond between mother and son to the profile of the csection incidence decreases some aspects are required to restore the protagonism of women at the labor process integrative and comprehensive vision of the phenomenon involving psychological affective emotional spiritual cultural and contextual aspects in which the labor takes place updating our way of thinking with new theories of thought will provide a new worldview in which the separation would be replaced by the interrelationship and integration of all physical biological psychological social political and cultural phenomena we should raise awareness about the cultural process in which we are inserted process which has the potential to produce a broader thinking able to fulfill our need to know given our need to want and our freedom to feel representing therefore the way amid this fragmented culture study limitations the scope of two thematic categories contributions to the field of nursing health or public policy indicating cda as an element to understand the social phenomena that relate to medicalization of obstetric care in brazil is essential to the professional ethos of nursing this understanding is essential to comprehend that the role of the nurse midwife in the childbirth care decreases unnecessary interventions which reflects on the reduction of the rates of csections the increase of womens protagonism and the respect concerning the physiological emotional and social dimensions within the giving birthbeing born process final considerations childbirth is established as a material element and a mental phenomenon of social practices therefore it is polysemic and subject to interventions especially when health is guided by a hegemonic biomedical model which produces medicalization of vital events this process has as consequences the increase of medical intervention in labor and birth which in brazil is reflected on the increase in csection rates beyond what is considered acceptable by international public organs and on the loss of womens autonomy hence we acquired a knowledge that standardizes behaviors disciplines bodies and controls the physiological events that are inherent in life however the body is not linear but complex there are physiological events which are culturally meaningful to express its creative potential oxytocin understood as the hormone of love and delight is produced during labor and causes pain which is inherent in life but which promotes and encourages the labor process and therefore increases the potential to generate happiness in order to the rebirth of childbirth takes place it is necessary to interrupt this hegemonic model of obstetric care in brazil to allow the body during parturition and as physiological and cultural unit to express itself through the release of oxytocin to decrease the segregation between mother and son that the csection causes and restore womens autonomy improving the creation of affective bonds between patients the newborn family and healthcare professionals making this vital event less negative and considering the complex understanding that such is part of the sexual emotional and social life of women

objective to refl ect on the medicalization process of childbirth and birth and its consequences based on a brazilian audiovisual media artifact method refl ective and interpretive analysis of the documentary o renascimento do parto the rebirth of childbirth based on critical discourse analysis results csection emerges as an alternative to adverse conditions of pregnancy however it has become a routine and abusive practice of a medicalized obstetric care thus becoming a social problem in order to the incidence of csections decrease womens protagonism must be restored in addition to considering psychological affective emotional spiritual cultural and contextual aspects in childbirth conclusion childbirth is established as a material element and a mental phenomenon of social practices we must interrupt the predominant model allowing the body to express itself through the release of oxytocin and decrease the segregation that csection causes thus enabling affective bonds descriptors childbirth natural childbirth medicalization obstetrics doulas resumo objetivo refl etir sobre o processo de medicalização ao parto e nascimento e suas consequências a partir de um artefato midiático audiovisual brasileiro método análise refl exiva e interpretativa do documentário o renascimento do parto baseada na análise do discurso crítica resultados a cesariana confi gurase como alternativa para condições adversas gestacionais entretanto tornouse uma prática rotineira e abusiva de uma atenção obstétrica medicalizada passando a ser um problema social para que a incidência de cesarianas diminua é necessário que seja restituído o protagonismo da mulher além de considerar aspectos psicológicos afetivos emocionais espirituais culturais e contextuais no parto conclusão o parto confi gurase como elemento material e fenômeno mental das práticas sociais é necessário romper com o modelo predominante permitir que o corpo se expresse por meio da liberação de ocitocina e diminuir a segregação que a cesariana provoca proporcionando a formação de vínculos afetivos descritores parto parto natural medicalização obstetrícia doulasobjetivo refl exionar sobre el proceso de medicalización al parto y nacimiento y sus consecuencias a partir de un artefacto mediático audiovisual brasileño método análisis refl exivo e interpretativo del documental o renascimento do parto basado en el análisis crítico del discurso resultados la cesárea se confi gura como alternativa a condiciones adversas en la gestación sin embargo se convirtió en una práctica rutinaria y abusiva de una atención obstétrica medicalizada pasando a ser un problema social para que la incidencia de cesáreas disminuya es necesario que sea restituido el protagonismo de la mujer además de considerar aspectos psicológicos afectivos emocionales espirituales culturales y contextuales en el parto conclusión el parto se confi gura como elemento material y fenómeno mental de las prácticas sociales es necesario romper con rebirth of childbirth refl ections on medicalization of the brazilian obstetric care renascimento do parto refl exões sobre a medicalização da atenção obstétrica no brasil renacimiento del parto refl exiones sobre la medicalización de la atención obstétrica en brasilrebirth of childbirth reflections on medicalization of the brazilian obstetric care

background regular physical activity is associated with several health benefits such as lower risk of hypertension reduced risk of depression and improved cognition 13 among the physical activity domains leisuretime physical activity is a wellestablished protective factor for several negative health outcomes including mental disorders 4 different types of cancer 5 mortality due to cardiovascular disease and allcause mortality 6 beyond its open access correspondence association with health outcomes ltpa is also associated with a higher quality of life and wellbeing 7 however the promotion of ltpa remains a global challenge in brazil a study carried out with adults living in capital cities reported that the prevalence of ltpa participation was 44 in 2006 and 54 in 2016 8 the most widely reported types of ltpa practiced in brazil were outdoor walking soccer and strength training 9 however there were important inequalities related to gender age and income in the different types of physical activity 9 given the inequalities in ltpa continuous monitoring of these indicators is essential to provide evidence on the trends in inequality and to plan public policies to target risk groups in brazil both the brazilian surveillance system for risk and protective factors for chronic diseases by telephone survey and the national health survey provide monitoring data on ltpa in the adult population however most previous studies carried out in brazil analyzed only the trend in the level of ltpa 8 10 11 12 with little available information about trends in types of ltpa 1314 information on the most commonly practiced types of physical activity is strategic because the type of physical activity provides quick practical and objective information on preferences and contexts aspects influenced by culture the development of personal skills and inequalities in access to facilities and equipment suitable for practice although previous studies investigated the trends in different types of ltpa 15 and social inequalities in the participation in different types of ltpa 9 the trends in inequalities in the participation in different types of ltpa were not explored 15 monitoring these trends makes it important to analyze how the participation in ltpa is variating among populational groups constantly unfavored 9 as well as to identify whether changes in the participation in different types of ltpa have been driven by specific subgroups in addition given that studies on trends in ltpa level have shown increases especially among the richest groups 16 increases may occur in specific activities such as activities traditionally paid consequently understanding these trends can support public policies to reduce inequalities in access to ltpa thus the current study aimed to describe the trends in gender ethnicity and education inequalities of types of ltpa practiced by brazilian adults from 2006 to 2019 methods design and sample this study used data from 2006 to 2019 from the vigitel survey the vigitel is an annual telephonebased crosssectional survey with adults living in brazilian state capitals and the federal district to estimate the frequencies of risk factors among the population 95 confidence interval and maximum error of 2 the minimum sample size in each city was 2000 participants initially 5000 telephone lines were drawn in each city with stratification by region after the exclusion of commercial and nonoperational lines 2000 lines were randomly selected and in each household one adult was randomly selected to respond to the questionnaire further information is available elsewhere 17 leisuretime physical activity ltpa was assessed by the question in the last three months did you practice any type of exercise or sports possible answers were yes or no those who answered yes responded to the following question what is the main type of physical exercise or sport that you practiced possible answers were categorized into walking running strengthgymnastics sports and other ltpa sociodemographic characteristics the sociodemographic characteristics consisted of gender ethnicity and education statistics the descriptive analysis was performed by relative frequencies and their respective 95 confidence intervals the 95 ci were used to identify the trends in the prevalence of different types of leisuretime physical activity between 2006 and 2019 absolute differences were used to present the gender and ethnic inequalities with results reported in percentage points the slope index of inequality was used to measure the education inequality considering the intermediate group equiplots were created using the equiplot command the sii was calculated using the siilogit command all the analyses considered the sampling weights the analyses were conducted in stata 150 software results figure 1 presents the trends in walking running strengthgymnastics sports other types of ltpa and no ltpa participation between 2006 and 2019 we noticed increases in participation in walking running strength gymnastics and other activities on the other hand there was a decrease in sports participation in addition we observed a reduction in the frequencies of those who did not participate in ltpa between 2006 559 and 2019 430 figure 2 shows the trends in different types of ltpa and no ltpa participation between 2006 and 2019 according to gender in general we observed an increase in the percentage of women and men who participated in walking women 2006 the supplementary tables 1 2 and 3 present the prevalence and their respective 95 ci of walking running strengthgymnastics sports other types of ltpa and no ltpa participation between 2006 and 2019 according to gender ethnicity and education level respectively discussion we aimed to analyze the trends in the gender ethnicity and education inequalities of different types of ltpa among adults living in brazilian capitals despite the general increase in ltpa participation over the years fig 3 trends in the prevalence of different types of ltpa and no ltpa participation among brazilian adults living in capital cities according to ethnicity note diff is referring to the absolute difference in percentage points diff black versus white diff brown versus white diff yellow indigenous versus white ltpa leisuretime physical activity focusing only on the overall prevalence can hide inequalities among population subgroups in this sense our stratified analysis revealed persistent disparities related to gender ethnicity and education several studies have reported gender inequality in physical activity as a major challenge in physical activity promotion 1819 some factors that help explain these inequalities have been reported in the literature such as social and cultural norms where involvement in household chores is much higher among women than among men even among youth studies have demonstrated that parental and school support for participation in sports is higher for boys than for girls demonstrating that actions aiming to tackle gender inequality need to start early 20 in brazil cruz et al 8 observed that between 2006 and 2016 men were more active during leisure time than women with a slight decrease in gender inequality fig 4 trends in the prevalence of different types of ltpa and no ltpa participation among brazilian adults living in capital cities according to education level note sii slope index of inequality ltpa leisuretime physical activity however we observed different trends depending on the type of ltpa with an increasing trend of inequality in women being more engaged in walking and strength gymnastics and an increasing trend in men being more engaged in running than women despite the changes in the inequalities we highlight that there was persistent gender inequality especially in sports participation which could be the main driver for a higher prevalence of no ltpa participation among women although men and women can prefer certain types of physical activities men reported more ltpa participation than women over all the years analyzed thus our findings suggest that differences in sports participation can be not only a preference but also a difference in access and support in this way promoting the participation of women in sports is a key point to decreasing the gender inequality in ltpa as well as increasing physical activity levels worldwide 2122 we noted trends in the ethnicity inequalities especially for strengthgymnastics there were also consistent inequalities over the years where white people had more access to these activities than their black and brown peers and the proportion of no ltpa participation was greater among brown than white adults over the years analyzed the association between ethnicity and ltpa among adults has already been presented in the brazilian context 2324 but less is known about the different types of ltpa 9 therefore our findings can be interpreted considering different perspectives in brazil there is great inequality in society concerning ethnicity including structural racism for several historical reasons poverty levels are higher among brown and black people for example the percentage of white people with an income below 55 dollars a day is 154 while the percentage of black brown ethnicities is 329 25 higher poverty rates can lead to less access to private structures for physical activity such as gyms these findings demonstrate the urgent need for public policies to improve income distribution giving greater autonomy for individuals to engage in ltpa as well as enhance other health conditions 2627 our results also indicated that education inequalities increased over the years for strengthgymnastics with increased participation among those with a higher education level than those with a lower education level the inequalities also persisted over time for the other types of ltpa where those with more education presented a higher prevalence of the different ltpa types except for walking likewise although ltpa is increasing among brazilian adults this was especially observed among the higher education group 16 thus our findings expand previous research by showing that the biggest inequalities occurred in strengthgymnastics activities some facts can help in explaining these inequalities for instance strengthgymnastics activities commonly include membership fees and the fact that individuals with higher education may have higher incomes than those with less education increases the probability of access to this type of ltpa 28 other reasons could also partly explain the maintenance of these inequalities over time such as the unequal distribution of physical activity facilities which especially affects areas with disadvantaged socioeconomic backgrounds 29 our results also revealed that the proportion of participants with no ltpa participation was higher among those with a low education level in 2019 than among those with a higher education level in 2006 reinforcing the urgency to promote physical activity especially to socially disadvantaged groups in brazil the promotion of physical activity within the unified health system is part of the national agenda with the national health promotion policy 30 family health support centers and health academy program 31 the health academy program is freeofcharge inclusive and with easy access to people from different socioeconomic backgrounds as it is located in the same reference territories as the facilities of the family health strategy teams 32 in 2017 the health academy program was present in 2678 of the 5570 brazilian municipalities especially in small municipalities with greater social vulnerability 32 despite these issues universal access to the health academy program is not guaranteed for reasons related to opening hours lower participation of men precariousness in the employment relationship of professionals and some difficulties in articulating with the network of primary health care services which can lead to interruptions in the provision of activities 33 notwithstanding the importance of these policies for physical activity promotion and reduction of inequalities since 2016 brazil has undergone fiscal austerity measures that have deepened the underfunding of the unified health system and negatively impacted the functioning of these programs strengths and limitations our study has strengths such as the use of a large sample from 14 different years on the other hand some limitations should also be considered such as physical activity was all selfreported which could present recall bias however currently there are no viable objective methods available to assess types of physical activity in populational studies despite the large population vigitel is representative only of adults living in state capital cities and consequently the survey is not representative of noncapital cities and the rural population the vigitel is a telephonebased survey with a sample restricted to people with landline telephones this limitation in the representativeness could affect the estimates especially in regions with lower coverage of landline telephones given that ltpa has been less frequent among those most socially unfavored 34 based on our results strategies to promote physical activity in the population should focus on improving the distribution of physical activity facilities especially in areas with disadvantaged socioeconomic backgrounds through the expansion and reinforcement of public policies such as the health academy program furthermore these strategies could include the improvement of macroeconomic policies to increase the employment rate together with income distribution policies to reduce socioeconomic inequality and the monitoring of barriers to the practice of different types of physical activities among the most disadvantaged groups which in addition to socioeconomic factors may include interpersonal factors such as lack of motivation lack of time illness and physical limitations 35 conclusion even though there was an increase in the participation in different physical activity types the increase was not equal in all population groups with women black and brown people and subjects with less schooling being the most unfavored groups in addition while some inequalities persisted over the years others increased such as the ethnicity and education inequalities for strengthgymnastics continuous surveillance is essential to explore whether inequalities are reducing or not and this is even more necessary in the present period to monitor the inequalities and challenges for physical activity promotion in the postcovid era this specific study did not receive funding rhoa is supported by the coordination for the improvement of higher education personnel with a phd scholarship aow is supported by the são paulo research foundation with a phd scholarship drs is supported by the european union nextgenerationeu for the recovery transformation and resilience plan and by the ministry of universities within the framework of the grants maria zambrano for the requalification of the spanish university system 20212023 convened by the pablo de olavide university seville this paper presents independent research the views expressed in this publication are those of the authors and not necessarily those of the acknowledged institutions funding additional file 1 competing interests authors declare no competing interests

the current study aimed to describe the trends in gender ethnicity and education inequalities of types of leisuretime physical activity ltpa practiced by brazilian adults from 2006 to 2019we used data from 2006 to 2019 of the brazilian surveillance system for risk and protective factors for chronic diseases by telephone survey which is an annual survey with a representative sample of adults ≥ 18y living in state capital cities the types of ltpa considered were walking running strengthgymnastics sports other ltpa and no ltpa participation gender women or men ethnicity white black brown or yellowindigenous and years of formal education were also selfreported we used relative frequencies and their respective 95 confidence intervals to analyze trends the absolute and relative differences between the proportions were used to assess the inequalitieswe observed increases in inequalities related to gender and education running and strengthgymnastics while gender inequalities for sports other types and no ltpa participation decreased there were persistent inequalities related to gender walking and education sports other types and no ltpa participation considering ethnicity we noted increases in inequality for strengthgymnastics where white adults were more active than black and brown adults in addition white adults reported more access to ltpa than brown adults over the years analyzedwomen black and brown people and subjects with less schooling were the most unfavored groups while some inequalities persisted over the years others increased such as ethnicity and education inequalities for strengthgymnastics

introduction depression the most common mental disorder accounts for 97 years lived with disability in the 2010 global burden of disease study 1 depressionrelated disability compounded by lack of access to care impacts on social and physical health prevalence estimates of depression in india have varied widely depending on the assessment tools used and the communitys sociodemographic profile 2 3 ganguli 3 reviewed 15 studies of psychiatric morbidity and found a mean prevalence of 34 reddy and chandrasekhars 4 metaanalysis of 33 572 participants described prevalence at 89 with urban rates nearly double rural rates other studies in south asia have shown even higher rates for example 151 in urban south india 5 and 459 in urban pakistan 6 robust evidence from india and other low and middle income countries links socioeconomic deprivation with increased strengths and limitations of this study ▪ data derived from this communitybased crosssectional randomly selected sample shows that over 6 of adults in dehradun district uttarakhand are depressed ▪ risk of depression is two to three times higher for people who have had very little schooling who live in poor housing who have taken a recent loan and who identify as belonging to a scheduled caste or tribe ▪ there is a large gap in access to effective care 0 had received talking therapy and only 33 of people with depression had been prescribed antidepressants although the majority had attended a primary care provider in the previous 3 months ▪ a limitation of this study is that the estimate of prevalence is through a screening tool rather than definitive diagnosis by a psychiatrist the crosssectional design cannot indicate causation and the survey covered only one district of uttarakhand state which may limit generalisability risk of depression 7 8 9 other groups shown to be at higher risk for depression in india are women the elderly urban dwellers and people who are divorced or widowed 35 7 9 indias highly inequitable distribution of mental health resources means at least 90 of people with mental disorders are undiagnosed and untreated 10 there are also huge disparities in access to mental health services particularly for people in rural areas 4 barriers to helpseeking include unavailability of services poor quality of the majority of existing services lack of knowledge about mental illness and fear of stigma and discrimination 11 12 people with depression in india report distress primarily as unexplained somatic symptoms and usually seek help from primary care rather than specialist mental healthcare providers 13 14 simultaneously conceptual understandings of depression are not well captured by current disease classification systems 15 and ongoing reflection is needed about when mental distress becomes a disorder there is an urgent need to understand the burden of disease in areas where prevalence studies have never before been conducted 16 and to understand the pathways to care currently utilised 17 few studies of depression in india have examined the associations between depression and social determinants of health and almost none have considered the association between depression and caste 25 7 there are very few studies of depression prevalence in the hindispeaking belt with existing studies predominantly from southern and eastern india 25 9 18 we could find no study on the prevalence or epidemiology of depression in uttarakhand a state with a population of 10 million this study describes the prevalence of depression sociodemographic associations and the helpseeking behaviours of people with depression methods setting this study was conducted in two blocks in dehradun district uttarakhand as part of the baseline survey for burans a community mental health partnership project with the emmanuel hospital association and the uttarakhand community health global network burans is directed by the first author housing is an important indicator of socioeconomic status in this setting permanent materials housing refers to housing that is predominantly made with a sealed floor walls of a solid material and a corrugated iron roof temporary materials housing refers to housing with a dirt floor andor walls and roofing constructed from strawtarpaulin or plastic sheets the national district mental health plan had not been implemented in uttarakhand at the time of this survey during the survey period there were two government psychiatrists and no government psychologists with 1015 private psychiatrists and psychologists across uttarakhand government primary care services did not generally treat pwmds nor did they supply essential medicines such as antidepressants sample selection we selected 960 people from 30 randomised clusters cluster sampling was conducted in three phases ward or panchayat household and participant we used stata 19 to calculate a sample size of n480 3 5 and a sampling frame of 235 000 30 clusters and 95 cis to account for the effects of clustering we allowed a design effect of 2 giving a final total of 960 persons clusters were stratified based on ruralurban ratios in the districts 2011 census 20 to require 21 urban and 9 rural clusters these were selected by random number generation from the publicly available list of census panchayats and wards to select at household level the surveying team walked to the centre of the community and spun a pen to ascertain which direction to start every 6th house on the right was surveyed and at each junction roads alleys on the right were followed if no one was present at a selected household the team revisited that household later if no one was present on the second visit the first house to the right was selected only one person from each household was surveyed generally male field staff surveyed male respondents and female staff surveyed female respondents once the requisite 50 of female participants was reached all survey staff surveyed male respondents inclusion criteria were that participants should be occupants of a household 18 years or older and able to comprehend and respond to a survey data collection project burans field staff all from the district of dehradun collected data in july and august 2014 all were trained in sampling strategy use of the survey tool data recording and management and ethical research and were supervised and supported by km a comprehensive survey tool was translated to hindi back translated to english and piloted extensively by the prime team in madhya pradesh 21 the survey was interviewer administered in hindi components reported in this paper are ▸ sociodemographic information including indicators of housing quality indebtedness caste marital status highest education level attained and employment status adapted from the indian version of the demographic and health surveys 22 proxy measures of socioeconomic status included housing quality educational status and employment status we used norms of the government of india to assess housing quality where permanent material housing referred to classifications of pukka and semikaccha and temporary material housing referred to the kaccha classification 23 ▸ general health helpseeking behaviour and health service utilisation 23 ▸ adapted questions from the client service receipt inventory 24 used to ask participants about recent inpatient and outpatient services including type of provider ▸ talking therapy or medication prescription received ▸ patient health questionnaire a selfreport screening tool assessing clinical depression 25 26 27 this questionnaire comprises nine items each is scored 0 to 3 which thus yields a severity score from 0 and 27 response categories based on frequency of a particular symptom over the last 2 weeks are scored 0 1 2 and 3 for not at all several days more than half the days and nearly every day respectively in our study a person with a phq9 score of 10 or higher was assessed as having at least moderate depression in line with international norms for phq9 27 ▸ mental health service seeking behaviour among those screening positive for depression using the same codes as for general health seeking behaviour at census enumeration and on birth registration indians of jain sikh and hindu religion must identify themselves as general caste other backward classes or a member of a scheduled tribecaste based on the identity of their parents 28 in the dehradun area the vast majority of muslims are included under the obc category christians and buddhists are classified into the general caste category analysis survey data were analysed using stata v131 19 open text was translated into english grouped thematically and coded univariable logistic regression analysis was performed using all relevant socioeconomic variables and significant variables were considered in the multivariable logistic regression analysis the dependent variable was dichotomised no depression0 depression1 the original interpretation defined a total score of 59 as mild depression and above 9 as moderatetosevere depression in this study we designated all respondents with a score of greater than 9 as being depressed χ 2 test was used in analysis of tables 1 and 2 a p value 005 was considered statistically significant all participants gave written consent to participate in the study and respondents who screened positively for depression were given information on depression and advised on health services and other sources of help results within two contact attempts 958 of 960 selected households were successfully surveyed and the remaining two were surveyed on the third visit survey participants demographic characteristics are summarised in table 3 nearly onequarter were lowest caste or had tribal status thirtyfive per cent had six or fewer years of schooling the sampled survey population had a mean age of 394 years and a median age of 375 years the mean period of education completed was 80 years and the median was 9 years the sample differs significantly from the wider uttarakhand population 20 by greater representation of middleaged people classified as scst and unschooled people table 4 summarises the prevalence of depression sociodemographic characteristics and their association with the phq9 depression score with crude and adjusted ors depression prevalence was 6 the significant association with increased risk of depression in women disappeared when other confounding factors such as educational status and economic deprivation were accounted for people in their middle years had a slightly higher risk of depression than those under 30 years and over 50 years of age people who lived in a house made of temporary materials were almost twice as likely to be classified as depressed and those who had taken a loan recently were three times more likely those classified as sc or st had three times the odds of being classified as depressed a doseresponse relationship was seen in educational status with risk of depression increasing with decreasing years of completed schooling table 1 shows the helpseeking behaviours of those screened as depressed or who selfreported a 2 week episode of depression in the last 12 months people with depression were five times more likely to have visited outpatient or inpatient providers than people without depression separate analysis showed that all women with and without depression were significantly more likely than men to have visited a health provider in the prior 3 months table 2 shows the type of health provider visited by the 183 people who made an outpatient visit in the previous 3 month depressed people compared to nondepressed consult health providers significantly more and are far more likely to visit general health providers than to visit mental health services only two people had visited a mental health service provider in the previous 3 months no one with depression had received talking therapy two people with depression at the time of the survey had been prescribed antidepressants through private practitioners while one respondent who screened negatively for depression had been prescribed antidepressants discussion this study shows a 6 prevalence of depression using a depression screening tool in a randomly sampled population in dehradun district uttarakhand some studies suggest prevalence in india may be higher 4 6 29 in this study no one had received talking therapy indicating a treatment gap of 100 for the recommended firstline treatment of mild or moderate depression 30 antidepressants are the recommended secondline treatment for depression 30 and although we cannot ascertain how many of the 963 people would have benefitted from these medicines it is likely this also represents a large treatment gap extrapolating these findings to uttarakhands adult population of 66 million 20 we estimate 400 000 people may have depression of whom just 4000 may have access to antidepressants and almost no one is likely to have access to talking therapya huge mismatch between disease burden and health service provision this study shows much greater risk of depression for three groupsthe poorest those who selfidentify as obc sc or st and the unschooledilliterate each of these associations has an adjusted or for depression of at least twice that of their reference group a systematic literature review in lmic shows depression to be strongly associated with socioeconomic deprivation 8 supporting the who commission on the social determinants of health concept of mediating pathways that link poverty with lack of access to political recognition and economic power 31 other indian studies also suggest socioeconomic factors as the key determinants of depression 4 5 7 similar to a canary in a coal mine depression may be conceptualised as an indicator of social inequity and vulnerability although mental health has been linked with socioeconomic disadvantage and social exclusion caste a key indicator of social identity in india has not been well investigated as a risk factor one indian study of the prevalence of cmds among rural women found no association with caste 7 a further study in rural nepal found that castebased disparities in mental health are mediated by poverty lack of social support and stressful life events 32 however sens 33 capabilities approach emphasises rights and command over goods recognises the relational roots of deprivation and underscores the importance of agency and participation for genuine social inclusion this view is supported by others describing psychosocial and biological pathways between social exclusion and health 34 35 it seems likely therefore that social exclusion marked by caste increases the risk of depression for decades indian national policy has sought to legislatively benefit sc and st for example the reservation in admission act 2006 36 and the protection of civil rights act 1955 37 despite such measures and even after controlling for socioeconomic status members of sc and st groups in this study had more than twice the risk for depression compared to the general caste it is likely that persisting social structures of exclusion and discrimination are more penetrating than legislation and that they continue to create relative deprivation reduce agency and exclude people associations between poverty and cmds in lmic countries and in india are well described 13 this study found that depression prevalence among people who had taken a recent loan was thrice that of those who had not two other studies from india show indebtedness as a risk factor for primary care attenders diagnosed with a cmd 13 38 links between personal debt and mental health are well described 13 39 40 although there have been no prospective longitudinal studies to show the direction of association possible mediating pathways between depression and indebtedness include shame stress of financial insecurity 39 and less capacity to earn income due to depression another strong risk factor for depression in this study is educational status people who had not completed primary schooling had almost four times greater risk after controlling for caste housing indebtedness and employment status our results show a striking doseresponse relationship increasing years of education provide increasing protection a metaanalysis examining the associations between socioeconomic inequality and depression also reported this finding 41 education status has been described in india and other lmics as predictive of mental health outcomes 41 42 43 social consequences of low levels of education are multiple and move beyond schooling as a marker of deprivation including reduced opportunity to access resources and to develop protective social and cognitive skills and increased risk for mental distress reverse causality is unlikely to be a factor as primary education occurs at an age when cmds are uncommon although people with depression were seeking care they were not getting the help they needed this study shows that most people with depression had attended primary healthcare providers in the previous 3 months in the government as well as in the private sectors the somatisation of depression among people with depression in asian cultures particularly women is well described 44 many health providers are unable to recognise somatisation leading to excessive costly and often inappropriate investigation and treatment also noteworthy is that only eight people in this sample reported consultations with traditional healers others have described up to twothirds of people with severe mental disorders in india seeking help from traditional healers during their illness 17 the strong association between somatoform disorders and cmds highlights the need for primary care providers to be equipped with knowledge and skills to recognise and manage the diverse presentations of cmds 14 44 this study shows depression as a community outcome of macroeconomic and political decisions that can lead to mental distress and suffering for communities as well as for individuals there are several important implications for policy and practice foremost since social determinants of health almost certainly contribute to depression macropolicies that address determinants such as poor housing caste indebtedness and low education will also reduce depression disease burden policies to improve mental health must seek to reduce poverty and social exclusion 45 and actively include communities second action is urgently required to increase provision of mental health services and medicines as strongly advocated by the lancet mental health group and series 29 45 however perhaps more importantly primary care doctors in india being the healthcare providers most commonly consulted by people with depression 9 14 need the knowledge skills and perception to recognise the diverse presentations of cmds such as depression and anxiety and to treat them appropriately with both talking and pharmaceutical therapies methodological considerations a major strength of this study is that its data are from a randomly selected population covering rural semiurban and urban populations typical for a district in north india in 2014 multivariable analysis ensured that potentially confounding factors were considered however there are some methodological limitations selfreported measures may risk recall bias and cultural factors phq9 is a screeningnot diagnostictool constructed using a definition of depression it has been critiqued as being over simplistic and risks labelling components of normal human experience as a disorder 15 this crosssectional study cannot attribute causality to apparent risk factors the survey tool excluded three key risk factorsstressful life events chronic illness and disability the lower than expected prevalence of depression may be related to the emphasis in the phq9 on cognitive manifestations of depression possibly missing the somatic features common in asian cultures 44 conclusion depression in dehradun district of uttarakhand with a prevalence of at least 6 is two or three times more common among people who are economically deprived those who are part of the most excluded caste group or those who have had little education almost no one with depression accesses effective primary or secondary mental healthcare social policy and health service responses must urgently address this preventable and treatable disease burden and treatment gap cmds are indeed common and disproportionately affect the most vulnerable

objectives this study sought to use a population based crosssectional survey to describe depression prevalence healthcare seeking and associations with socioeconomic determinants in a district in north india

introduction stigma of mental illness constitutes a major problem worldwide 1 it not only affects people living with a mental illness 2 but also their families 3 referred to as courtesy stigma 4 associative stigma 5 stigma by association 6 or family stigma 7 it is widespread and occurs across cultures regardless of nationality and socioeconomic status 8 12 it exists in different domains of life 12 and is associated with both subjective and objective burden of family members 6 7 9 13 15 a variety of campaigns have been undertaken to tackle stigma 1 and some have been shown to be successful 16 17 ; however they are generally broad nonspecific and their effect size is moderate 18 19 interventions seeking to reduce stigma in the family context are scarce and rarely take into account the views of service users 18 further research is needed to better understand how stigma is experienced in the family context and how these experiences vary in different cultural contexts ie what matters most in different settings 20 information of this type is essential to inform the development of interventions that take into consideration the effects of stigma and its crosscultural variability 18 there is very little evidence available from eastern europe 21 and to the best of our knowledge this is the first paper presenting firsthand experience of families of people receiving mental health care in belarus information of this type is particularly important in countries of eastern europe as there is insufficient development of communitybased treatment 22 23 and most of the care for mentally ill people particularly those who are severely and chronically ill depends on the fms 425 we undertook a qualitative study of the firsthand experience of fms with three main objectives to investigate experiences of stigmarelated challenges of the fms of people living with schizophrenia in belarus both in the private and public domain of life; to identify strategies that fms use to face the stigmarelated challenges in belarus; to identify relevant and acceptable targets for interventions to help overcome stigmarelated challenges for families within the belarusian context there is a lack of widely accepted theories on stigma within the family with an awareness of the existing conceptualizations of stigma 20 24 28 we upheld a broad perspective and took an inductive approach to the experience of stigma rather than the process of stigma per se therefore the analysis was focused on the direct experience of stigma related challenges by fms of pls and specifically any examples of devaluation experienced by fms either in the private or public domain because of the presence of schizophrenia in the family by private domain of life we meant personal relationships interests and activities as distinct from public or professional life 29 and focused on discrimination within a family in relationships with neighbors friends and colleagues in contrast by public domain of life we meant experience of contacting social institutions and focused on stigma and discrimination in these contexts we here present results related to the experience of stigma and discrimination in the private domain of life of fms of pls the materials of the study related to the stigma and discrimination in the public domain are available on request from the authors and will be published in a separate paper methods the research participants were recruited via purposive sampling in both minsk and grodno so as to obtain data from the capital and a regional city to achieve maximum variation we recruited cases according to the following core attributes for the sample fm and pls sex and age duration of disease degree of kindred first degree relative 525 second degree relative distant relative or other before approaching fms we contacted the patients described the study and asked them for permission to approach the nominated fm after obtaining the permission researchers contacted the selected fms described the study asked them to sign informed consent and conducted semistructured indepth interviews 30 a topic guide was developed based on a literature review 4 10 15 consultations with service users and mental health professionals which was piloted during initial interviews interviews lasted approximately 15 h were conducted in russian recorded digitally and transcribed verbatim two bilingual members of the research group proceeded with the thematic analysis 31 in russian coding of the interviews was done by hand and both analysts independently processed each interview analysts initially familiarized themselves with the data by listening to the recordings and transcribing them words phrases and larger sections of text were highlighted and coded to identify relevant themes discrepancies in the coding were discussed and resolved the final list of themes was discussed with other members of the research team and adjusted until final agreement was reached the final results and supporting quotations were translated into english and doublechecked by bilingual and native englishspeaking authors the study was approved by the ethical committee of belarusian psychiatric association results stigma experience following thematic analysis of the interviews we grouped the experiences of fms into three main themes challenges in the private domain; subjective burden and feelings associated with experiences of stigma; challenges in the public domain as previously mentioned results related to stigma in the public domain are covered in a separate paper and are available from the authors challenges in the private domain experience of stigmatization in the private domain is covered within two subtopics attitudes within close environment and life within the family in relation to the attitudes within close environment nearly half of respondents expressed suspicions that derogatory attitudes are hidden andor apprehensions that there may be bad or dangerous consequences to the relatives partners half of the respondents described difficulties with a tendency of families to come apart following the diagnosis of mental disorder the breaking up of the family happened in different ways divorces from the pls with the pls returning to the parental family ; former spouses initiating the process of governmental removal of children from the pls parental custody ; general reduction of contacts from the rest of the family with primary carer and a pls as a consequence of such family break up more than a third of the fms providing primary caregiving were the only people remaining in the life of pls and were bound to them without the possibility of temporal separation her husband returned her to me and said come and take back this schizophrenic children were taken away from her everyone has abandoned him x once went to my brother but they refused even to let him come into the house x was sitting on the bench all the time he called me and said come here and take him back and didnt even allow him to enter do you understand … earlier we communicated somehow but later when he married his wife forbade it because children will be afraid of x that is it do you know how painful it is for me to bear this my sister asks why dont you visit me this summer i replied ok let me come with x she no i do not need this tagalong ie no one needs him so he will stay and i even do not have anyone to be his guardian … so everyone has abandoned him subjective burden respondents expressed a number of negative feelings associated with being part of a family with a pls shame andor guilt were the feelings most frequently mentioned as burdensome in one form or another guilt for the lack of awareness of the need for treatment denial of the need for treatment during the first years of the disorder; sins bad actions that were perceived as a possible explanation of the onset of the disorder ; vague reasoning ; shame caused by the patients bizarre behavior in public fms expressed fear anxiety and hopelessness related to the presence of diagnosis within a family which were mainly connected to uncertainty about the future lack of support from the rest of the family and within the health care system worsened the situation more than third of primary carers expressed tiredness loneliness and regret as a consequences of the family dissolution following the diagnosis of schizophrenia what will happen after i am not able to care for x who will take care of me when i am old i dont see how it may be resolved amongst other emotions regret sorrow and mourning feelings of loss frustrated hopes were often mentioned as well as overload and depression in most cases the first episode of psychosis the first hospitalization and especially the first exposure to the diagnosis of schizophrenia were mentioned as the most stressful and difficult period for the whole family respondents remembered feelings of despair hopelessness shame and fear home i howled at nights for many years i was very upset we were crying for weeksme and my wife we didnt know what to do we felt bad… it was very hard in the beginning… there were thoughts that a persons life is crippled strategies that fms use to overcome stigma in the private domain strategies adopted by respondents to cope with stigma and discrimination in the private domain included concealment avoidance of the rest of the family and taking full responsibility and sacrificing ones personal life the whole set of strategies to cope with stigma and discrimination in both the private and public domain of life is presented in the appendix 2 concealment suspicions and fear of experiencing derogatory attitudes towards the family or lived experience of it due to the presence of a pls within the family lead to the tendency to live behind closed doors hide and to pretend a normality in the eyes of others more than a half of respondents reduced contacts with the external world and tried to avoid social activities if these were unavoidable they would prepare the pls so that they looked and behaved as normal even if the current situation resulted in a significant burden the relative were not ready to implement any alleviating actions or share their difficulties with others avoidance of the rest of the family more than twothird of fms who were not primary caregivers expressed a tendency to stay away from plss or even leave the family because of lack of practical knowledge general tiredness and fear of consequences for their personal life and career if the diagnosis within their family was disclosed at the same time they mentioned feelings of shame and guilt because of this taking full responsibility and sacrificing ones personal life insufficient support in mental health care and from the rest of the family and living life behind closed doors whilst avoiding contact with the external world led to fms bearing substantial responsibility for the actions of pls and totally controlling their decisionmaking the majority of primary caregivers mentioned this at the same time fms were usually aware of the necessity to reduce control over the plss actions so as to increase their autonomy we all must somehow to let children go however he is like this but even if he is like this he also must be somehow slightly although maybe not totally released … but i dont know how respondents expressed perplexity in such ambivalence and lack of knowledge on how to manage the situation the intense devotion to the life of the pls led to fms sacrificing their own personal lives with an inability in some cases to even express their own needs requests for interventions to decrease burden of stigma and discrimination in private life of fms interventions mentioned by respondents as possibly helpful to decrease stigmarelated challenges in the private domain included provision of better access to appropriate information and assistance in the life of pls information and education one of the main needs of fms mentioned by 40 of respondents was that of access to correct information that is delivered sensitively part of the request was related to advice on ways of treating and managing relapses and of solving difficulties in relationship within a family eg how to communicate with other fms and pls how to discuss challenging situations within the family although there are taboo or difficult issues that need to be discussed but relatives either do not know how to raise these issues or are afraid of doing so what i would like to change in the medical services is to increase the quantity of available information… about new approaches and it should not be my responsibility to elicit this information but someone else who will give it to me… but there is nobody… i would like to be guided when i address the doctor how should i behave in these situations should i call the police or should i not should i wait for x or talk to her somehow specifically how to behave how to act how to persuade her ie i need some kind of recommendations on how to behave with her assistance in the life of pls nearly half of respondents also expressed a wish to help the patient with having more communication with peers assist them in socializing and in living a more independent life i would be happy if there were at least somewhere where he could spend time with peers drawing or doing some job i only want him to be able to communicate more with his peers discussion the results of the study shows the presence of stigma experience in the private life domain of the family members of people living with schizophrenia with a specificity of the stigma experience in primary and secondary social groups life within primary social group was described as changed after onset of mental disorder mainly because of dissolution of families on the other hand within secondary social group stigma was perceived as problematic predominantly due to suspicions of hidden discrimination and apprehension of bad consequences in the case of the diagnosis 1425 disclosure although there were relatively few examples of perceived stigma and direct discrimination whereas experience of perceived stigma within a primary social group was salient in the study this was not the case in the secondary social group there was a contradiction between anticipated and perceived stigma while contacting outsiders on the one hand respondents presented feelings of fear suspicions and apprehension of possible hidden discrimination and its consequences on the other hand the majority of these respondents could hardly remember real examples of discrimination and were satisfied with the relationships with friends neighbours colleagues this contradiction was previously discussed in relation to associative stigma by catthoor et al who noticed a marked difference between the presentation of the perceived stigma and feelings associated with it in particular respondents claimed there were no problems in contacting outsiders although they tended to conceal and keep the disorder secret 11 this phenomenon of mismatch between experienced and anticipated discrimination was described even more thoroughly in research on stigma towards people with mental disorders it has been found that anticipated discrimination was reported more frequently then experienced acts of discrimination and not necessarily associated with it 2 32 the described mismatch was however not found within the primary social group in the current study where clear examples of family dissolution with consecutive challenges and subjective burden of caregivers were presented this is in line with other research showing relationships problems within the family 33 34 and deterioration of relationships with extended family because of a relative with a mental illness 6 9 13 14 according to the theory of yang et al 20 35 where family was ranged as the most important value the literature on coping strategies for carers of people with psychosis 36 40 has highlighted the importance of understanding both the severity and scope of the problems and how carers appraise the situation and cope with it 37 38 41 adequate coping strategies promote good living environments and reduce the level of expressed emotion which have been shown to play a substantial role in both the burden of carers and patients outcomes 42 44 life behind closed doors avoidance of distant relatives taking full responsibility for the life of patients and sacrificing ones personal life were the strategies mentioned by the studys respondents in relation to stigma in the private domain the overall solution to cope with stigmarelated challenges in the family was living a hidden life or behind closed doors this strategy resulted in social exclusion of the direct caregiver and burdensome feelings that included guilt tiredness and loneliness together with fear and anxiety due to uncertainty in the future and feelings of loss and frustration because of hopes for a better life held in past in summary according to the data of the current study stigma experience in the private life of family members of people living with schizophrenia includes anticipated stigma within the secondary social group; dissolution and lack of support within families; strategies to conceal disorder living a hidden life behind closed doors and taking full responsibility for the life of the patient; being exposed to resulting subjective burden in a situation of this sort access to appropriate support and assistance provided by mental health care could improve the quality of life of family members however mental health care in belarus is hardly able to provide such support as it has just recently started a deinstitutionalisation process of its services 23 45 and is still based in centralised psychiatric hospitals institutionalised mental health services are known as associated with structural stigma bad living conditions 46 47 human rights abuses and negative outcomes from longterm treatment 48 lack of appropriate support from mental health service absence of peer support groups patients and family organizations 1625 in belarus make the situation even worse breaking the vicious circle of disempowered families and nonresponsive mental health service is an important direction for addressing the burden of stigma within families of people with schizophrenia in belarus what should be a priority for reforms of mental health care number of approaches have been offered to tackle stigma and discrimination 49 50 we recommend the implementation of several such strategies in belarus for example important steps to be taken include empowerment of family members as well as people with schizophrenia themselves; their inclusion in decision and policy making; reforming mental health service with increased access to care within communities; development of family support services; facilitating appearance of service users and family organisations; assistance in communication resocialisation and independent living of people diagnosed with schizophrenia 49 strengths and limitations there are a number of limitations to our study firstly it is difficult to generalize the results because participants were recruited through mental health services potentially resulting in the overrepresentation of the views of people who are in touch with services secondly interviews were conducted and analyzed by researchers who are both clinical psychiatrists from belarus this may have led participants to focus more on their experiences from the perspective of mental health services third difficulties with conceptualisation of the phenomenon studied must be taken into account it was at times not clear where to draw a line when trying to separate direct experience of discrimination from indirect the difficulty in separating direct and indirect experience of discrimination was also an issue in other studies on courtesy stigma 4 15 where it appears to be difficult for relatives to draw the line between negative reactions targeted at themselves and those targeted at mentally ill relatives feel thus stigmatized in a double sense 4 in addition stigma is a complex phenomenon multiply interwoven with other life experiences such as burden illness manifestation relationship within a family social interactions contacts with health service and other public institution 6 51 therefore it was not always possible to differentiate whether the topic discussed was related to stigma to its consequences or to some other concept however the study has many strengths including the use of an inductive approach in the analysis of participants accounts of their experiences; involvement of mental health professionals and service users while planning and conducting the study practical implications based on the results of the study a set of recommendations on reduction of stigmarelated burden in belarus might be produced to tackle the stigma and discrimination in families of people living with schizophrenia it is important to promote empowerment of families their inclusion into the decision and policymaking processes other important components would include providing better access to correct information support of people living with schizophrenia in their communication skills resocialisation and independent living

family stigma constitutes a major problem in schizophrenia worldwide data on firsthand experience of stigma in families is necessary for planning and implementing interventions to reduce its burden the aim of the study was to investigate the experience of stigma among relatives of persons with schizophrenia in belarusqualitative research methods such as the thematic analysis of indepth semistructured interviews with 20 relatives of people diagnosed with schizophrenia were used experience of discrimination strategies used to cope with it and requests for interventions were investigatedthe most salient themes in experience of stigma in the private domain of life elicited in the narratives included anticipated stigma and dissolution of families the experience of stigma was associated with burdensome feelings of guilt tiredness and loneliness together with fear and anxiety due to uncertainty in the future and sorrow because of frustrated hopes in past analysis of the strategies used to overcome the difficulties revealed concealment and life behind closed doors avoidance of the rest of the family taking full responsibility and sacrificing ones personal lifeto reduce the burden of stigma in the private life of the family members of people living with schizophrenia in belarus important steps should be taken to promote the empowerment of families including reforming mental health services; provision of better access to information; family 2102016 eproofing 325 support services community care; development of family organisations; assistance in communication resocialisation and independent living for people diagnosed with schizophrenia

introduction the covid19 pandemic has had a profound impact on individuals communities and health systems worldwide however certain populations have been disproportionately affected by the pandemic including people living with hiv this is due to several factors including the fact that many people living with hiv face additional challenges such as stigma discrimination and limited access to healthcare which can exacerbate the impact of the pandemic on their health and wellbeing plwhv are unique due to their dysregulated immune system from their history of chronic hiv infection and their use of antiretroviral therapy some of which have been used experimentally to treat covid19 infection apart from immunosuppressed individuals people living with hiv are at risk of more severe covid19 infection as a result of overlapping demographic and medical characteristics that are known risk factors for severe covid19 diseases in a systematic review conducted by ssentongo et al it was found that people living with hiv have a higher risk of sarscov2 infection and mortality risk from covid19 than people without hiv the prevalence of hiv in covid19 patients and associated mortality vary across the world many researchers have highlighted the urgent need for plwhv to be vaccinated against covid19 a study in south africa reported that plwhv especially those not on antiretroviral therapy were at risk of severe infection from covid19 and vaccination should be a priority for them immunity is already compromised as a result of hiv infection now having a dual combination of viral infection with covid19 may lead to a more severe medical burden on the affected individual since there is no specific treatment for covid19 vaccination is still one of the most effective means of preventing the disease across the world there have been so many rumours and misinformation circulating the globe concerning covid19 vaccines it has been reported that people who were fully vaccinated died of covid19associated symptoms which has deepened public uncertainty about the safety and effectiveness of the vaccines about 377 million people were reported to be living with hiv globally there are currently 18 million plwhv in nigeria 15 million of whom are on art since covid19 vaccination began only about 3 of the eligible population has been fully vaccinated covid19 vaccination among people living with hiv has been reported to be low in a study carried out among plwhv it was reported that covid19 vaccination uptake was low and stated that plwhv will probably not get vaccinated as a result of vaccine safety and side effects a study carried out on the acceptance of covid19 vaccination in china also reported a relatively low covid19 vaccine acceptance rate among plwhv compared to the general population in another study conducted among plwhv in nigeria covid19 vaccine acceptance was low and was associated with respondents faith risk perception perception of the protective effects of antiretroviral treatment concerns about covid19hiv coinfection and infertilityrelated misconceptions there is little evidence as regards the perception of plwhv in nigeria towards covid19 vaccine which will be an important determinant in vaccine acceptance and uptake hence this study aims at determining the perception of covid19 vaccines among people living with hiv in ogun state nigeria methods design the study is a quantitative design adopting a descriptive crosssectional approach to determine the perception of covid19 vaccines among people living with hiv in ogun state nigeria setting and participants the study was conducted among people living with hiv who attended hiv support groups in selected local government areas in ogun state there are between three and four active support groups per lga each with an average population of about 330 regular members and an estimated total study population of 660 regular members across the two selected lgas in ogun state the target population is the people living with hiv between the ages of 1864 years old and are registered members of hiv support groups in ogun state nigeria sample size determination the sample size was determined using charans formula a 95 confidence interval 5 margin of error and estimated proportion of 8294 representing the proportion of plwhv with a positive attitude toward covid19 vaccine in a similar study after adjusting the minimum sample size for a 10 nonresponse rate a sample size of 243 was derived samples were selected through a threestaged probability sampling scheme in the first stage two lgas were selected purposively and two support group each was selected by simple random sampling out of the three hiv support groups in each lga in the second stage a list of all duly registered members of the selected support groups was obtained and a computergenerated randomization scheme was used to select study participants data collection the study data were collected using an intervieweradministered structured questionnaire with closedended questions the study adapted items from previous research and literature review to assess the perception of covid19 vaccines among people living with hiv section a consists of questions that assessed participant characteristics including sociodemographics section b assessed the covid19 vaccines related concerns and section c assessed the perception of plwhv towards covid19 vaccines recruitment and training of research assistant five research assistants who were graduates of health and related disciplines and spoke both english and yoruba languages fluently were recruited for data collection the researcher conducted two days of training each lasting five hours on the objectives and processes of the research for the research assistants the training also included ethical conduct of research and all study staff passed the nigerian national code for health research ethics online course validity and reliability the questionnaire was first assessed by two epidemiologists who determined that the scales had both face and content validity the questionnaire was then pretested among people living with hiv in oyo state nigeria based on the assumption that plwhv in southwest nigeria have similar characteristics the goal of pretesting was to assess the acceptability and ease of answering the questions as well as their tendency to elicit appropriate answers data analysis data were analyzed using spss version 22 means and standard deviations were used to summarize numeric data frequencies and percentages were obtained for categorical variables the proportions of all measured variables were computed and presented with relevant tables and charts results participants sociodemographic characteristics and clinical characteristics a total of 236 properly filled responses were received giving a response rate of 971 table 1 shows the sociodemographic characteristics of the study participants the majority of the participants are females with an average age of 407 are married 614 are christians and a majority of them are from the yoruba ethnic group more than half of the participants had secondary education the majority of the study participants had comorbid medical conditions the majority of the respondents believe that getting the covid19 vaccine will protect themselves their families or their patients and that it will help prevent the transmission of the disease there is also a large percentage of respondents who believe that the vaccine is effective and safe and that it confers longterm immunity we assessed the perception of the covid19 vaccine alongside the vaccinerelated concerns among plwhv in ogun state nigeria we found that the majority of the study participants have a good perception towards the vaccine nearly twothirds of the participants in the study also identified vaccinerelated concerns which may have affected the uptake of the vaccine this may indicate that there is poor knowledge of the dangers associated with covid19 infection among plwhv moreover the vaccinerelated concerns reported mostly by the respondents were that the covid19 vaccine has serious side effects and can aggravate health conditions less than half of the respondents reported that the virus can be gotten from the vaccine while a small proportion also prefer to acquire covid19 immunity by getting infected with the disease rather than take the vaccine perception of covid19 vaccine in our study was in contrast with the study carried out among the general population in nigeria where a poor perception of covid19 vaccine was reported among the participants the good perception in our study might be due to increased health education and awareness at hiv clinics about the vaccines benefits and effectiveness the reported vaccinerelated concerns in our study was similar to the study carried out in china where long time side effect of the covid19 vaccine was also reported as a major concern the study carried out among the general public in nigeria also reported vaccine side effects as a major concern for vaccine acceptance the fact that this concern has been reported across several studies indicates a lack of public awareness about the proven safety and efficacy profile of the covid19 vaccine not only among plwhv but across the general population the result of these findings indicates that a good perception alone is not enough predictor for vaccine acceptance or uptake if vaccinerelated concerns are not addressed among the target group it also suggests that people are more likely to vaccinate if they are presented with information from trusted sources that will eradicate their fears and doubts when rolling out new vaccines being responsive to the concerns and information needs of vulnerable groups holds the key to the successful rollout of vaccines interventions should focus on the provision of essential information about the covid19 vaccine study limitations there were a few limitations in the study the study design was crosssectional and the findings could differ over time since all covid19 preventive measures have been eased out and daily reports of infected people with covid19 infection have reduced this may have changed the perception of the target population compared to when the pandemic was still very active since our study was among plwhv the findings cannot be generalized to the general population conclusion one of the most important predictors of vaccine acceptance among plwhv is the perception of the safety and effectiveness of the available covid19 vaccines the majority of our participants have a good perception towards the covid19 vaccine but not without vaccinerelated concerns that may affect the uptake of the vaccine covid19 vaccination of plwhv is important because of their already immunocompromised state yet vaccine coverage among them was found to be below recommended targets since perception and misconceptions are known to affect vaccine coverage it is therefore recommended that vaccine education and more awareness to clarify misconceptions and misinformation as regards vaccine development be addressed to improve the overall covid19 vaccine uptake among plwhv research assistants for their efforts to make this research a success list of abbreviations the research assistants stressed the voluntariness of participation and withdrawal at any point during the study without negative consequences data confidentiality was assured and ensured all study data were deidentified while the names and addresses of the participants were not required instead everyone was allocated unique identifiers before the commencement of the study all the respondents gave written informed consent all relevant ethical principles were also adhered to competing interests the authors declare that there are no conflicts of interest

since there is no specific treatment for covid19 infection vaccination is still one of the most effective means of reducing the severity of the disease despite the rollout of covid19 vaccines evidence has reported low vaccine acceptance especially among plwhv which is associated with perception towards the vaccine the study adopted a crosssectional descriptive research design to assess the perception of plwhv towards the covid19 vaccine the study revealed that most respondents believe that getting the covid19 vaccine will protect themselves their families or their patients 873 and that it will help prevent the transmission of the disease 839 there is also a large percentage of respondents who believe that the vaccine is effective 771 and safe 826 and that it confers longterm immunity

introduction job loss and job insecurity were among the topics that were of most concern as consequences of the worldwide spread of the coronavirus exportdependent economies and economies that rely on tourism have struggled adjusting to fluctuating and shifting demand the world travel and tourism council suggested that the global job market was at risk for 75 million people in 2020 1 while the world economic forum reported that the lockdown and layoff practices during the covid19 pandemic resulted in 114 million job losses in 2020 2 even employees who survive the layoffs become anxious about their career and suffer high levels of job insecurity 34 according to prior studies job insecurity is a significant hindrancerelated stress that negatively influence tourism businesss ability to achieve its desired work 4 5 6 and can lead to absenteeism and anxiety 7 as a result of the covid19 pandemic and according to social cognitive theory employees who face job insecurity in addition to increased family financial strain are more likely to use moral disengagement practices to disable moral selfregulation resulting in increased levels of unethical behavior moreover researchers asserted that the heavy losses suffered by business organizations created significant unethical organizational practice 389 approximately 90 of companies indicate that covid19 is a risk to ethical behavior at work according to a report from ernst and young 10 similarly in a survey conducted in india by bhattacharyya 11 during the covid19 outbreak many employees were found to be willing to engage in unethical behavior such as falsifying records of customers and disclosing false information to their managers researchers have recently been interested in researching the reasons behind unethical practices during the covid19 pandemic and understanding the relationship with job loss and perceived job insecurity for example guided by appraisal theories of emotion hillebrandt and barclay 4 argued that covid19 provokes anxiety and can drive employees to prioritize their selfinterest and promote cheating behavior in workplace elshaer and azazz 3 surveyed 650 employees working in the egyptian tourism industry to explore the psychological process that would drive unethical organizational behaviors by employees who contend with job insecurity they found that perceived job insecurity reduces job embeddedness strengthens turnover intentions and encourages unethical behavior in addition previous studies asserted that employees who suffer from stresses due to workplace threats may conduct uob as a way to protect their gains and job assets 1213 employees conducting unethical organization behavior can also be driven by selfserving interest to acquire personal gains 14 or benefiting their organization or group 15 while benefiting themselves accordingly 16 based on behavioral ethics research people can generally fail to make an objective assessment of the ethics of their behavior in the workplace 17 since their cognitive biases cause them to underestimate or ignore their unethical behavior elshaer et al 18 added that often employees do not make an explicit decision to act unethically but rather seek to convince themselves that there is nothing wrong with their behavior in general uob can lead to devastating effects such as significant financial losses legal prosecutions and corporate closures 1920 while even simple unethical behaviors in organizations can lead to significant hidden costs tarnishing employee morale and damaging a companys reputation 21 despite the thrive of behavioral ethics research negative behavior displayed within organizations has such a wide scope that it is virtually not possible to explore within the scope of a few research projects 22 and various studied contexts are needed to unpack the drivers of uob for mitigating resulting risks most previous research on unethical behavior in the workplace focus on unethical proorganizational behavior 9 with little attention to unethical practices in the name of selfinterest 22 23 24 or the family 225 the prevalent unethical behaviors during the covid19 pandemic 3 and their possible relations with job insecurity 2 have raised significant questions about the different forms of unethical organizational behavior during crises the possible psychological process that drive such practices and how it can be mitigated therefore to address this gap of research and based on theories of conservation of resources social cognitive and behavioral ethics the current study aims to further investigate the effect of job insecurity on unethical organizational behavior among employees amid the covid19 pandemic using family financial pressure and family motivation as mediating variables the results of this study thus extend prior research results on conditions that shape unethical practices in the workplace and better explain the widespread uob during the covid19 pandemic it also provides insights into how organizations can address ethical challenges theoretical background and hypotheses development 21 job insecurity and unethical workplace behavior job insecurity has long been a subject of study in a wide variety of research papers 242627 numerous studies have been conducted in the hotel and tourism industries notably on job insecurity and its effect on human behavior 228 job insecurity is a perceptual phenomenon that focuses on a persons current job stability threats 29 hellgren et al 30 proposes two categories of job insecurity quantitative threats to the job as a whole and qualitative threats to desired job characteristics quantitative job insecurity focuses on the expected job loss triggered by intentional or unintentional administrative signals or appraisal reports by employees supervisors while qualitative job insecurity illustrates how an individual perceives their future job loss in light of a perceived threat 30 given the devastating effects of the covid19 pandemic on the economy downsizing has become a common strategy in recent years downsizing is a method of reducing labor costs streamlining operations and increasing organizational competitiveness 31 according to 3233 organizational restructuring and the downsizing process have proved to threaten workers and their careers resulting in exacerbating perceived job insecurity 34 the resulting stresses of perceived job instability may motivate employees to engage in unethical actions that they believe might protect them against the threat of job loss or even keep some important features of their job 23 35 36 37 38 39 unethical workplace behavior may include actions that benefit the organization group or employee selfinterest such as diminishing colleagues efforts to improve personal relationships reputations and professional success 40 employees activities and behaviors that are in direct conflict with the organizations norms and values may create significant financial losses 41 and jeopardize organizational image 42 accordingly as shown in figure 1 the below hypothesis is suggested hypothesis 1 job insecurity has a positive impact on workplace unethical behavior job insecurity has long been a subject of study in a wide variety of research papers 242627 numerous studies have been conducted in the hotel and tourism industries notably on job insecurity and its effect on human behavior 228 job insecurity is a perceptual phenomenon that focuses on a persons current job stability threats 29 hellgren et al 30 proposes two categories of job insecurity quantitative threats to the job as a whole and qualitative threats to desired job characteristics quantitative job insecurity focuses on the expected job loss triggered by intentional or unintentional administrative signals or appraisal reports by employees supervisors while qualitative job insecurity illustrates how an individual perceives their future job loss in light of a perceived threat 30 given the devastating effects of the covid19 pandemic on the economy downsizing has become a common strategy in recent years downsizing is a method of reducing labor costs streamlining operations and increasing organizational competitiveness 31 according to 3233 organizational restructuring and the downsizing process have proved to threaten workers and their careers resulting in exacerbating perceived job insecurity 34 the resulting stresses of perceived job instability may motivate employees to engage in unethical actions that they believe might protect them against the threat of job loss or even keep some important features of their job 23 35 36 37 38 39 unethical workplace behavior may include actions that benefit the organization group or employee selfinterest such as diminishing colleagues efforts to improve personal relationships reputations and professional success 40 employees activities and behaviors that are in direct conflict with the organizations norms and values may create significant financial losses 41 and jeopardize organizational image 42 accordingly as shown in figure 1 the below hypothesis is suggested hypothesis 1 job insecurity has a positive impact on workplace unethical behavior job insecurity family financial pressure and unethical workplace behavior employees as well as their families face financial difficulties as a result of the high percentage of job insecurity 43 despite remarkable advances in our understanding of the impact of job insecurity on wellbeing stress and health over the last several years job insecurity family financial pressure and unethical workplace behavior employees as well as their families face financial difficulties as a result of the high percentage of job insecurity 43 despite remarkable advances in our understanding of the impact of job insecurity on wellbeing stress and health over the last several years 3044 it is difficult to infer causality financial stress on the family is likely to exacerbate job insecurity which in turn leads to financial pressure 4546 a few research studies have explored the relationship between job insecurity and employees financial wellbeing and pressure and provide contradicting results between significant 47 and insignificant 45 effects therefore the relationship between job insecurity and family financial pressure requires further investigation families financial difficulties are not just felt by the impoverished they are also felt by rich people who want to maintain pace with their friends when confronted with strong financial difficulties from family members an employees principal purpose is to relieve those pressures the more pressing the need the more significant this goal will become generally supporting ones family monetarily is a key worth in human culture 48 liu et al 25 elaborated that social expectations are framed and laws are laid out to uphold the satisfaction of familial monetary obligations when stressed to assist their families employees are bound to consider it to be their responsibility to make any strides important to help their family subsequently obscuring their moral obligation regarding their actions based on the theory of conservation of resources developed by hobfoll 12 when people face a concern of losing their valuable resources they become pressured to protect those resources by for example acquiring recuperation assets accordingly when employees encounter substantial financial difficulties in their families they are more likely to concentrate their efforts on obtaining financial compensation from their employer 46 as a result selfjustification of immoral actions in the workplace can then thrive 49 unethical workplace activities may help alleviate the stress and aggravation felt by employees while simultaneously improving the financial wellbeing of the employees families many sorts of unethical behavior in the name of the family are directly linked to financial advantages that might relieve financial stress such as bringing organization possessions home for use or accompanying relatives to the workplace to gain benefit from the organizations resources according to the social cognitive theory proposed by bandura 50 and the selfconcept maintenance theory developed by mazar et al 51 the readiness of selfjustifications encourages unethical behavior through an expanded moral disengagement selfjustifications can make the ub looks less immoral costs of the dishonest action are limited disregarded or confounded or casualties of the wrongdoing are undervalued or accused in summary when family financial pressures are increased because of perceived job insecurity employees may become more likely to participate in unethical workplace behavior to benefit their family and decrease these related stresses thus the following hypotheses were proposed hypothesis 2 job insecurity has a significant impact on family financial pressure hypothesis 3 family financial pressure has a significant impact on unethical workplace behavior hypothesis 4 family financial pressure mediates the impact of job insecurity and unethical workplace behavior job insecurity family motivation and unethical workplace behavior supporting ones family is a significant justification for why many people work yet surprisingly few researchers have investigated the effects of family motivation 47 particularly in relation to perceived pressures and job insecurity moreover liu et al 25 noted that no previous study has thoroughly examined the role of the family as a motivating factor for unethical behavior in organizations menges et al defines family motivation as the desire to expend effort to benefit ones family prior research suggested that workers with a high family motive are more likely to prioritize family concerns and perceive the familys best interests as a main consideration 254648 this would likely drive employees who place a high value on their families to justify immoral behavior in the workplace since it benefits them personally and socially as well as their own families 5253 relatedly previous studies 53 54 55 explained that employees ted to perceive their desire protect to benefit another partys or beneficiaries interest as a moral justification for unethical behavior based on the concept of bounded ethicality an employee may often behave unethically as heshe either consciously or unconsciously was able to disregard and justify hisher own misconduct 30 accordingly this study suggests that when job insecurity increases workers with high family motivation may engage in unethical practices to benefit their family interests and will demonstrate less attention to organizational moral standards in other words whether individuals choose to be engaged in unethical organizational behavior that violates the moral code and interests of the firm can be determined by their familial motives employees thus become more prone to justify their unethical workplace behavior in order to alleviate their job insecurity hypothesis 5 job insecurity has a significant impact on family motives hypothesis 6 family motivation has a significant impact on unethical workplace behavior hypothesis 7 family motivation mediates the impact of job insecurity on unethical workplace behavior methodological approach development of study measures and instrument the formulation of the scales in this study was based on an extensive survey of previously employed theoretical items in the literature this survey creates four factors each with their own set of items which are then revised to fit the context of the hospitality industry the operationalization of the study variables is depicted in table 1 we use the fundamental processes proposed by maddox 56 and churchill 57 to create 21 variables on a standard fivepoint likert scale where strongly disagree is 1 and strongly agree is 5 the items measuring job insecurity were created with a multiitem scale developed by hellgren et al 30 and employed by elshaer and azazz 3 in the tourism industry family financial pressures were operationalized by three variables based on the work of conger et al 58 and employed by elshaer and azazz 3 in the hotel industry we adopted the five items of family motivation of menges et al 47 a sample item is it is important for me to do good for my family finally unethical workplace behavior in the name of the family was measured by seven items derived from liu et al 25 a sample item is i took advantage of my position in the company to make things more convenient for my family the questionnaire was formerly in english then the backtranslation approach was adopted 59 three qualified academics translated the research questionnaire from its original language to respondents language furthermore another three academics conducted the back translation from respondents language to english the resulted revealed that the two versions were the same and consistent with no differences using extensive pretesting and piloting stages the research instrument was internally validated with input from six academics and fifteen employees in the field of the hospitality industry the pilot participants indicated the measures high consistency and face and content validity the final instrument was administered to 1000 employees working in fivestar hotels and travel agents in greater cairo egypt process of collecting data the study data were gathered in a threewaves process from 30 fivestar hotels and 35 travel agents classified as category a in greater cairo egypt it was decided to use the threewave approach with at least a onemonth period between each wave in order to reduce the probability of common method variance 60 participants in the first wave provided information about their demographics as well as their perceptions of job insecurity after one month participants who had completed the first wave were surveyed regarding unethical workplace behavior in the name of the family after one more month those who completed both the w1 and w2 surveys answered questions about family financial stress and family motivation to ensure that the data collected in all three waves came from the same respondents a coding system was used the participants were chosen with the help of the hotelstravel agencies mangers who agreed to let us use their staff lists for scientific purpose a total of 1000 nonmanagerial employees were randomly chosen to participate in the three waves of the survey process replies were obtained from 890 800 and 770 people respectively demonstrating response rates of 89 80 and 77 respectively results descriptive statistics of the 770 who completed the questionnaires in the final third wave 70 were male ten percent of those who responded in the final wave were between the ages of 18 and 23 15 were 2429 years old 25 were 3035 years old 30 were 3641 years old and 20 were above 42 years old in terms of education 50 of the participants achieved high school level 30 obtained a college degree and 20 had a bachelors level or above regarding work experience 30 of participants had experience for one year or less 40 had work experience of two to three years while participants who had work experience for more than five years accounted for 15 of the total targeted participants the variables mean ranged from 346 to 413 while the items standard deviation scores were from 0649 to 1293 suggesting that the study data are more distributed and less gathered around its mean value 61 the skewness and kurtosis scores are not exceeding 2 or 2 suggesting that the study data have satisfactory normal distribution 62 furthermore as depicted in table 1 variance inflation factors scores for all items were below 04 which confirm that multicollinearity is not an issue in our study 63 measurement model assessment for construct reliability and validity we used confirmatory factor analysis to combine all dependent and independent unobserved latent variables into a single cfa model that showed a satisfactory model fit model fit χ 2 489891 p 0001 normed χ 2 2677 rmsea 0031 cfi 0977 tli 0978 nfi 0977 as depicted in table 2 6164 we examined the composite reliability and discriminant validity of our constructs using the estimates from this model 65 measuring the construct validity was completed by examining convergent and discriminant validity for each construct to test the convergent validity of the factors table 2 shows that all factor loadings for our constructs items are statistically significant at the 0001 level and exceed the minimum criterion of 05 second the average variance extracted for all research constructs is greater than 05 finally the construct reliability scores for all the employed four factorsjob insecurity family financial pressure family motivation and unethical workplace behavior in the name of the family exceeded the recommended 070 cutoff point thus as anderson and gerbing 64 and hair et al 62 recommend our cfa output results revealed that all research constructs have a high satisfactory level of convergent validity the discriminant validity of constructs was assessed using cronbach alpha values correlation matrixes and the square root of aves as recommended by fornell and larcker 65 table 2 showed the correlation matrix composite cronbach alphas and ave values of the research four factors as displayed in table 2 bold diagonal values are larger than offdiagonal values which support a satisfactory discriminant validity for research factors as advocated by fornell and larcker 65 finally the ave values for all the four factors surpass the maximum shared values further supporting a satisfactory level of discriminant validity overall our measurement model demonstrates satisfactory levels of composite reliability and discriminant validity according to the previous findings structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 the interrelationship in the suggested model contains seven justified hypotheses that investigate interactions among the research latent variables the sem analysis revealed that all seven hypotheses are significant at a statistical pvalue less than 005 hypothesis 1 investigated the direct effect of job insecurity on unethical workplace behavior in the name of the family which was supported with a path coefficient of 021 demonstrating that the two variables have a positive direct relationship likewise the sem analysis revealed that the job insecurity significantly and positively affects family financial pressure with a path coefficient of 039 thus supporting hypothesis number 2 additionally in line with our proposition the effect of family financial pressure on unethical workplace behavior in the name of the family was found to be significant and positive with a correlation coefficient of 045 therefore supporting hypothesis number 3 furthermore as proposed hypothesis number five tested the impact of job insecurity on family motivation and the analysis gave signals of a positive and significant association between the two factors with a correlation coefficient of 037 thus supporting hypothesis number 5 finally as proposed in hypothesis number 6 the impact of family motivation on unethical workplace behavior in the name of the family was found to be significant and positive thus hypothesis number 6 was confirmed structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 table 3 result of structural model df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 hypotheses table 3 result of structural model hypotheses structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 structural model assessment following the establishing of confidence in the adequacy of the employed measures we conducted structural equation modeling to test the impact of job insecurity on unethical workplace behavior in the name of the family via family financial pressure and family motivation the evaluation of the hypothesized model is confirmed through two main criteria the overall model goodness of fit using the recommended indices such as x 2 df tli cfi rmr and rmsea and the statistical significance level for the models hypotheses as shown in table 3 the gof measures for the structural model yielded satisfactory results additionally the results of the anticipated model are illustrated in figure 2 and table 3 to test hypotheses 4 and 7 suggestions introduced by 6266 were adopted to evaluate the mediation impact of family financial pressure and family motivation in the relationship between job insecurity and unethical workplace behavior in the name of the family specifically zhao et al 66 declared that for directonly nonmedication effects only direct path coefficients should be observed and that only direct path coefficients should be observed with a significant pvalue while all indirect relationships should not be statistically significant for complementary mediation all direct and indirect correlations should be significant pvalue with the same sign finally competitive mediation is supported when all relationships are significant but with opposing signs as pictured in figure 2 all the tested paths are significant with the same positive sign as depicted in table 4 specifically the direct relationship between job insecurity and unethical workplace behavior in the name of the family is significant and positive and job insecurity directly positively and significantly affects family financial pressure and family motivation in the same vein family financial pressure was found to have a direct positive and significant relationship with unethical workplace behavior in the name of the family similarly family motivation was found to have a direct positive and significant relationship with unethical workplace behavior in the name of the family these results supported the complementary mediation of family financial pressure and family motivation in the relationship between job insecurity and unethical workplace behavior in the name of the family therefore supporting hypotheses 4 and 7 furthermore specific indirect estimates from job insecurity to unethical workplace behavior through family financial pressure was calculated from the sem amos output to detect mediation in which the lower and the upper value generated a significant standardized indirect estimates of 0303 similarly the specific indirect estimate from job insecurity to unethical workplace behavior through family motivation was lower and the upper value created a significant standardized indirect estimate of 0326 the previous results further support h4 and h7 finally the standardized indirect path coefficient and total effects may also be reviewed in the sem output to detect mediation impacts 62 the standardized indirect path coefficients from the job insecurity to unethical workplace behavior in the name of the family via the mediating role of family financial pressure and family motivation increase the direct impact from 021 to a total impact of 065 this suggests that unethical workplace behavior in the name of the family increased by 44 via the mediating role of family financial pressure and family motivation furthermore the proposed structural model showed a high level of explanatory power explaining 52 of the variation in unethical workplace behavior in the name of the family discussion and implications the outbreak of covid19 has created an opportunity to better understand the relationship between unethical behavior and perceived risk of job insecurity in tourism organizations drawing to theories of conservation of resources social cognitive and behavioral ethics this study examined family motivation and financial pressure as mediators of the relationship between job insecurity and unethical organizational behaviors the results provide insights into the reasons behind the increased uob during the covid19 pandemic 2389 and they would add to researchers and practitioners understanding of how to address ethical challenges in their organizations a survey was created and distributed to 770 employees of fivestar hotels and category a travel agencies to evaluate the proposed structural model as well as the measurement model two main data analysis methods were used sem was used to evaluate the proposed structural model and cfa was used to evaluate the measurement models convergent and discriminant validity respectively the findings revealed that the measurement model exhibited good convergence and discriminant validity and that the proposed structural model accurately represented the data a total of seven hypotheses were proposed and evaluated the results revealed that job insecurity has a direct impact on unethical workplace behavior in the name of family as well as an indirect impact through financial pressure and motivation imposed by the extended family the indirect effect increases the total effect of job insecurity on unethical organization behavior in the name of the family by 44 providing evidence that both family financial pressure and family motivation play a role in mediating the relationship between job insecurity and unethical organization behavior in the name of the family all endogenous variables combined account for 52 of the variance in unethical organizational behavior to benefit family according to the findings these results extend the prior results of lawrence and kacmar 38 who found emotional exhaustion as a mediator in the relationship between job insecurity and unethical behavior this is by highlighting the role of emotional exhaustion that derived from family financial pressures and motivation complementing prior research family financial pressures 2546 and motivations 955 were found to reduce selfregulatory resources and motivate unethical behaviors in the name of the family the results indicated that participants who suffered high job instability in their workplace experienced higher levels of family pressures and were more prone to practice uob to benefit their relatives in support zhang et al 46 articulated that when employees encounter substantial financial difficulties in their families they are more likely to focus on obtaining financial benefits from their employer in addition this study provides empirical support for the argument of hillebrandt and barclay 4 that anxiety elicited by covid19 may focus employees attention on their selfrelated interest and encourage cheating and other unethical behaviors implications to theory the result of this study has a threefold contribution to theory first it extends the discussion of previous studies on conditions that shape unethical practices in workplaces most previous studies have identified that perceived job insecurity results in uob that are either for benefiting the organization or selfserving while this study adds empirical evidence on the important effect of familyrelated pressures financial or motivational on uob with particular attention of the influence of these factors when accompanied with job insecurity second this study tries to answer the calls of prior researchers 34222566 to further examine the influence of environmental factors on uob the results add to explaining the reasons of the widespread unethical behaviors in organizations encountered during the covid19 pandemic in particular the current study adds to the understanding of the psychological process that employees may go through in making unethical decisions when faced by job insecurity it is also the first study to discuss the mediating role of family motivation and financial pressure in the relationship between perceived job insecurity and uob third this study answers calls to examine the employees family as a source of motivation to possible uob 2546 despite previous warnings of its possible strong influence on unethical workplace behavior 46 family motivation has received little empirical and theoretical attention instead most studies have regarded family motivation as a driver of work effectiveness therefore by demonstrating the role of family motivation in triggering unethical workplace behavior this study extends research knowledge about possible psychological aspects that fuel uob at the same time it gives insights to the possible dual role of family motivation as a source of desirable and undesirable organizational actions implications to practice the tourism industry was the most affected during the covid19 pandemic the large seen shutdowns and layoffs during the pandemic and their effect on employees psychology and behavior would have a longlasting difficult influence on tourism workplaces and hospitality industry if not well understood and dealt with by decisionmakers although the influence of covid19 on job loss and job insecurity has received much attention in recent tourism and hospitality research a more comprehensive picture of the detrimental effect of job stress and anxiety on employees behavior still needs to be explored to better inform tourism decisionmakers 923 in this regard this study contributes to the understanding of why the covid19 pandemic has induced uob in the tourism industry and highlights the role of job insecurity and family pressures and motivation in increasing uob in the name of the family this would inform tourism decisionmakers and managers toward preventing unethical behavior and the possible damaging consequences on financial performance and reputation decisionmakers should strive to advocate social messages and enact policies that reduce employees perceived job insecurity since this is a gateway to uob in addition based on the concept of bounded ethicality the current study asserted that ambiguous circumstances may veil the ethical aspects of employees decisions as people lean to selfjustification of their immoral actions in the workplace 171867 therefore pressures of job loss may drive even honest employees to engage in minor dishonesty and simultaneously stay ignorant of the ethical repercussions of their acts 1868 thus with this in mind organizational managers need to carefully observe the actions of all employees and regularly provide moral reminders which can be a useful tool to reduce or prevent uob organizations also should assess the ethical development of employees promote moral actions and punish for unethical behavior conclusions limitations and further research the prevalent and costly unethical practices in workplaces and their different types have attracted recent research attention especially during the covid19 crises this study investigated a neglected yet important form of uob unethical organizational practices in the name of the family it proposed a model that may assist academics and practitioners in better understanding of how perceived job insecurity influences uob through the mediating effect of family financial pressure and family motivation the results revealed that perceived risk of job insecurity predicts employees engagement in uob while intentions of unethical behaviors increase by high family motivation and financial pressures however this study has some limitations that offers opportunities for future research papers the current results of the analyzed data showed that family motivation and financial pressure partially mediated the impact of job insecurity and unethical workplace behavior to further our understanding on the relationship between job insecurity and uob future research papers can investigate more mediating variables that can affect the relationship between job insecurity and unethical workplace behavior in the name of the family moreover future studies should investigate possible boundary conditions such as moral identities and religious commitment since previous studies for example revealed that moral identity undermines the strong influence of the selfcontrol depletion on dishonesty and unethical practices 69 although this study ensured the confidentiality and anonymity of the questionnaire for the participants the selfreported survey used in this study may encourage participants to biases their answers since questions were about unethical actions to benefit the family thus future studies can allow peer evaluation through colleagues or supervisors for more objectivity in addition future research can address the practices of decision makers to diminish uob for family benefit and suggest methods that can be followed to control unethical practices furthermore the collected data were crosssectional therefore causal association between latent variables cannot be completely confirmed and it is recommended for future investigations to collect longitudinal objective data or a different data source to validate the study model finally a multigroup analysis approach can be conducted in future studies to validate and compare the results of the current study with data collected from different context 70 finally it is important to highlight that the current study explores the relationship between family pressure and unethical workplace behavior under job insecurity accordingly the uob examined is not general but rather related to the benefit of the family future research would need to study general and other specific unethical behaviors that prevail in times of crisis and apply them to different contexts to understand how prevalent uob is and how to mitigate its undesired consequences data availability statement data are available upon request from researchers who meet the eligibility criteria kindly contact the first author privately through email institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the deanship of scientific research ethical committee king faisal university informed consent statement informed consent was obtained from all subjects involved in the study

in organizations unethical behaviors are pervasive and costly and considerable recent research attention has been paid to various types of workplace unethical behavior this study examines employees behaviors that are carried out for the benefit of ones family but violate societal and organizational moral standards drawing upon the selfmaintenance and bounded ethicality theories this study examines the engagement of unethical organization behaviors uob in the name of the family during the covid19 pandemic it examines the influence of job instability and the mediating role of family financial pressure and family motivation a total of 770 employees in hotels and travel agents in egypt were targeted and the data were analyzed using structural equation modeling the results posit that perceived risk of job insecurity predicts engagement in unethical organizational behaviors while intentions of uob increase by high family motivation and financial pressures toward the end of this paper a discussion on the theoretical and practical implications and are presented

introduction theoretical models of family economic stress have long associated socioeconomic hardship with risk factors in child and adolescent development including chronic experiences of stress and diverse indicators of poor psychosocial wellbeing more specifically socioeconomic stress has been consistently linked to adolescents academic adjustment with low family income conferring disadvantages in school achievement and success although a relatively large body of literature has established such maladaptive links aside from a few exceptions prior research pinpointing negative effects of socioeconomic stress on academic outcomes predominantly has focused on adolescents from european american and african american backgrounds to the exclusion of adolescents from immigrant backgrounds and particularly those with asian ancestry our work extends the current literature on how socioeconomic stress shapes adolescents lives by focusing on an understudied sample of asian american youth using a risk and resilience framework to not only document negative effects of socioeconomic stress on academic adjustment but to also identify family obligation as a potentially protective factor in adolescents lives and comparing direct and interactive effects of socioeconomic stress and family obligation at two different developmental periods namely during the early years of high school and again in adolescents later high school years by identifying risk and protective factors associated with academic adjustment and considering developmental differences related to family processes we can extend existing knowledge and ultimately determine ways to best foster asian youths adjustment socioeconomic stress among asian american youth immigrant youth from underresearched asian backgrounds represent a particularly interesting case for studying both socioeconomic stress and academic adjustment given that the model minority stereotype presumes that each of these areas are highly relevant to their group but not especially problematic in terms of socioeconomic status a common misperception is that asian families are generally welladjusted and do not suffer from financial hardships as much as families from other ethnic minority groups official accounts do suggest that asian american households report a relatively high median income however these average income levels do not preclude the fact that socioeconomic stress if experienced can still negatively impact outcomes moreover it is important to note that these same federal reports also suggest that 12 of asian american families live below the poverty line which is actually similar to the rates found among nonhispanic whites it is also critical to acknowledge that individuals from asian backgrounds represent a highly diverse panethnic group and the degree to which each family experiences socioeconomic adversity likely depends on factors such as specific country of origin individual reasons for immigration and refugee or citizenship status as one example of such ethnic variability recent reports document a substantial difference between the yearly median income for south asian indians and bangladeshis hence rather than assume that socioeconomic stressors are not universally salient for asian american families it seems critical to examine how financial struggles can in fact influence these adolescents lives and ultimate adjustment there are a variety of reasons to expect adverse associations between socioeconomic stress and adolescents academic outcomes drawing from research with other ethnic minority groups poverty can influence cognitive and socioemotional functioning which have direct repercussions on school achievement a number of indirect influences also can be seen for example socioeconomic stress might contribute to adolescents feelings of distress or hopelessness as well as family conflict which can then have indirect effects on childrens academic commitment and success family economic stress also might require adolescents to assist their families or work at a parttime job thereby potentially interfering with their academics collectively based on prior research that has identified both direct and indirect effects of socioeconomic stress we anticipated that for asian american youth experiencing more stress would be related to lower academic adjustment we considered a range of academic outcomes to demonstrate the diverse implications that socioeconomic stress can have on adolescents development the academic arena itself plays a particularly prominent role in the lives of asian youth children from immigrant families are often socialized to believe that education is a major key to economic mobility hence among these families there tends to be a strong emphasis on school achievement similarly for many immigrant youth excelling in school might be perceived as one way to help their family succeed and ultimately achieve the american dream given the cultural importance of education among asian immigrant families identifying possible obstacles or risk factors in adolescents academic success is crucial yet this group in particular is often overlooked in terms of resources and concerns over academic adjustment referring again to the model minority myth these cultural stereotypes might come into play in the wrongful assumption that most asian youth are largely high achievers hard workers academically motivated and welladjusted there are numerous implications in terms of having to face such a stereotype and most relevant to the current study is the fact that some adolescents may be mistakenly ignored in terms of the academic and other struggles that they actually encounter we thus address these pressing concerns and notable gaps in the literature by explicitly focusing on both socioeconomic stress and academic outcomes among asian youth and identifying family obligation as a putative moderator of such stress family obligation as a protective buffer a resiliency framework pinpoints specific features that protect against risk and encourage healthy adjustment adaptation and social and psychological competence despite stress or adversity in the face of socioeconomic stress what resiliency factors might counteract any negative effects and promote healthy outcomes paradoxically family financial stressors might present youth with a greater need to help out around the house and assist their families as best they can which could then lead to positive outcomes indeed a familistic orientation and positive attitudes toward family obligation which can be broadly defined as values and expectations regarding family assistance and support have been implicated as culturallyprotective factors in youth development perhaps because they promote social support and close family relationships assisting ones family might also contribute to internal feelings of purpose or meaning which could then permeate other forms of achievement or academic goals family cultural values are particularly relevant to asian youth prior research has found that asian americans report high levels of family obligation and often view school success as one of the most important and meaningful ways that they can assist and help their families advance socially and economically in the literature positive links between family obligation and adolescents academic outcomes have been demonstrated among diverse immigrant samples moderating effects also have been found for instance among latinos who also tend to report strong familistic connections family obligation buffered adolescents from negative effects of stress on risky behaviors and depression although economic stress was included in their conceptualization of risk academic adjustment was not examined as an outcome taken together based on prior research supporting the benefits of family obligation we similarly expected to find positive associations between these family attitudes and academic outcomes although to our knowledge family obligation has not yet been examined as protective factor in terms of the detrimental effects of socioeconomic stress on academic adjustment we also expected that family obligation would act as a resiliency factor and weaken the negative impact of socioeconomic stress furthermore one additional layer of complexity that we explored was whether associations among socioeconomic stress family obligation and academic outcomes might vary based on adolescents developmental status developmental considerations longitudinal associations between adolescents experiences of socioeconomic stress and their academic achievement have been documented however rather than model change over time multiple waves of data can be used to determine whether direct and interactive effects of socioeconomic stress and family obligation are more or less relevant to the same youth but at different times in their lives in terms of academic outcomes we might expect a developmental shift in the salience of educational aspirations and importance attributed to academics as youth more seriously contemplate their pending high school graduation and plans for the future the developmental context of late high school would then differentially influence the relationship between socioeconomic struggles family obligation and these academic outcomes especially as youth have to make decisions about whether to stay home enter the workforce or go to college in contrast the developmental context of younger high school students could be more concerned with the transition to high school and focus less on pressing graduation concerns moreover younger adolescents might also be more limited in the actual support that they can readily provide to their families some empirical work does support differences in the extent to which socioeconomic stress affects development educational disparities associated with family income and backgrounds tend to increase as students advance in school other studies argue that family economic conditions in early and middle childhood are more important for shaping ability and achievement than are economic conditions during adolescence perhaps because family socioeconomic status tends to increase as children get older to shed light on these key and competing developmental concerns we used our data to determine whether the effects of socioeconomic stress and family obligation on academic adjustment are different for adolescents when they are in early versus late high school years given our range of outcomes included we also explored whether the impact of developmental stage would be particularly strong for those outcomes focused on the future compared to more immediate concerns the present study the present research seeks to examine whether socioeconomic stress hinders adolescents academic outcomes as well as to identify family obligation as a possible moderator of any negative effects based on prior research we expected that socioeconomic stress would be associated with lower academic adjustment among our sample of adolescents from asian american backgrounds consistent with recent work that points to positive benefits of family obligation we expected that family obligation would be linked positively to academic adjustment both directly and via moderation against negative effects of socioeconomic stress we also explored whether direct and interactive associations found are consistent across different periods of development namely for adolescents who are in the earlier versus later years of high school we contribute to the literature by examining understudied asian american youth considering multiple indices of academic outcomes and using two waves of data to explore developmental variations in effects in addition previous research commonly has measured socioeconomic stress according to variables created from family income parental education andor parental occupational prestige rather than rely on such proxies we used a more direct measure of family economic strain as our primary independent variable methods procedures using a stratified sampling procedure public high schools in the southeastern us were targeted for recruitment adolescents were ultimately drawn from six schools that varied in terms of academic achievement and ethnic diversity for initial recruitment all 9th10th grade students who were identified through school enrollment forms as asian were convened in small groups and invited to participate in a study on their culture and daily lives parental consent and adolescent assent forms were distributed researchers returned for a followup visit and those students who returned their forms were given a packet of questionnaires which took about 3540 min to complete upon completion adolescents were given instructions and materials for a twoweek daily diary study not reported on here at the end of the daily diary period researchers returned to schools to collect materials and to give adolescents 25 for participating adolescents were asked to participate in followups in consecutive years that consisted of the questionnaire packet only the current study focuses on data collected in the first wave of the study when students were in 9th10th grades and two years later when students were in 11th12th grades data for the followup were collected during school visits and students who were absent or no longer enrolled in the school were sent questionnaires through the postal mail approximately 87 of the original sample was retained in w2 and these participants did not differ from those who participated only in w1 on any demographic or key study variables using a p 01 cutoff given the number of tests run in w2 of the study adolescents were given 15 for participating measures socioeconomic stress socioeconomic stress was measured using an index of family economic strain or financial insecurity on a 0 no to 1 yes scale adolescents were asked to indicate whether their families experienced economic stressors we included five items adolescents were instructed to think about the past 12 months in their responses responses were summed across all items the internal consistencies found in the present study were 67 and 69 at waves 1 and 2 respectively which are similar to those found in prior research on adolescents family obligation a 12item scale was used to assess adolescents attitudes toward family obligation and the provision of family assistance adolescents were asked to determine how important each item is on a fivepoint scale ranging from not at all important to very important with higher scores reflecting higher family obligation sample items include help take care of brothers and sisters run errands that the family needs done and help out around the house items concerning attitudes toward future support and obligation were also presented using a sixitem scale samples include help your parents financially in the future spend time with your parents even after you no longer live with them and help take care of your brothers and sisters in the future following prior research both scales were combined and averaged to reflect an overall index of family obligation selfreported grade point average adolescents were asked to writein their current grade point average although a recent metaanalysis suggests that selfreports of gpa may be systematically inflated and should be used with caution they still generally predict outcomes to a similar extent as actual gpa indeed as shown in table 1 patterns of association between our measure of gpa and other academic outcomes were as expected further in a followup study in which school reports of gpa were collected on a small subset of this sample self and official reports of gpa were significantly correlated however due to some missing data and undecipherable responses analyses with this variable were conducted with a more limited sample table 1 omitted importance of academic success importance of academic success was assessed through a sixitem scale asking adolescents to place importance on doing well and succeeding in school this measure was based on research from eccles and has been used successfully in prior work on a scale ranging from 1not important to 5 very important students reported how important the following things are to them that you do well in school that you get good grades that you get an a on almost every test that you go to college after high school that you be one of the best students in your class that you go to the best college after high school items were averaged and the internal consistencies were 8586 educational aspirations and expectations also drawn from eccles to assess educational aspirations adolescents were asked how far would you like to go in school response options were 1 finish some high school 2 graduate from high school 3 graduate from a 2year college 4 graduate from a 4year college 5 graduate from law medical or graduate school one item was similarly used to assess educational expectations adolescents were asked how far do you think you actually will go in school identical response options as for educational aspirations were used results preliminary analyses bivariate correlations among primary study variables are shown in table 1 stratified by study wave as shown in both earlier and later years of high school high socioeconomic stress was consistently associated with poor academic outcomes as defined by all four indices of gpa importance of academic success and educational aspirations and expectations in both waves of the study family obligation was positively associated with adolescents reported importance of academic success in wave w1 family obligation was also linked with higher educational expectations although this association was only marginally significant in w2 family obligation was significantly associated with higher educational aspirations as would be expected all academic outcome variables were significantly associated with each other remaining relations though not statistically significant were in expected directions means and sds are also shown in table 1 variable means appeared to be generally stable over time in w2 significantly higher levels of socioeconomic stress were reported t 221 p 05 compared to w1 higher gpa at w2 was also reported t 258 p 05 remaining means did not significantly vary across the two waves of the study ts 138192 ns each measure at w1 was significantly correlated with measurements at w2 which further suggests temporal stability among the constructs these correlations ranged from 47 to 69 p 001 main and interactive effects of socioeconomic stress and family obligation on adjustment to examine main and interactive effects of socioeconomic stress and family obligation on adolescents academic adjustment a series of hierarchical multiple regressions were conducted main effects of socioeconomic stress and family obligation were entered first followed by their interaction variables were centered before creating the interaction term gender was also entered in the initial step as a covariate given that prior research has documented gender differences in academic adjustment among asian american youth regressions were conducted separately for each outcome and within w1 and w2 early high school results for w1 are shown in table 2 as expected and consistent with bivariate correlations socioeconomic stress was negatively associated with all four academic adjustment outcomes main effects of family obligation were also found in terms of positive links with importance of academic success and educational expectations these initial models accounted for 1115 of the variance in outcome variables no other main effects or interactions were found but an interaction between socioeconomic stress and family obligation approached significance in terms of adolescents importance of academic success table 2 omitted late high school table 3 illustrates regression results from w2 of the study again main effects of socioeconomic stress were found for all four adjustment variables main effects of family obligation were also found with respect to importance of academic success and educational aspirations with the exception of gpa the initial models themselves were significant explaining between 9 and 18 of the variance in adjustment in addition three interactive effects were found table 3 omitted specifically as shown in fig 1 strong attitudes toward family obligation protected youth from the negative effects of socioeconomic stress simple slopes analyses suggested that experiencing socioeconomic stress was associated with lower importance of academic success but only for adolescents who reported low levels of family obligation for adolescents who indicated strong importance towards helping and assisting their families the association between socioeconomic hardships and academic importance was not statistically significant similar buffering effects were found for educational aspirations and expectations although simple slopes for adolescents who reported both high and low levels of family obligation were significant the effect of socioeconomic stress on aspirations appeared stronger for adolescents with low compared to high endorsements in terms of expectations the effect of socioeconomic stress was statistically significant for adolescents who reported low levels of family obligation but not for those with high obligation which again supports the protective role of family obligation on adolescents academic adjustment figure 1 omitted figure 2 omitted figure 3 omitted discussion the impact of socioeconomic stress on the adjustment of adolescents from asian american backgrounds has not been a topic of much attention especially when compared to research focusing on these themes among other ethnic groups the primary aim of the current study was to address this gap in the literature by examining whether experiencing family financial hardship is associated with poor academic adjustment widely measured through multiple outcome variables including gpa importance of academic success and educational aspirations and expectations in the face of these negative influences we also were interested in pinpointing family obligation as a possible buffer and considering whether main and interactive effects of socioeconomic stress and family obligation might developmentally vary over time in line with prior research with other ethnic groups we found that socioeconomic stress is indeed a significant risk factor in asian american adolescents academic outcomes although average levels of socioeconomic stress were relatively low for the sample as a whole more experiences of household financial stress were associated with lower selfreported gpa lower valuing of academic success and lower educational aspirations and expectations these negative associations were consistent for adolescents in both early and late high school years it thus appears that socioeconomic struggles can be critical issues for american adolescents with asian ancestry who are often widely presumed to be the model minority and generally welladjusted notably gender also had a main effect on several academic outcomes which is consistent with prior work that points to females faring better than males in the academic arena providing some resilience in the face of stress we found family obligation to act as a positive resource in adolescents lives direct effects were found whereby family obligation was associated with various indicators of positive academic adjustment in both early and later years of high school these results are congruent with previous research documenting the virtues of family obligation and positive links between family obligation and academic outcomes more specifically moreover in the later high school years family obligation buffered the negative effect of socioeconomic strain on adjustment variables such as importance of academic success and educational aspirations and expectations more specifically the academic risks that were associated with socioeconomic stress were attenuated in older adolescents who endorsed the importance of family assistance compared to those who reported low levels of family obligation although these results demonstrate that family obligation can serve as a resiliency factor in helping older adolescents deal with the negative effects of socioeconomic stress several unanswered questions remain for example one important topic for future research is to explore whether the protective effect of family obligation also extends to other negative experiences similarly do the positive effects of family obligation generalize to adolescents from diverse ethnic groups our focus on an asian sample was important in addressing a dearth in the literature but also limits the generalizability of our results constructs of family assistance and closeness might be especially meaningful to adolescents from asian backgrounds but whether or not its benefits are equally noteworthy among other samples particularly in light of protecting against socioeconomic stress remains largely unknown notably recent evidence does point to family obligation as being associated positively with academic adjustment among both european american and chinese adolescents and as an effective moderator against stress among latino samples more work along these themes would be informative the specific mechanisms by which such family cultural values have a positive effect are also unclear perhaps helping to maintain family functioning and generally assisting ones family promotes family closeness which is beneficial in and of itself alternatively it is possible that family obligation affects other areas in adolescents lives which can then protect against risks to achievement and boost academic success in line with this idea recent research suggests that daily acts of family assistance is directly related to adolescents purpose or meaning in life such purpose could then help to promote adolescents academic aspirations goals and achievements despite their experience of obstacles that might thwart those positive outcomes developmentally moderating effects of family obligation were only found for adolescents in later years of high school in fact although the interactions between family obligation and socioeconomic stress among early high school students were not statistically significant several of the interaction terms were in opposite directions compared to those found in later high school one explanation for these differences is that family obligation tends to become increasingly salient as adolescents mature are able to take on more responsibilities and gain more practical ways to assist their families for example although virtually all children can help with various household chores it is not until the later years of high school that children can drive which may make it easier to run errands for the family take on an afterschool job or engage in more diverse assistance behaviors it is also possible that with impending high school graduation issues such as socioeconomic stress and family obligation are in the forefront of adolescents lives and come together in more marked ways to impact their academic adjustment a third explanation is that socioeconomic stress may interact with family obligation differently when it is experienced at a more chronic level by the time adolescents reach the later years of high school they presumably have had a longer opportunity to experience socioeconomic stress and it is thus possible that these experiences of chronic stress differentially interacted with family obligation to predict academic outcomes notably average levels of socioeconomic stress were also significantly higher in later years of high school than in earlier years these mean differences could be potentially due to older adolescents being more aware of their familys financial situations and perhaps the moderating effect of family obligation does not become relevant until adolescents gain such awareness andor socioeconomic stress reaches a certain threshold it is also notable that interactive effects were not found for gpa which could have been due to limitations in selfreports of the construct or the idea that the interactive effects of socioeconomic stress and family obligation are more salient for academic outcomes that are more futureoriented rather than those that are more immediate in nature clearly more research is needed to better disentangle the differential developmental patterns that we found although the focus of this article was on concurrent reports examined at two different developmental periods multiple waves of data also can be used to investigate longitudinal associations among constructs for example using our data in a different way we conducted post hoc analyses to help shed light on the developmental differences that we found we ran a series of regressions using w1 reports of socioeconomic stress and family obligation to predict w2 outcomes after controlling for outcomes at w1 with the exception of one interactive effect that approached significance in terms of gpa and one main effect of w1 socioeconomic stress predicting importance of academic success at w2 no other main effects or interactions were found given that early reports had little influence on later outcomes these results confirm our overall findings that suggest that socioeconomic and family constructs are more salient in later versus earlier years of high school these results also suggest that family stress and resilience processes function in a more temporally proximal manner rather than over time which supports our initial framework in examining the immediate impact of family obligation and its relevance across differential phases of development it was somewhat surprising that socioeconomic stress and family obligation were not correlated with each other it would be reasonable to expect that more financial hardships would be related to adolescents obligations to step in and assist their families either by their working at a parttime job to contribute to family income or by helping out around the house while parents work one explanation is that our measure of family obligations assessed attitudes toward assistance behaviors rather than the behaviors themselves nonetheless the fact that these are independent constructs supports the need to further examine how such family attitudes are socialized or learned prior work suggests that family obligation is a culturallybased construct that may be tied closely to cultural values and ethnic identity perhaps examining ethnic identity development as one potential pathway towards family obligation would be an interesting avenue for future research indeed our results highlight the benefits of cultivating attitudes toward family obligation as a resiliency factor determining how individual differences in family obligation develop would be helpful in understanding ways to enhance such attitudes and thus promote adolescent outcomes taken together there are several important implications regarding the main effects found and the manner in which socioeconomic stress and family obligation interacted in predicting academic outcomes our results suggest that assuming that asian americans adolescents are uniformly on a path to high achievement seems unreasonable and potentially flawed however many teachers and other school staff may observe such a phenomenon with asian youth performing well to reconcile these perspectives our findings speak to the possibility that high family obligation which is often found among asian youth helps to compensate for the negative effects of socioeconomic stress and maintain the high achieving stereotype in addition given that the actual buffering effects of family obligation did not emerge as statistically significant until the later high school years future research and intervention efforts that are focused on somewhat younger high school students might allow more of an opportunity to observe adverse effects of low family socioeconomic stress and to subsequently intervene early in order to promote better academic outcomes indeed the model minority stereotype involves a complex interplay between adolescent characteristics and both inschool and outofschool experiences and our work contributes to the understanding that asian youths school achievement is considerably multifaceted

socioeconomic stress has long been found to place youth at risk with low family income conferring disadvantages in adolescents school achievement and success this study investigates the role of socioeconomic stress on academic adjustment and pinpoints family obligation as a possible buffer of negative associations we examined direct and interactive effects at two time points in the same sample of asian american adolescentsearly high school n 180 9th10th graders 60 female and 2 years later in late high school n 156 11th12th graders 87 of original sample results suggest that socioeconomic stress is indeed associated with poor academic adjustment measured broadly through selfreported gpa importance of academic success and educational aspirations and expectations family obligation was positively related to adjustment and also was found to buffer the negative effects of socioeconomic stress but only during adolescents later high school years adolescents reporting more family obligation experienced less of the negative effects of financial stress on academic outcomes than those reporting lower obligation cultural and developmental implications are discussed in light of these direct and moderating effects

introduction even the most conservative estimates anticipate that at least 45 million jobs in the eu27 labor market are directly at risk from the coronavirus disease 2019 disruptions 1 the outbreak of covid19 has had a drastic impact on work at a global scale 2 changes in when where and how work is completed are profound evidenced for instance by widespread remote work directives 3 4 5 the extent to which employees can adjust to remote work is crucial for individual outcomes and organizational outcomes hence this study explores factors related to employees adjustment to remote work practices during the first phases of the covid19 pandemic in achieving the aim of this study we contribute to emerging research on the impact of the covid19 pandemic on work 3 5 6 7 8 in line with raghuram et al 9 we view adjustment to remote work as an overall state of adaptation to environmental demands and conditions several critical indicators of adjustment to remote work have been identified including employees satisfaction with remote work conditions perceived job performance as a consequence of remote work and the ability to balance work and nonwork demands 910 in contrast to previous investigations of adjustment 9 the covid19 crisis required organizations and their employees to abruptly change their work environments and ways of working as such there is a need to understand what factors are related to employees adjustment to remote work during this crisis 6 based on the theory of work adjustment 1112 and previous work on individual adjustment in a work context 1013 and adaptation to virtual work 9 we identify and examine a framework of environmental factors that may affect individual adjustment to remote work during the covid19 pandemic specifically based on crosssectional survey data we provide empirical insights into the extent to which employees adjustment to remote work is associated with structural factors relational factors and contextual factors furthermore we investigate moderating factors that potentially influence the relationships underlying employees adjustment to remote work organizational communication quality has been found to be pivotal when dealing with uncertainty and crises including organizational responses to the covid19 pandemic 14 at the same time technological advances have been heralded for their ability to facilitate work across spatial distances and both synchronous and asynchronous collaboration 15 16 17 18 hence we investigate the role of organizational communication quality and ctu in qualifying the impact of structural relational and contextual factors on adjustment to remote work remote work settings involve temporal and spatial dispersion and depend on ctu to allow employees to interact across these boundaries 19 20 21 22 23 remote work is defined as work done by an individual while at a different location than the person directly supervising andor paying for it 24 in the context of the covid19 pandemic this location was typically employees homes although previous studies have indicated that working from home might help employees collaborate across time zones concentrate better than in the primary work location and accomplish work tasks 25 it is unclear what factors impact employees ability to adjust to new demands of their work environment when they are mandated to work from home we use remote work to refer to the current situation in which employees are mandated to work from home during the pandemic literature review and hypotheses this study takes a work adjustment perspective to examine how employees have adjusted to an abrupt transition to remote work adjustment to new work contexts typically involves adaptation to new environmental stimuli or demands it has been suggested 9 that adjustment to virtual work refers to employees ability to adapt to virtual work modes as they transition from traditional office environments to remote work specifically adjustment refers to an overall state of adaptation because a transition to remote work highlights the inherent tradeoffs involved in adjustment 9 several aspects are considered critical indicators of employees successful adaptation to a virtual work including satisfaction commitment productivity and the ability to balance work and nonwork demands successful adaptation often requires a tradeoff between these aspects to examine the underlying factors that impact employees adjustment to remote work we identified several structural relational and contextual factors that may impact employees adaptation these factors align with those proposed by raghuram and colleagues 9 but we extend this framework by including crisisspecific concepts such as perceived disruptions and social isolation our conceptual model has its theoretical roots in the theory of work adjustment 111226 and in the interactional model of individual adjustment 13 it identifies several categories of factors relevant to individual adjustment including individual job and organizational factors recently carillo and colleagues 6 adopted a similar approach to identify the individual job and organizational factors underlying telework adjustment in a crisis context we further extend this work by exploring the role of several moderating factors including organizational communication quality and ctu structural factors structural factors are the fundamental preconditions and organizational expectations related to a job description that may facilitate or forestall the possibilities to work remotely key aspects include work independence and clarity of job criteria 9 when work can be conducted independently and the criteria for a specific job are clear employees may be more confident in their ability to complete work remotely facilitating better adjustment work independence work independence refers to the ability of remote employees to complete tasks without having to engage in continual interaction with their coworkers 27 work independence can be facilitated by supporting asynchronous work for example allowing access to common databases through technology and ensuring that colleagues can connect with others if needed 9 remote employees who must rely continually on their coworkers thereby making them reciprocally or sequentially interdependent with others are likely to experience time pressures loss of control and a decline in personal productivity 2829 however independence may facilitate adjustment to remote work 9 because it allows workers to exercise more control over their behavior for instance when drawing boundaries between work and nonwork 30 or when enacting discipline to organize their work and apply their skills in an isolated work environment 9 hence employees with greater degrees of independence are found to experience greater adjustment to a remote work context 9 this is in line with research suggesting that individuals have an innate need for autonomy and selfdetermination 3132 thus we propose the following hypothesis 1 work independence is positively associated with employees adjustment to remote work clarity of job criteria the clarity of job criteria means that performance assessment at work is perceived as objective quantifiable and transparent 9 clear and explicit criteria are especially beneficial to guide the performance of remote employees and develop accurate expectations among them 930 this is because remote employees compared with nonremote employees have fewer opportunities to seek or receive informal performance feedback or clarifications from their supervisors and coworkers unclear evaluation criteria may lead to insecurity and uncertainty concerning workrelated expectations however when clear and explicit evaluation criteria are in place remote employees may be even more capable of managing themselves which may lead to enhanced performance and satisfaction 930 additionally clear evaluation criteria can help build mutual expectations and perceptions of procedural fairness and establish perceptions of equity among remote employees who cannot use physical behaviors to compare work outcomes 2933 when evaluation criteria are clearly understood remote employees are also more likely to work on initiatives that are valued by their organization 34 hence we propose the following hypothesis 2 clarity of job criteria is positively associated with employees adjustment to remote work relational factors relational factors refer to the social relationships and forms of collaboration within an organization in the context of remote work they relate to for example support and interpersonal trust 9 among employees working remotely and their supervisors and coworkers hence we examine how trust can help to overcome barriers to adjusting to remote work 9 in addition issues of social isolation at work are especially profound during the covid19 pandemic hence we investigate how these issues may deter adjustment to remote work 35 interpersonal trust because remote work inherently involves physical and psychological distances factors that create a stronger sense of relationships between coworkers may prevent physical distance from becoming psychological distance 9 and are expected to have a positive influence on employees ability to adjust to remote work 36 feelings of trust for instance may give remote employees greater confidence in their role within the work group or organization and facilitate further adjustment 37 interpersonal trust can be defined as the willingness to accept vulnerability and a positive expectation of others trustworthiness 38 it has been shown to have a positive effect on workplace cooperation 39 knowledge sharing 40 and organizational commitment 41 trusting relations between employees 42 and employees trust in supervisors 43 enhance organizational change and can therefore affect how employees adjust to remote work trust also lowers the need for both employees and their supervisors to monitor and verify each others work in the virtual context 44 and is crucial to the effectiveness of virtual workers 45 thus we hypothesize the following hypothesis 3 interpersonal trust is positively associated with employees adjustment to remote work social isolation social isolation is related to physical and psychological distance between coworkers isolation can be defined as the perception of a lack of availability of support and recognition missed opportunities for informal interactions with coworkers and not being part of the group 35 in other words isolation is a state of mind or a belief that one is out of touch with others in the workplace as such the desire to feel socially connected is thwarted 46 in a remote work setting perceptions of social isolation may be exacerbated even though it is proposed that isolation is created mainly due to the lack of availability and not just spatial distance 35 perceived isolation has been identified as a potential obstacle for effectiveness among remote employees 47 and may reduce job satisfaction 46 hence we hypothesize the following hypothesis 4 social isolation is negatively associated with employees adjustment to remote work contextual factors we extend previous models 9 of adjustment by explicitly considering the covid19 context within which adjustments are required specifically we suggest that the severity of the change in work locationhere the discrepancy between earlier remote work experience and current remote work frequencyand the extent of broader disruptions of work routines triggered by the covid19 crisis impact on employees adjustment to the new normal 548 change in work location the sudden requirement to work from home has led most employees to increase the frequency with which they work from home for some these changes are more substantial because they either did not engage in remote work practices or did so to a very limited extent prior to the covid19 outbreak in contrast for employees who are more familiar with these work practices either because they frequently work remotely or are used to working with dispersed colleagues these new work realities may require less adjustment limited connections and access in remote locations seem to be the main challenges of virtual working spaces despite recent technological advances we examine the role of changes in work location as the discrepancy between current remote work practices and remote work practices before the covid19 crisis transitioning to a remote work location may require adjustment to the working environment including physical technological and social conditions of work 16 the intuitive hypothesis here is that larger differences indicate more substantial changes in where work is conducted which in turn could complicate adjustment hypothesis 5 changes in work location are negatively associated with employees adjustment to remote work disruption of work routines unlearning refers to the breakdown of routines habits and cognitive frameworks 49 we use the term disruption to refer to an unlearning process in which routines habits norms and procedures are changing 50 as a result of the covid19 pandemic the adjustment required by employees depends on the level of disruption experienced by employees greater disruption requires greater adjustment prior research demonstrates that environmental turbulence causes organizations and their subunits to face performance gaps work stress toxic work environments and blame shifting as well as anxiety and fears 50 hence we hypothesize the following hypothesis 6 disruption of work routines is negatively associated with employees adjustment to remote work moderating factors in addition to structural relational and contextual factors remote work is structured and shaped by communication technologies that enable employees to interact across temporal and spatial boundaries the quality of organizational communication and the frequency of ctu in times of changing work environments and dispersed work may prove to be of particular importance for employees to adjust to new work conditions organizational communication quality is defined here as the informativeness accuracy and timeliness of communication about organizational changes during the pandemic 51 organizational communication quality and relational and contextual factors communication has been found to mitigate the relationship between geographical distribution and conflict 52 although not directly related to adjustment these findings imply that communication might have a positive impact on conflict identification and conflict handling and as such may optimize remote work effectiveness and satisfaction which are key indicators of adjustment in addition highquality organizational communication can be viewed as a sign of organizational support that may help employees refocus on collective goals 53 to meet their performance expectations in the absence of a traditional office environment the role of organizational communication may be even more profound because it may substitute in part for a lack of facetoface interaction while facilitating the information purposes of social support networks that are normally present in organizations 54 finally communication tends to clarify role expectations and enhance performance by reducing uncertainty 51 therefore we ask the following question rq1 does organizational communication quality moderate the impact of structural relational and contextual factors underlying adjustment communication technology use and relational and contextual factors communication technologies are the enabling force behind most remote work settings allowing workers to maintain necessary levels of connectivity to share information and coordinate work across various boundaries 5556 in addition the effective use of communication technology is an important facilitator of trust in virtual teams 175758 indeed many organizations can be argued to have adopted some degree of virtual practices under the studied conditions and collaboration strongly depends on the effective use of communication technology ter hoeven and van zoonen 59 demonstrated that control over ctu reduces the negative consequences of spatial distance in remote work arrangements for helping behavior because ctu may amplify the positive association of relational factors with adjustment while mitigating the negative impact of other relational factors we pose the following research question rq2 does ctu moderate the impact of relational and contextual factors underlying adjustment materials and methods this crosssectional study targeted employees who had been asked to work remotely in finland since the lockdown began in midmarch 2020 the survey started on the 26th of march 2020 and was open for responses until the 13th of april 2020 open survey invitations were published online and we solicited the help of several large labor unions and ministries to distribute the survey link to their members the survey included about 100 items in total including background questions and attention checks the survey was administered through the xm platform qualtrics and programmed such that all statements needed to be answered for the survey to be completed and responses to be considered for analysis explicit informed consent was obtained from all participants prior to the survey data were exported to ibm statistical software packages spss and amos for further analysis there were no missing values as we used forced response options respondents who failed the attention checks or dropped out were automatically excluded embedded data and identifying information were assessed to guard against duplicate responses but were not used in the analysis stage this convenience sampling procedure resulted in a total response of 5452 finnish employees employees in our sample indicated low probabilities of job loss in the near future with 844 indicating that this was improbable the average age of the respondents was 453 years old most respondents were female and 1593 were male most respondents were employed by the state or public utility while 1318 respondents worked for private enterprises and others worked in nongovernmental or semigovernmental organizations the respondents mostly worked in organizations with 50 to 249 employees 250 to 999 employees or more than 2000 employees the majority of respondents worked remotely 4 or more days per week 65 worked remotely 2 or 3 days and 26 worked remotely 1 day per week or less furthermore respondents indicated they worked 386 h per week on average and the average reported overtime was 23 h per week approximately 14 of the respondents worked in a managerial position their average organizational tenure was 109 years most respondents were part of single or twoperson households and 40 had at least 1 child under the age of 18 in their household measures all statements were measured using sevenpoint response scales ranging from strongly disagree to strongly agree unless indicated otherwise all survey items were derived from earlier studies and reviewed by the research team but we did not conduct a pilot study table 1 lists all measurement items including descriptive statistics and factor loadings dependent variable adjustment to remote work was measured with a fiveitem scale assessing satisfaction with remote work perceived performance as the consequence of remote work and ability to balance work and nonwork demands the measure was adopted from raghuram et al 9 who used it in the context of virtual work adjustment refers to an overall state of adaptation because a transition to remote work highlights the inherent tradeoffs involved in adjustment 9 for instance research by 9 indicated that expending greater efforts to increase productivity may come at the expense of greater worknonwork balance hence an overall measure of adjustment may most accurately assess employees relative level of adaptation to environmental demands structural factors independence was measured using four items adopted from 60 similar to raghuram et al 9 respondents were asked to indicate the degree to which their performance was dependent on working with others clarity of job criteria was measured using four items adopted from 61 the items deal with handling problems on the job figuring out what should be done to accomplish ones work and being sure of how the job needs to be done items are based on role conflict and role ambiguity scales proposed by house and colleagues 62 relational factors interpersonal trust was measured using four items based on 61 adopted from 9 in line with earlier research 9 our measurement strategy focused on an overall measure of trust rather than assessing the many specific determinants of trust two items relate how much the individual trusts hisher supervisor and colleagues and two items measure the extent to which the respondent perceives that hisher supervisor and colleagues trust the individual social isolation was measured using three items derived from 35 social isolation measures the extent to which employees feel isolated and separated from others in the workplace contextual factors change of work location was measured by calculating the difference between remote work before the pandemic and current remote work frequency respondents were asked about the frequency with which they normally worked remotely ranging from 1 to 7 subsequently we asked respondents to indicate the frequency with which they worked remotely since the moment their organization took measures related to the covid19 crisis by subtracting the scores we calculated a difference score such that a higher value indicates a larger discrepancy in remote work practices compared with normal circumstances perceived disruption was measured by adopting eight items from 5063 the items address changes in work routines since routines are reflected in operating procedures during the performance of work changes in plans deadlines and informationsharing mechanisms are indicative of an overall disruption of work we asked employees to indicate the extent to which several activities including project plans and deadlines have changed since the organization took measures related to the covid19 crisis moderators organizational communication quality was measured using six items from bordia et al 64 these items have previously been applied in the context of uncertainty during organizational change quality of communication was measured using items such as the communication my organization provided adequately answered my questions about the changes communication technology use was measured by asking respondents to indicate the frequency with which they used various technologies to communicate with their colleagues the communication technologies we inquired about were email telephone instant messaging online meetings collaborative tools enterprise social media and public social media responses ranged from 1 to 7 the items were computed to indicate an overall score for the frequency of ctu with higher scores indicating more frequent communication with colleagues through these technologies results measurement model a confirmatory factor analysis was used to examine the hypothesized factor structure and investigate the validity of our measurement model subsequently we examined common method variance using a common latent factor approach the model demonstrated good model fit χ 2 443249 cfi 096 tli 095 srmr 004 pclose 1000 and rmsea 0039 following recommendations and threshold values reported by hair et al 65 the model demonstrated convergent and discriminant validity of the measures in our model the average variance extracted ranged between 043 and 071 discriminant validity was examined through the maximum shared variance which ranged between 007 and 037 for the constructs in our model and is smaller than the ave values additionally the square root of the ave was greater than the interconstruct correlations inspection of the model parameters indicated the absence of crossloadings overall suggesting good discriminant validity reliability was examined through the composite reliabilities and the maximum reliability which ranged between 075 and 093 and between 077 and 093 respectively second we examined common method variance using a common latent factor approach squared regression estimates indicated that common method variance was 36 indicating that common method variance is not a substantial concern in our data curve estimations for all relationships in our model indicated that these relationships were sufficiently linear finally the correlation between interpersonal trust and communication quality was relatively high hence we inspected collinearity statistics for all independent variables and discovered no problems with multicollinearity in sum these results justify further inspection of the structural model controls we considered several potentially confounding factors in our analysis specifically we controlled for gender age working hours per week managerial position organizational tenure and job security gender significantly predicted adjustment suggesting that female respondents were better able to adjust to remote work gender did not affect any of the hypothesized relationships in the model age did not affect adjustment to remote work similarly the number of work hours per week did not significantly affect adjustment to remote work however the results indicated that managerial positions had a significant and negative relationship with adjustment suggesting that individuals in managerial positions seem to have more difficulties adjusting to remote work finally organizational tenure and job security did not affect adjustment to remote work or any of the relationships in our model in sum all hypothesized relationships remained unaffected when these variables were included hence these variables were excluded from the final model for reasons of parsimony hypotheses testing the hypothesized model was examined using path modeling in amos by estimating regression coefficients between the structural relational and contextual factors on adjustment to work table 3 provides the standardized and unstandardized regression results for the full model structural factors hypothesis 1 assumes that work independence is positively related to adjustment to remote work the results demonstrate a significant positive relationship p 0001 hence hypothesis 1 is supported in addition hypothesis 2 reflects the assumption that clarity of job criteria makes it easier for employees to adapt to remote work the findings demonstrate a significant positive relationship between the clarity of job criteria and adjustment to remote work p 0001 hence hypothesis 2 is also supported overall these results provide strong support that the structural factors of an employees job have an important influence on the employees adjustment to remote work relational factors hypothesis 3 posits that interpersonal trust is positively related to employees adjustment to remote work the results demonstrate a significant negative relationship between trust and adjustment p 0006 hence contrary to our expectations trust between coworkers and supervisors does not increase adjustment to remote work but rather decreases it a possible explanation could be that employees who exhibit lower levels of trust in their peers and supervisors rather work remotely as this gives them more autonomy from people they do not trust and therefore they are less frequently confronted with such relationships however as the relationship is in the opposite direction than the one we hypothesized we do not find support for hypothesis 3 hypothesis 4 suggests that social isolation is negatively related to adjustment to remote work the results demonstrate a significant negative relationship between perceived social isolation and adjustment to remote work p 0001 providing support for hypothesis 4 contextual factors hypothesis 5 reflects the rationale that the relative change in work locations influences employees adjustment to remote work the results show that a change in work location is negatively related to adjustment to remote work p 0001 this result suggests that a larger change in work location reduces employees adjustment to remote work hence hypothesis 5 is supported this implies that employees who were already used to working remotely before the pandemic adjusted better to the new situation hypothesis 6 suggests that perceived disruption is negatively related to adjustment to remote work the findings demonstrate a significant negative relationship p 0001 providing support for hypothesis 6 the more work practices changed during the pandemic the less employees were able to adjust moderations before discussing the interactions it should be noted that both moderators organizational communication quality and the frequency of ctu are significantly and positively related to adjustment note that all variables that comprise product terms were mean centered prior to testing the interactions for all interactions we inspected the values of the interactions effect at different values of the moderator using the johnsonneyman technique when the interaction reported was not significant at all values of the moderator we reported the value of the moderator at which the interaction becomes significant to facilitate interpretation the meancentered values are also reported as actual values organizational communication quality there was no significant interaction effect between organizational communication quality and trust p 0995 social isolation p 0149 and disruption p 0722 on employees adjustment to remote work there was a significant interaction between organizational communication quality and change in work location p 0001 on adjustment to remote work this result suggests that at low levels of organizational communication quality starting at 411 perceived change in work location negatively impacts adjustment to remote work organizational communication quality has a limited impact in mitigating this negative relationship finally we did not find significant interactions between organizational communication quality and clarity of job criteria on adjustment p 0620 nor did we find an interaction between communication quality and job independence on adjustment p 0263 communication technology use there were no significant interactions between social isolation and ctu p 0149 ctu was found to moderate the negative relationship between trust and adjustment to remote work p 0002 the result indicates that trust negatively affects adjustment to work when the meancentered value of ctu is below 0562 this suggests that when ctu is low trust stifles adjustment to remote work but when ctu is high there is no significant negative effect of trust on adjustment to remote work arguably frequent ctu is important when trust is low to mitigate a decline in employees commitment satisfaction and productivity however ctu is also important for adjustment when trust is high as a lack of communication may be more detrimental to adjustment in hightrusting environments for instance trust may be an indicator of highquality relationships missing out on such relationships in remote work settings may be detrimental to several aspects of adjustment increasing the frequency of ctu to communicate and collaborate with trusted peers and supervisors might reduce the negative impact on employees adjustment in addition ctu was found to moderate the negative relationship between change in work location and adjustment p 0045 the findings suggest that change is negatively related to adjustment at all levels of ctu however smaller levels of change and a higher frequency of ctu yield the highest levels of adjustment at one standard deviation below the mean of change adjustment is higher when ctu is one standard deviation above the mean rather than below the mean in which case adjustment is 507 finally ctu moderates the relationship between disruption and adjustment to remote work p 0006 the confidence interval of the slope indicates that disruption has a negative impact on adjustment to remote work at all levels of ctu however it should be noted that higher frequencies of ctu allow employees to adjust better to remote work when disruption is high than when the frequency of ctu in these situations is low discussion the findings of this crosssectional study during the early phase of the covid19 outbreak in 2020 in finland indicate that structural factors make it easier for employees to adjust to remote work settings in turn relational factors are negatively related to adjustment contrary to our expectations and to the earlier findings by 9 interpersonal trust was negatively associated with adjustment to remote work arguably trust serves as a proxy for important interpersonal functions such as socialization and support when such cues are missing employees may feel less satisfied and effective and may therefore experience lower levels of adjustment to remote work our findings also show that feelings of social isolation decrease adjustment to remote work providing further evidence that the social dynamics of work present a key barrier in adjustment during the covid19 pandemic furthermore the results indicate that greater discrepancy between the amount of current and normal remote work and greater disruption in work practices both decrease adjustment these results imply that beyond smaller changes in work location greater experience with remote work seems to enhance adjustment to remote work finally the findings demonstrate a relatively small positive impact of organizational communication quality and ctu in adapting to increased remote work organizational communication quality does not mitigate the negative impacts of relational factors on adjustment or facilitate the relationship between disruption of work practices and adjustment however more frequent use of various communication technologies with colleagues seems to mitigate the negative relationship between trust and adjustment probably by reviving social relations more research is needed to study the potential buffering effects of communication technology use and remote work adjustment theoretical implications the findings have several theoretical implications first based on the theory of work adjustment 12 and the interactional model of individual adjustment 13 this study identified several crisisspecific environmental factors 6 in addition to traditional environmental factors proposed by 9 that may underlie employees adjustment to remote work for instance we demonstrated that isolation is a relevant predictor that could be conceptualized as a relational factor underlying adjustment in addition we conceptualized contextual factors that include crisisspecific indicators such as changes in work location and perceived disruptions that impact adjustment finally this study further considered how communication quality and ctu may mitigate some of the challenges in adapting to remote work ultimately the study contributes to the literature on adjustment by identifying how employees ability to adjust to abrupt transitions to remote work has been affected by various relevant factors of the work environment specifically this study contributes to personenvironment theories and the theory of work adjustment by identifying how the work environment may enable or constrain employees ability to adapt in other words the work environment has reinforcement capabilities that can satisfy a persons needs 12 second work independence and clarity of job criteria were positively and significantly related to work adjustment this suggests that employees who know what is expected from them and can complete their tasks without others adjust better to working remotely hence with regard to the structural factors underlying remote work we were able to replicate the findings presented by 9 in the context of virtual work and add that these factors operate in similar ways across organizational settings during a global health pandemic characterized by abrupt lockdowns and en masse remote work directives furthermore the findings align with 66 who find that telecommuters with higher autonomy report greater job satisfaction relative to those with less autonomy our findings are in line with previous literature linking performance management and goalsetting theory in colocated work settings it has been established that specific goals can enhance motivation and performance by leading people to focus their attention on specific objectives 67 facilitate their attempts to achieve these objectives 68 persist in the face of setbacks 69 and invent new strategies to better deal with complex challenges related to goal attainment 70 more broadly the finding that work independence and clarity of job criteria are positively related to adjustment also signals a potentially important tension in remote work designs while some level of independence and clarity at the individual level is desirable for job satisfaction effectiveness and performance in remote settings modern work tasks require some level of interdependency and employees may desire feedback socialization and relatedness with peers for example in selfdetermination theory relatedness is considered a basic human need that consists of interacting with being connected to and experiencing caring for others 31 recent studies on remote work 69 and global work 54 demonstrate the importance of considering both the job characteristics and the social characteristics of work research 5455 indicates that as workers are afforded more autonomy and work becomes more unpredictable and volatile employees need to adapt to contend with the demands of their work environment including relational demands this means that employees are active agents crafting their own jobs rather than passive recipients of work characteristics this perspective aligns well with the findings of this study which refer to agentic processeshere independence and clarity which empower employees to meet the demands of remote work and to adjust third with regard to the relational factors our findings do not support the hypothesis of a positive relationship between interpersonal trust and adjustment to remote work the negative relationship between trust and remote work adjustment is a counterintuitive finding that contradicts most of the past research on the relationship between trust and remote work 971 the findings indicate that higher levels of interpersonal trust decrease individuals adjustment to remote work alternatively the reverse is also true as employees who report low levels of trust seem to adjust better to remote work this result can be understood from an out of sight out of mind perspective suggesting that some employees may benefit from being separated from colleagues or supervisors they do not trust or even distrust indeed in the context of this pandemic scholars have chronicled that the transition to remote work may have benefits for employees as they might be less exposed to toxic workplace relationships or relieved from bullying colleagues 5 our findings align with such insights in addition trust among colleagues and in supervisors could be an indication of a valued interpersonal relationship having to miss such a relationship may reduce ones satisfaction with their job and make it more difficult to maintain productivity levels or overall job performanceall indicators of adjustment hence employees who report high levels of trust in coworkers and supervisors and who feel trusted by them may be less satisfied with remote work feel less effective and feel less adjusted employees may even want to return to the office as soon as possible to reconnect with their colleagues because the gratification of social needs is arguably satisfied through recurring physical interactions with colleagues furthermore trust built in the physical context may not have transferred to the technologymediated interactions of remote work environments yet and if the respondents see limited opportunities to do so this could lead to a less gratifying remote work experience finally the notion that greater disruption requires greater adaptation certainly rings true for most individuals the findings suggest that employees who experience greater disruption appear to face more difficulties adjusting to the work setting hence it seems that disruption may indeed require adaptation but the negative relationship suggests that employees have difficulty making the required adjustments arguably because adaptation in these cases requires employees to learn new skills and competencies to deal with environmental demands hence the findings demonstrate that employees adjustment to abrupt remote work transitions is complicated by the perceived strength of the disruption overall the findings suggest that factors underlying agentic processes facilitate adaptation and the reappraisal of event outcomes while relational factorstrust and isolationoperate as barriers to adjustment this phenomenon calls for further research into the managerial and sociopsychological processes that help to understand the relationship between disruptive events and organizational outcomes practical and managerial implication this study investigated the antecedents of adjustment to remote work some factors are directly within the scope of organizational control while others may be more difficult to influence directly however the results provide important and actionable implications for organizations first our results indicate that employees who report higher levels of independence and clarity of job instructions are better able to adjust to remote work in these circumstances organizations could provide clearer objectives and goals and minimize interdependencies between organizational members by designing and allocating autonomous jobs and tasks where possible in doing so organizations facilitate agentic processes of individual employees improving their adjustment to these settings in addition organizations need to ensure that there are adequate resources for employees to conduct work independently while maintaining interdependencies at the collective level for instance our findings show that ctu in particular as well as organizational communication quality may bolster adjustment to remote work managing relational factors deserves slightly more thought because higher levels of trust reduce adjustment but isolation also reduces adjustment social isolation can be reduced in various ways such as through synchronous video meetings and informal communication for example virtual coffee breaks may help employees feel connected to their coworkers and may lead to less isolation in the workplace in addition these initiatives might be important in the context of trust we found a negative relationship with adjustment however we argue that trust in this case signals the absence of important interpersonal cues in the physical workplace hence facilitating interpersonal mechanisms of socialization and support might mitigate the negative impact of trust on adjustment furthermore to facilitate greater adjustment in times where resources could be particularly scarce and feelings of isolation particularly high scholars have suggested that teleconsultations and informal online support groups could help people stay connected 72 73 74 in addition the findings demonstrate that greater change in work location and greater perceived disruption hamper adjustment to remote work this is important because it signals that organizations and managers should be attentive especially to employees whose work processes require the greatest adaptation our findings show that employees with more experience in remote work adapt to new situations better because they have already learned some practices and competencies needed in remote work this implies the importance of training organizational support for workhome issues significantly improves wellbeing 75 and may aid adjustment for instance organizations may support their employees through lower workloads or other job demands giving them greater opportunities to adjust additionally for employees working on vital processes organizations could have different approaches based on the extent to which the work routines of individuals or groups are disrupted for instance these workers could be given priority to use workplace facilities limitations and future research several limitations need to be acknowledged first this study relies on crosssectional survey data obtained through a convenience sampling method this method presents two limitations first the data do not permit any causal inferences and do not permit us to track how changes in for instance perceived disruptions and continued adjustment to the work environment develop over time second the sampling method resulted in a relatively homogeneous group of employees limiting the generalizability of the findings the nonrandom sampling technique as well as the sample and population information do not provide sufficient auxiliary information to correct survey responses using weight adjustments the sample consisted predominantly of finnish civil servants many of whom engaged in what could best be described as knowledge work in addition we surveyed respondents who had the available means to participate in the study furthermore the relatively stable work context of these employees and the finnish socioeconomic system may be fertile ground for the adjustment of employees which may not be the case in other types of occupations 5 other socioeconomic systems or countries that were more strongly affected by the pandemic 6 future research is needed to demonstrate the generalizability of our findings across a broader range of occupations countries and socioeconomic systems second some of the effect sizes are relatively small which raises questions about the predictive validity of the model to substantiate these findings future research is needed to confirm these results over time with various occupational groups in different socioeconomic systems in addition although the measures were adopted from previous studies not all measures have been validated and we do not have prepandemic benchmark indices for our population limiting our ability to draw a conclusion about the relative changes in addition responses were collected within the first month of the outbreak although this timeframe is considered appropriate to investigate adjustment processes these processes are also likely to continue as the pandemic evolved in addition people now have had more time to adjust and find ways to meet challenges and demands associated with teleworking hence it would be worthwhile to follow up on this study as the relative newness of the pandemic and associated teleworking has decreased finally our findings suggest that employees seem to adjust well to remote work this aligns with studies that conclude that the general attitude toward working from home seems positive 76 however this study was conducted in the early stages of the pandemic therefore limited assumptions can be made about the longterm implications in addition future research may probe more deeply into different aspects that are central to adjustment to remote work such as those related to worklife dynamics for instance now is the opportune time to study whether childless and single employees face increased expectations and work responsibilities and how these demands may interfere with nonwork demands 3 conclusions the findings presented in this study provide important insights into the factors that are consequential to employees adjustment to remote work these findings contribute to our understanding of how the covid19 pandemic has impacted work this is important because the current crisis is far from over 7477 future pandemics are increasingly likely 74 and other disruptive events such as economic downturn natural disasters activism and war may require continuous adjustment from employees and organizations our findings contribute to an understanding of how employees adjust to changes in their work environment by identifying and demonstrating the interplay between various environmental and contextual factors data availability statement the data presented in this study are not publicly available survey respondents were assured raw data would remain confidential and would not be shared author contributions conceptualization wvz as kb to ar kh and mv methodology wvz software wvz validation wvz formal analysis wvz investigation wvz resources as and kb data curation wvz writingoriginal draft preparation wvz writingreview and editing wvz as kb to ar kh and mv supervision kb project administration as and kb all authors have read and agreed to the published version of the manuscript funding this research received no external funding institutional review board statement ethical review and approval were waived for this study as the study did not involve any of the following underage subjects exposure to strong stimuli potential for longterm mental distress or intervention with the physical integrity of the participants informed consent statement informed consent was obtained from all participants involved prior to the study

the covid19 crisis has disrupted when where and how employees work drawing on a sample of 5452 finnish employees this study explores the factors associated with employees abrupt adjustment to remote work specifically this study examines structural factors ie work independence and the clarity of job criteria relational factors ie interpersonal trust and social isolation contextual factors of work ie change in work location and perceived disruption and communication dynamics ie organizational communication quality and communication technology use ctu as mechanisms underlying adjustment to remote work the findings demonstrate that structural and contextual factors are important predictors of adjustment and that these relationships are moderated by communication quality and ctu contrary to previous research trust in peers and supervisors does not support adjustment to remote work we discuss the implications of these findings for practice during and beyond times of crisis

introduction individuals from marginalized populations in the united states are at elevated risk of poor health disability and premature death such health disparities are defined as adverse health outcomes for communities that have as a result of social economic and environmental disadvantage systematically experienced greater obstacles to health although a primary objective of the nih is to eliminate health disparities among marginalized groups it was only in healthy people 2020 that lesbian gay bisexual and transgender people were for the first time identified in us health priorities as an atrisk population the institute of medicine has determined lgbt populations are health disparate and underserved recognizing the lack of attention to sexual and gender identity as critical gaps in efforts to reduce overall health disparities while health disparities research mainly documents group differences in health outcomes a more propelling goal is to promote health equity defined by whitehead and dahlgren as the opportunity to attain full health potential krieger et al describe a health equity perspective as the instrumental use of human rights concepts and methods for revealing and influencing governmentmediated processes linking social determinants to health outcomes especially in relation to the principles of participation nondiscrimination transparency and accountability lgbt health disparities according to populationbased surveys about 35 of us adults selfidentify as lesbian gay and bisexual and 03 as transgender which correspond to approximately 9 million people these numbers increase dramatically when samesex sexual attraction and behavior are also considered clearly there is a sizable subgroup of americans whose health merits increased research attention sexual and gender identity are complex constructs and are highly contingent upon culture and social context which can shift rapidly over time sexuality encompasses at least three key components sexual identity sexual attraction and sexual behavior sexual identity is an individuals own perception of his or her overall sexual self for many people their sexual identity such as lesbian gay bisexual or heterosexual is consistent with their sexual attraction and behaviors but for some individuals sexual identity may be inconsistent with attraction andor behavior for example a man whose primary sexual partner is a woman may identify as heterosexual yet occasionally have sex with men sexual identity may be more fluid than previously assumed especially among women gender refers to the behavioral cultural or psychological traits that a society associates with male and female sex transgender generally refers to people whose gender identity is at odds with the gender they were assigned at birth according to their sex and physiological characteristics of their bodies for example a transgender woman is a person who was born physiologically male but whose deepest sense of self is as female it is important not to conflate sexual and gender identity because they are separate constructs with the inclusion of questions on sexual identity in an increasing number of national populationbased health surveys a growing body of research is documenting health disparities among lgb people specifically lgb people are at higher risk for poor mental health psychological distress suicidal ideation and mental health disorders compared with heterosexuals more recent research is investigating the physical health of lgbt people relative to heterosexuals lgb populations have higher rates of disability more physical limitations and poorer general health elevated rates of hiv are also observed among gay and bisexual men and transgender women among lesbian and bisexual women there are higher rates of overweight and obesity although findings are mixed some studies have indicated lgb adults may be at elevated risk of some cancers and cardiovascular disease large populationbased studies have found that lgb adults are more likely to report diagnoses of asthma than their heterosexual counterparts with few exceptions limited research has focused specifically on the health status of transgender individuals two recent studies with large national samples of transgender individuals found that rates of depression anxiety and overall psychological distress were disproportionately higher for this population than for nontransgender women and men research findings also document disproportionate rates of military service incarceration sexual violence and poor general health among transgender people lgbt historical context historically homosexuality in the united states has been largely invisible because it was often equated with deviancy sickness and shame samesex sexual behavior was against the law with sodomy a criminal offense in all 50 states prior to 1961 until its removal from the diagnostic and statistical manual of mental disorders in 1973 homosexuality was treated as a sociopathic personality disorder both prejudice and stigma likely result in higher rates of mental health problems among lgbt people which is reflective of the historical practice of pathologizing and criminalizing lgbt people despite the larger social stigma underground communities accessible to sexual minorities began to develop in major metropolitan areas during and after world war ii in 1969 after a routine police raid on an lgbt night club in new york city the stonewall riots erupted as an act of resistance sparking the modern us gay rights movement despite the progress a growing backlash from conservative and religious elements in society combined with aidsrelated losses in the early 80s and into the mid90s shifted the dominant discourse of homosexuality to a sin punishable by death yet this too was actively resisted by lgbt activists and grassroots political organizations shifting from resistance to a growing urgency for emancipation more recently the marriage equality debate has shifted dramatically since the federal prohibition of samesex marriage through the defense of marriage act lgbt people can now legally marry in more than 30 states and washington dc and lawsuits regarding marriage equality are pending in all other states as well as the commonwealth of puerto rico yet still today discrimination in employment housing and public accommodations is not prohibited on the basis of sexual orientation or gender identity by federal law in 2013 while the dsm5 reclassified gender identity disorder as gender dysphoria which is no longer pathological per se the classification continues to stigmatize transgender people via a mental disorder classification that is dependent on clinically significant distress or impairment risk factors for lgbt health disparities while biological and genetic influences on health in the general population receive ample attention much less is known about the effects of structural and environmental contexts on health and the roles of social determinants which may vary considerably across marginalized groups indeed the world health organization has affirmed that the root causes of health inequities are to be found in the social economic and political mechanisms yet only a handful of studies have examined the effect of discrimination and social stigma on physical as well as mental health outcomes in lgbt populations in conceptualizing the determinants of lgbt health disparities researchers have relied almost exclusively on stress and coping models the stress process model first addressed the influence of stressful life events associated with structural inequalities on mental health according to the model disadvantaged status traumatic early events and unexpected life transitions in ones social role behaviors and social relationships cause both longterm stressors and proliferated stressors which in turn impact health and wellbeing most notably the minority stress model postulates that sexual minorities experience increased mental health problems because of stress processes unique to their status namely discrimination expectations of rejection concealment and internalized homophobia hatzenbuehler expanded upon this model with the psychological mediation framework which suggests that emotion dysregulation interpersonal problems and cognitive processes mediate the link between heightened stressors because of sexual minority status and psychopathology while these theories advance our understanding of lgbt mental health disparities current conceptualizations fail to explain why many lgbt people enjoy good health despite adversity and to articulate the multilevel factors that may influence the continuum of lgbt health over the life course reconceptualization of lgbt disparities the health equity promotion model we propose a new conceptual framework that situates lgbt health across the life course and focuses on how minority status related to sexual and gender identity can result in variations in health for lgbt populations over time examining the resilience as well as risks that influence lgbt people is a first step toward a comprehensive understanding of their health across the life course resilience factors that may delink the relationship between stressors in early life and consequential health deterioration in later life have not been adequately addressed in previous frameworks based on a conception of health equity a primary premise of this framework is that all individuals have a right to good health and it is a collective responsibility to ensure all obtain their full health potential highlighting the importance of intersecting social positions within a life course perspective the framework acknowledges both interand intragroup variability and that an individuals development of health potential can vary within a group of individuals who share a similar life course the framework points to structural and environmental factors as determinants of health as well as community and individuallevel factors highlighting resources resilience human agency and risks a life course perspective provides a means for taking into consideration both historical and social contexts that are shared by age cohorts and the unique needs adaptation and resilience of lgbt individuals as human agency this perspective highlights differences in experience between an lgbt person who came of age when homosexuality was considered a psychiatric disorder compared with an lgbt adult now in early adulthood during the marriage equality debates equally important a life course perspective identifies an individual life trajectory as important in understanding current health outcomes the health equity promotion model considers the ways in which both the exclusion and resistance of lgbt people has played out over time given the shifting historical and social context according to elder individuals construct their own life course through the choices and actions they take within the opportunities and constraints of history and social circumstances for example despite historical and social marginalization lgbt individuals have developed their own ways of building communities and behavioral and psychological coping skills the health equity promotion model building upon the minority stress theory and the psychological mediation framework integrates a life course development perspective within a health equity framework to highlight how social positions and individual and structural and environmental context intersect with healthpromoting and adverse pathways to influence the continuum of health outcomes in lgbt communities while not intended as a theory or exhaustive classification of the determinants of lgbt health the framework provides a guide to consider the multiple levels and intersecting influences on the full continuum of lgbt health especially as they relate to equity and resilience in lgbt communities it aims to stimulate research that addresses the full component of factors influencing the range of lgbt health outcomes social positions as health occurs within a social context it is not surprising that marginalized social statuses are linked to disparities in health outcomes a consideration of social positions and health must include attention to the complex nature of intersecting social positions including diverse sexual and gender identities and how social locations interact and the potential for synergistic disadvantage or advantage based on multiple statuses yet most health research has ignored heterogeneity within lgbt communities without exploring how lgbt health is differentiated by social position as figure 1 demonstrates combinations of these social positions may be associated with types of marginalizationas well as potential for strength resilience and opportunities we do know that there are sex differences in lgbt health behaviors social networks and health outcomes gender expression appears to be another important factor to consider as ones level of femininity or masculinity has been found to be associated with different types of stressors both transgender and bisexual people experience systemic disparities and emerge as critically underserved and atrisk populations who also display important strengths for example evidence has documented pronounced socioeconomic risks and health disparities among transgender people yet they also have larger social networks as compared with lgb people such sexual minority social positions can be sources of strength for lgbt people such as providing a family of choice community support and pride in ones identity and community less is known about the health of lgbt persons of color as described in the health equity promotion model race and ethnicity and culture intersect with sexual and gender identities for example studies find differential response rates to sexual orientation questions by race and ethnicity although the term lgbt is most often used research has found that asian americans often identify their sexual orientation as queer and african americans often use the term samegender loving both of which are most often treated as missing in research studies furthermore some commonly used sexuality terms related to sexual identity are not translatable in spanish a potent example of the intersection of culture race and sexual and gender identities is the experience of twospirits according to walters and colleagues the term twospirit is used currently to reconnect with native american and tribal traditions related to sexual and gender identity to transcend the eurocentric binary categorizations of homosexual versus heterosexual or male versus female to signal the fluidity and nonlinearity of identity processes and to counteract heterosexism in native communities and racism in lgbt communities multilevel context individual manifestations such as microaggressions discrimination and victimization and structural and environmental such as societal and institutional levels of oppression and social exclusion microaggressions and interpersonal assaults and overt acts of discrimination may have a significant impact on lgbt individuals health characterized as enacted stigma such acts have been defined as the overt behavioral expression of sexual stigma through actions such as the use of antigay epithets shunning and ostracism of sexual minority individuals and overt discrimination and violence the minority stress model specifically addresses the negative influence of such social stressors on mental health among lgbt individuals in addition recent studies also found that discrimination is associated with physical health outcomes among gay and bisexual men discrimination and victimization has been found to be associated with disability depression and poor general health lgbt people who have been physically assaulted report more loneliness poorer mental health and more lifetime suicide attempts among transgender older adults lifetime victimization explains heightened risks of poor health outcomes injustice in health is also exercised at the societal and institutional level hatzenbuehler and his colleagues argue that although societal conditions and social norms can systematically and institutionally disadvantage marginalized individuals and lead to poorer health outcomes little research has examined to what extent such social exclusion influences physical health structural and contextual factors create a context of marginalization and oppression including laws and policies that unfairly treat sexual and gender minorities as well as cultural and institutional oppressions widespread societal stigma and religious intolerance and persecution for example populationbased data indicate that most americans have access to health care yet evidence suggests that lgbt adults may have less access to health care when needed in one of the largest surveys of transgender individuals participants indicated high levels of postponing medical care when sick or injured as well as significant barriers to accessing health care in addition differences in geographical contexts may impact health for lgbt populations for example a study found that nonurban dwelling lesbians are less likely than urbandwelling lesbians to disclose their sexual identity to health care providers social inclusion also positively impacts the health of lgbt adults populationbased longitudinal data offer support that legally recognized marriage for example bestows benefits for health and longevity for both men and women in the general population the american medical association acknowledges that lack of access to the benefits of full marriage equality contributes to health disparities among lgb adults living in states that specifically ban samesex marriage is linked to increases in mood disorders research suggests that samesex couples in legally recognized relationships experience less psychological distress and lower levels of internalized heterosexism and better health than their counterparts in committed but not legally recognized relationships healthpromoting and adverse pathways including behavioral social psychological and biological mechanisms as figure 1 indicates these four mechanisms mediate the effects of individual and structural and environmental context on health outcomes equally importantly the four mechanisms can moderate these relationships which account for how health trajectories may differ among lgbt individuals who share similar life experiences in other words despite the stressful experiences of discrimination and social exclusion some lgbt individuals maintain health potential by utilizing healthpromoting resources that they have cultivated through life as discussed below the proposed model suggests that the four pathways offer both healthpromoting and adverse mechanisms as behavioral pathways both healthpromoting and adverse health behaviors are observable human acts by an individual or group of individuals to change or maintain health adverse health behaviors that are linked to poor health as well as the action of individuals in the promotion of good health and prevention of illness are important components of the proposed model lgbt adults report disproportionately higher levels of some adverse health behaviors including higher rates of smoking excessive drinking and in some cases drug use which are leading causes of preventative deaths studies found that experiences of discrimination are associated with elevated use of substances among lgbt individuals in terms of health screenings lesbian and bisexual women may be at risk of not utilizing preventive health care and screenings although findings are mixed studies found that lesbians with higher levels of perceived health care discrimination are more likely to delay utilizing cervical cancer screening moreover transgender individuals report high levels of postponing medical care often because of fears of discrimination or inability to afford care how behavioral pathways operate and their interaction with social and historical marginalization as well as community norms and expectations among lgbt populations remains unanswered obesity is one example the rates of obesity in the united states have steadily increased in recent decades and studies suggest that chronic discrimination may be associated with elevated risk of obesity yet despite experiencing greater discrimination gay men are less likely than heterosexual men to be overweight or obese and they are more likely to diet be fearful of becoming fat and feel more dissatisfied with their bodies lesbians on the other hand are more likely than heterosexual women to be obese in a study matching lesbian and heterosexual sisters lesbians had greater waist circumferences waisttohip ratios higher bodymass indices and more extensive weightcycling nonetheless they are more likely to exercise on a weekly basis indeed in a study that examined health behaviors over the adult life course by sexual identity lesbians under the age of 50 had increased odds of moderate activity and bisexual women had increased odds of muscle strengthening relative to their heterosexual counterparts diet and exercise as well as weight management are critical determinants of morbidity and mortality and thus should be examined in lgbt populations to understand the complex ways in which these behaviors and community norms interact to impact health in both positive and negative ways social processes which include the effects of interrelationships with others on health have been widely documented as hatzenbuehler and colleagues proposed discrimination and social exclusion lead to social isolation among lgbt individuals but for those who have developed strong social resources through their life course the negative impact of adverse experiences on health may be alleviated antonucci argues that social relations and networks are shaped through ones life course and differentiated by personal and social factors in the general population social network size and type influence health outcomes yet social networks differ between lgbt people and the general population lgbt people often develop families of choice extended networks of partners and friends with less reliance on legal or biological family members there is compelling evidence that social factors may increase social capital and that living in states that have higher concentrations of samesex couples may be a protective factor for health a large communitybased sample of new york city lgb adults found that community connectedness and integration is significantly related to wellbeing with bisexuals and young adults evidencing the lowest levels of integration into these communities interestingly a recent study suggests that social network size among lgbt adults may not be related to positive physical health outcomes more likely it is the quality and not the quantity of social contacts that is more important in terms of psychological and cognitive processes hatzenbuehlers psychological mediation framework identifies general and minorityspecific psychological processes that mediate the link between stressors and psychological health general psychological processes include positive processes such as problem solving and active coping as well as negative processes such as rumination and avoidant coping minorityspecific psychological processes identified by meyer include internalized homophobia expectations of rejection and identity concealment the negative impact of minority stressors such as discrimination and victimization on psychological processes has to be further investigated a certain extent of exposure to stressors related to disadvantaged social positions over the life course may help to develop stresscoping capacity because most lgbt people are not readily identifiable to others as such they manage the disclosure of their sexual and gender identity disclosure which is in part dependent upon the degree to which a stigmatized identity has been integrated increases opportunities to strengthen social relations and allows for association and interaction with other lgbt people whereas disclosure can expose an lgbt person to hostility from others maintaining a positive sexual identity has been associated with positive health outcomes whereas biological influences on health in the general population are documented they have seldom been investigated in lgbt research yet some biological processes may be particularly relevant in lgbt populations given the larger social context and history of marginalization for example the biological stress process is applicable to the proposed framework physiological responses to chronic stressors are important predictors of health for example allostatic load a physiological stressrelated mechanism linking the psychosocial environment to physiological dysregulations is associated with cardiovascular disease cancer infection cognitive decline accelerated aging and mortality it is important to note that al may be influenced by the other mechanisms in the proposed model for example positive behaviors such as exercise as well as adverse behaviors such as smoking and excessive drinking both influence although in different directions the physiological responses to chronic stressors still such biological influences on both positive and negative health among lgbt individuals have not been adequately investigated although a growing number of studies are assessing physiological responses to stressors among sexual minorities especially among those living with hiv disease implications for future lgbt health research policy and practice the specific framework used for understanding health outcomes influences the type and targets of interventions proposed grounded in the health equity promotion model we make several recommendations for the field research implications previous lgbt health disparity studies have mainly utilized deficitfocused models to understand poor health outcomes while existing research shows manifestations of resilience and good health among lgbt people investigating sexual and gender identityspecific strengths and resources are equally important in the effort to understand lgbt health it is essential that efforts consider the healthpromoting mechanisms such as human agency and resistance of lgbt people as we explore the opportunity to attain full health potential as krieger and colleagues asserted to advance health both human rights and the important roles of participation nondiscrimination transparency and accountability must be considered research simultaneously needs to explore the myriad ways in which multiple forms of social exclusion and marginalization interact with behavioral social and community psychological and biological factors at multiple levels to identify factors that foster or impede health equity to this end it is required that information regarding sexual and gender identity behavior and attraction be collected as is data on other sociodemographic characteristics that are known to influence health including age race ethnicity gender income education and many others both bisexual and transgender people are found to be vulnerable to poor health and their distinct needs must be considered further research needs to also examine their adaptation and resilience in the face of social exclusion furthermore research studies must incorporate lgbt individuals of varying social positions to examine the influence of the intersectionality of social positions on health for example the experiences of lgbt people of color and those of varying socioeconomic statuses are largely absent in existing research exploring potential effects of cumulative risks and resources over the life course across multiple social positions that can be simultaneously occupied by lgbt individuals will allow for a better understanding of the full range of health outcomes and resources and risks for the development of culturally responsive interventions multilevel methods that allow for analysis of structuralenvironmental contexts are necessary to fully understand lgbt health disparities current intervention efforts are often solely focused on the individual such as dup defend yourself for black men who have sex with men to promote condom use for hivsti prevention smoking cessation for lesbian and bisexual women and support groups for lgbt youth to protect against suicide in addition to these targeting larger systems including policy or other environmental and structural change initiatives may better promote health equity and lead to improved health outcomes to this end longitudinal studies currently sparse in lgbt research are necessary understanding individual trajectories and cohort variations in health within shifting structural and environmental contexts would help to articulate ways to promote health equity in addition it is important to recognize the potential tension between heterogeneous approaches given the diverse nature of these communities and the need for systemlevel changes which often assume more homogenous needs for example promoting calorie reduction may be helpful for weight control among sexual minority women but may be potentially harmful for sexual minority men if body image issues outweigh obesity concerns researchers must work to translate such findings into practice and use results to advocate for policy change policy implications several policy changes are needed to promote health equity including nondiscrimination laws in employment housing and public accommodations marriage equality and legislation to support nonkin caregivers sexual and gender identity need to be added as protected classes in an expansion of the 1964 civil rights act in 2012 the equal opportunity employment commission ruled that gender identity is protected under title vii of the 1964 civil rights act although federal agencies are increasingly ruling that sexual and gender identity fall under the prohibitions against discrimination based on sex and sexstereotyping the lack of uniform application makes enforcement challenging policies and politics play a significant role in promoting good health another important policy debate impacting the lives of people in samesex relationships is recognition of samesex unions though not all lgbt individuals would choose or desire to be married most recently the number of states in the united states that have legalized samesex marriage continues to grow at a rapid rate legal marriage can provide access to significant economic benefits for example through social security those married and who reside in states with legal samesex marriage have access to spousal and survivors benefits that until recently were not available to samesex couples it is important to recognize that many of the current policy advocacy efforts are primarily addressing the needs of lgbt people in committed relationships yet such policies do not adequately address the needs of lgbt people who are single in nontraditional relationships or partnered with no desire to become married thus it is critical that families of choice and nextofkin that are not partners or biological or legal family members are also considered in policy advocacy efforts for example extending paid leave laws to friends and other informal caregivers in alternative family structures is needed given that legal marriage may also result in divorce it will be equally important to examine how these legal changes shift the nature of helping relationships and social resources in these communities such as support provided by expartners and family of choice practice implications utilizing an equity perspective focusing on resilience and human agency by capitalizing on the benefits of lgbt communities can allow for social movement akin to how the lgbt community united against hiv for example it is imperative to increase attention to health behaviors both positive and adverse and their role in health outcomes intervention research is needed that increases proactive preventive behaviors such as targeted screenings to reduce risk for msm of color in terms of hivstis and high rates of smoking in lgbt youth and adults also utilizing community norms and behaviors such as interventions for diet and weight control based on popular opinion leaders to endorse behavior change may be an innovative way to take advantage of social capital life course perspectives highlighting rapidly changing social norms related to both sexual and gender identity raise important generational issues for future study for example will the lexicon used today including the term lgbt remain stable or even useful given increasingly supportive views among the general population and the embracing by younger generations of diverse sexual and gender identities to shift practice to promote health equity practitioners will need to assess their own overt and covert biases regarding lgbt people and understand how these as well as the lives of lgbt people have been and continue to be shaped by contested shifting sociocultural and historical discourses in addition practitioners must use their practice knowledge and commitment to social justice to advocate for policy change and equitable access to services policymakers also need to understand the ways in which policies have and continue to shape the larger social context and access to resources within society empirically based information is needed to help shape the discourse relative to policy development and implementation so that policymakers can make the most informed socially just decisions regarding the distribution of resources and their role in promoting health equity finally adopting a health equity framework has global and human rights implications a health equity perspective endorses social justice by highlighting the role of societal structures and human rights in health increasingly international human rights agreements include rights to health care and endorse accountability for the health and health policies of nations achievement of health equity requires empowering lgbt people and their allies to take action and address the environmental and structural resources and risks that influence their health health equity promotion model

national health initiatives emphasize the importance of eliminating health disparities among historically disadvantaged populations yet few studies have examined the range of health outcomes among lesbian gay bisexual and transgender lgbt people to stimulate more inclusive research in the area we present the health equity promotion modela framework oriented toward lgbt people reaching their full mental and physical health potential that considers both positive and adverse healthrelated circumstances the model highlights a heterogeneity and intersectionality within lgbt communities b the influence of structural and environmental context and c both healthpromoting and adverse pathways that encompass behavioral social psychological and biological processes it also expands upon earlier conceptualizations of sexual minority health by integrating a life course development perspective within the healthpromotion model by explicating the important role of agency and resilience as

introduction myocardial infarction and cardiovascular disease are prominent global health issues which also pose a major burden within the somali population the somali population encounters distinct obstacles as a result of the repercussions of armed conflict limited access to education and an underdeveloped healthcare infrastructure myocardial infarction commonly known as a heart attack is a critical medical condition characterized by the interruption of blood supply to a part of the heart muscle leading to the death of heart tissue it is a global health concern with significant variations in knowledge attitude and practices in different regions including africa and specifically somalia numerous researches have shed light on the significant frequency of cardiovascular risk factors within somali communities encompassing conditions such as diabetes hypertension and obesity 1 these identified risk variables are known to play a significant role in the pathogenesis of myocardial infarction and cardiovascular disease furthermore it has been observed that somali immigrants and refugees residing in the united states face an elevated susceptibility to obesity and associated cardiovascular health risks 2 this observation indicates the necessity of implementing specific interventions aimed at addressing these risk factors and enhancing cardiovascular wellbeing within the somali population while there is limited research specifically focused on mi in somalia studies conducted in other african countries and among somali diaspora populations provide valuable insights into the knowledge attitudes and practices regarding these conditions furthermore the prevalence of mi is unknown in somalia but is presumed to be high the influence of socioeconomic factors on the development and management of cardiovascular illnesses is of paramount importance research undertaken in the subsaharan african region encompassing adjacent nations such as ethiopia and tanzania has shed light on the influence of low socioeconomic level on cardiovascular risk factors and outcomes 34 understanding and managing cardiovascular illnesses requires a high level of health literacy for instance low health literacy has been linked to an increased risk of death in people with endstage renal disease 5 attitudes toward healthcare and preventative medicine also have an impact on the treatment of mi somali patients are less familiar with preventive healthcare practices and tend to seek medical attention only when they are sick 6 aside from individual knowledge attitude and practice the healthcare system is also important in preventing myocardial infarction the value of evidencebased preventative strategies is emphasized in guidelines for the management of acute myocardial infarction 7 this study aims to analyze knowledge attitudes and behaviors about myocardial infarction among mogadishu citizens focusing on socioeconomic issues and health literacy to address healthcare obstacles and improve cardiovascular health outcomes within the somali community methods and materials design and settings a crosssectional survey in the form of paperbased questionnaire was prepared for this study and used for data collection from 1 june to 31 august to examine somalia inhabitants perceptions attitudes and behaviors towards myocardial infarction a random sample of participants who arrived at our hospital mogadishu somali turkish training and research hospital for various reasons were referred to our cardiology clinic for the study they were greeted by a resident doctor consent was obtained and they were supported in understanding and answering the questions questionnaire the questionnaire utilized was similar to other myocardial infarction questionnaires it was however specifically created for our demographic the questionnaire was written in somali and the writing was clear and concise the process of creating the questionnaire began with the establishment of precise research goals pertaining to cardiovascular health within the community the selection of important variables was guided by a review of the literature the questionnaire was created using language that was considerate of cultural differences and underwent validity testing any problems with the clarity and cultural appropriateness of the questions were found and fixed in a pilot study with a diverse sample as a result the questionnaire is revised by giving the updated questionnaire to a subset of participants twice testretest reliability is guaranteed the final version is then utilized to collect data for the primary sample the data was collected and assisted by a resident doctor who was not involved with any patient care and the sample was random and was collected from participants who came our hospital for various reasons whether they had risk factors previous history of myocardial infarction or simply as a relative of a patient or those who came for a simple checkup everyone had an equal chance of being requested to participate for the study it takes around 7 minutes to complete the questions and any query or difficulty in comprehending was cleared by a resident doctor who assisted the patient at every step of the process questions included demographic data such as age weight height education level past medical data were also collected for instance diabetes or hypertension history and if there was any previous myocardial infarction knowledge attitude and practice questions were answered similarly with a binary yes or no and each response was scored 1 and 0 respectively in order to assess the reliability of the questionnaire it was subjected to a pretesting process including a randomly selected sample no notable languagerelated challenges were found throughout this procedure statistical analysis the study employed ibm spss 24 for windows for continuous variables descriptive statistics were reported as mean ± standard deviation while for other variables frequencies were employed the scores of the participants pertaining to knowledge attitudes and beliefs were presented and analyzed the highest attainable scores for knowledge attitude and practice were 22 9 and 7 correspondingly moreover the overall knowledge attitude and practice scores was categorized into two distinct groups for example knowledge was considered to be sufficient for any result above 11 while 11 or less was considered insufficient knowledge furthermore for attitude and practice we similarly scored them into two categories 5 and less was considered poor attitude while above was assigned as good attitude for practice scores 4 and less were considered inadequate practice in contrast scores above were acknowledged as adequate practice associations between knowledge attitude and practice with variable sociodemographic and health characteristics were assessed using logistic regression for every analysis we employed p 005 to establish statistical significance ethical consideration due to the fact that our hospital is a research hospital an informed consent is obtained from every patient before giving them the questionnaire and assisting them in answering the questions this study did not disclose any personal information the study was approved by the research ethics committee of mogadishu somali turkey training and research hospital the study was performed in line with the principles of the declaration of helsinki results sociodemographic features in this study the data collected from 313 participants in the hospital for various reasons regarding their perceptions attitudes and responses towards myocardial infarction were analyzed the mean age was 42 ±19 years of age one hundred and seventy patient of the subjects were male and 143 were female hypertension was the most common comorbidity in these subjects 64 followed by dyslipidemia 41 and diabetes 36 more than half of the respondents 163 did not have formal education only 12 had smoking history and 14 had regular practice of khat chewing the mean weight of patients was 68±27 kg eighteen of the respondents had previous history of myocardial infarction knowledge results the mean knowledge score of the participants was 1107 ± 0697 with a maximum score of 22 it was discovered that n167 5335 of respondents did not know enough about myocardial infarction using the cutoff criteria out of those surveyed 172 said that a clotinduced arterial blockage was the reason behind the myocardial infarction similarly 187 participants or 597 acknowledged that mi may be lethal additionally over 50 of the participants were aware that mi typically manifests as chest pain only 131 were aware that mi might occasionally manifest without chest pain only 153 141 and 141 of the respondentsor fewer than halfidentified hypertension diabetes and dyslipidemia as risk factors for mi when questioned about their potential contributions sedentary lifestyle was identified as a risk factor by 129 and obesity by 137 moreover the majority of participants did not regard weight attitude results the mean attitude score of the respondents was 5086±03756 using cutoff criteria a slight majority of the patient showed favorable attitude almost 168 said they could recognize the symptoms of myocardial infarction in contrast only 144 said they can recognize it in others furthermore 154 believed mi is unpreventable while 201 said they will accept a mi diagnose from a doctor lastly 202 said they are ready to do whatever it takes to lower their risk of myocardial infarction practice results the practice score average was 3463259±0352 majority of the patient had inadequate practice and behavior according to the cutoff score 168 of the respondents did not practice regularly or engage in any kind of sport only 119 of those questioned did not regularly check their blood pressure sugar level or their cholesterol level majority of the patient did not also control their salt sugar and fatty food intake noticeably out of those who had diabetes and hypertension or dyslipidemia more than 75 of them did not comply with their medications factors related to myocardial infarction knowledge attitudes and practices in a logistic regression the following predicator variables such as age gender educational status and a history of diabetes hypertension and dyslipidemia were input as variables against the knowledge attitude and practice scores to be analyzed with the exception of one group however we did not find any significant associations between the various variables and the level of knowledge it was discovered that participants who were male and had not received any formal education had a higher probability of having a lower knowledge unfavorable attitude and inadequate practice level dovepress discussion in this discussion we will compare mogadishus citizens understanding attitudes and practices around mi with those of other parts of africa and the globe we will also investigate the causes of the differences and provide potential solutions numerous researches have looked at various groups knowledge attitudes and practices about mi for instance research carried out in tanzania discovered that just a small percentage of people there believed they were at risk of mi and that everyone knew very little about the diseases symptoms 8 this result was similar to our population findings the prevalence of mi is rising throughout africa 9 however a study that was carried out in three nationsthe united states australia and new zealandreported similar findings with 56 of participants knowing enough about acs symptoms 10 moreover mi cases are rising in south africa which many considers the most developed country in africa 11 these data show that improved mi prevention education and management strategies are required in africa the relationship between health literacy and the management and prevention of cardiovascular disease is one crucial factor the scientific statement released by the american heart association highlights the basic need of health literacy for both primary and secondary cardiovascular disease prevention 12 another study also demonstrated that health literacy is connected to healthy behaviors and selfreported health in people with cardiovascular disease which further validates this 13 these studies emphasize how critical it is to raise health literacy in order to increase understanding and encourage healthy habits related to mi somalia is believed to have a low health literacy due to years of civil war and poverty according to a comprehensive review and metaanalysis by attitudes toward myocardial infarction have also been demonstrated to predict attendance at cardiac rehabilitation after an acute myocardial infarction 14 a small majority of our patients showed a favorable attitude towards myocardial infarction this may be due to a popular perception that heart attack is deadly acute condition in somali culture for instance patients perceptions of their myocardial infarction can differ according to a study by some consider it to be an acute heart attack instead of a sign of a longterm illness 15 effective management of myocardial infarction necessitates a thorough understanding of and implementation of preventative techniques 16 diabetes mellitus hypertension dyslipidemia and metabolic syndrome are risk factors for myocardial infarction 1718 based on the cutoff score most of our patients exhibited inadequate conduct and practice 536 of the respondents or 168 people said they did not play any sport or exercised on a regular basis improvements in lifestyle such as frequent exercise and physical activity are essential for preventing cardiovascular disease physical activity has demonstrated benefits for cardiovascular wellbeing and can lower the risk of atherosclerotic cardiovascular disease 19 furthermore most of the patients with chronic diseases did not comply with their medications in contrast to seventy percent of hypertensive people in a tshwane south africa research reported complying with treatment while more than 80 of our hypertensive patients did not comply 20 it is important to think about the effects of telemedicine mobile technologybased lifestyle in order to improve knowledge and practice people have seen telemedicine as a possible way to improve health care and practice especially for people with heart diseases 21 the use of mobile technology and smart devices has shown promise in changing the way people with a high risk of heart disease live providing a practical way to enhance patient outcomes these mobile technologies offer a way in which many people with the disease risk factors or relatives of these groups can be educated 22 moreover the internet provides a vast and extensive platform to access an audience of individuals who may have been previously deemed hard to reach sharing articles and videos about myocardial infarction can enhance understanding and influence behaviors related to this serious condition nevertheless deceptive information can also be spread online 23 to summarize effectively addressing knowledge about myocardial infarction in mogadishu necessitates implementing customized interventions that take into account cultural subtleties it is crucial to utilize health literacy and technology to develop efficient strategies for prevention and management limitations of our study in our study we faced several limitations first there may be a limit due to the sample size and representativeness our study may not have included a representative and varied sample of the somali population due to restricted access which could have resulted in selection bias second response bias is introduced by our data collection methods such as surveys and interviews as participants may give socially acceptable replies this could result in an underestimating of bad dovepress vascular health and risk management 202420 practices or an overestimation of knowledge and positive attitudes another issue with selfreported data is the potential for recollection or social desirability biases which could skew the responses and effect data quality finally the breadth of our study may be constrained by a lack of funding and time which could have an impact on the number of participants or data collection locations conclusion in conclusion our research highlights the serious gaps in the somali community of mogadishus knowledge attitudes and practices surrounding myocardial infarction to improve cardiovascular health awareness and management the results highlight the critical need for focused health education enhanced primary care and community involvement in order to close these gaps and guarantee that prompt and efficient interventions result in a healthier and betterinformed somali population policymakers and healthcare professionals must work together this will eventually lessen the incidence of mi in the area disclosure the authors report no conflicts of interest in this work

myocardial infarction and cardiovascular disease are significant global health issues particularly in somalia the somali population faces challenges due to armed conflict limited education and underdeveloped healthcare infrastructure cardiovascular risk factors like diabetes hypertension and obesity are prevalent and somali people face increased susceptibility methods this study examined somalia residents perceptions attitudes and behaviors towards myocardial infarction using a crosssectional paperbased questionnaire the sample consisted of 313 urban residents in mogadishu aged 20 and above the questionnaire was written in somali and was designed for the demographic knowledge attitude and practice scores were categorized into two groups with associations between knowledge attitude and practice with sociodemographic and health characteristics assessed using logistic regression results this study analyzed data from a random sample of participants who arrived at the hospital for various reasons regarding their perceptions attitudes and responses towards myocardial infarction the mean age was 42 ±19 years with 54 being male and 46 female hypertension was the most common comorbidity followed by dyslipidemia and diabetes over half of the respondents had no formal education and only 38 had a smoking history about 57 had a previous history of myocardial infarction the mean knowledge score was 1107 ± 0697 with 5335 of respondents not knowing enough about myocardial infarction the majority of the patients showed a favorable attitude but only a slight majority could recognize symptoms of myocardial infarction the majority of the patients had inadequate practice and behavior with 536 not practicing regularly or engaging in sportsthe research highlights gaps in mogadishus somali communitys knowledge and practices regarding myocardial infarction it emphasizes the need for health education primary care and community involvement to improve cardiovascular health awareness and reduce mi incidence

introduction among the regions of the globe africa is such a peculiar region with existential difference in the midst of the multitude of nations regions races and what have you this is evidence in the location of the continent the uniqueness of the race the natural resources as well as human capital distinguishing the region across histories by way of comparison among the so called developing nations it is only in africa that the american and european imperialistic institutions have found reliable human capital for sustainable development throughout the era of initial contact slavery and even the modern slavery which is currently ravaging africa in form of looking for greener pastures overseas through the hypocritical visa lottery work permit japa and all the likes this is also applicable in the distribution of natural resources which are mainly located across africa but are being exploited with impunity by the american and european league of imperialists this article explores these issues in the context of social work and development in africa africa an overview africa as a continent is home to more than 30 of the world mineral reserves more than 8 of the world natural gas and more than 12 of world oil reserves the continent has more than 40 of the global gold and 90 of chromium and platinum 90 of the world cobalt 60 of the world coffee 70 of the worlds cocoa etc according to saifaddin galal the population of africa is clocking 14billion with majority of the population being youths who are potential labour force and human capital for sustainable development according to the ilo africa is the largest supplier of labour to america europe china canada etc via migration this included in the health sector financial sector industrial sector as well as services sector according to world population review africa has the highest number of member nations in the united nations geographically africa is located within the tropic of cancer and that of capricorn with moderate weather and structural base devoid of frequent natural disasters in any case africa is naturally endowed for all round sustainability however the story about africa on the intercontinental scene is totally opposite of its natural appearance for instance statistics shows that africa has the largest chunk of the developing nations in the world africa is one of the continents permanently marked with poverty and backwardness africa is currently the destination of the majority of the global aid offering coming from europe america and even other emerging economies from asia latin america oceania and caribbean africa from the north to the south and from the east to the central and the west is all characterized by corruption political instability conflicts and poverty even in the midst of multiple natural resources and the huge donations from overseas although in the recent history the world extant bodies have made some claims of liberating individuals tribes ethnic groups race and nations from the domination and abuse by other superior individuals and groups the african case is certainly different and most certainly africa seems to be out of such claims if at all it is obtainable anywhere in the world the principle of the survival of the fittest and individualistic tendencies which ravaged the european world and spilled over to america in the earlier centuries seems to be holding down the global community especially after such found expression without challenge in the african continent via empire conquest slavery merchandise colonialism and the subsequent neocolonialism the principle of the survival of the fittest and individualistic tendency which found expression in the african continent through conquest for empire slavery merchandise colonialism and the current neocolonialism eventually created a sustainable generational attack on the overall system of the african continent leaving the system with a pathological abnormality in durkheims parlance which subsequently gained acceptance in the circle of social scientists and humanity studies pathological society or system is marked by some characteristics of ill health in connection with the clinical terminologies of health this is identifiable through social indicators of abnormality in the social institutions of the society such as family economy education religion culture politicsgovernance and their ineffectiveness in dealing with the overall needs of the society itself and the members of the society pathological system or society as can be observed currently in africa is characterized by failure of the system to meet the needs of the human elements in the system abnormal functioning of the components of the system autoimmune crises such as human elements in the system becoming a tool to destroy the system itself dependency instead of selfsustainability degeneration instead of regeneration and other characteristics of ill health pathological condition is a symptom of pathogen attack on the system which compromises the ability of the system to continue in a sustainable health in the case of africa colonialism and neocolonialism have remained the major pathogens sustainably attacking the system and leaving the system in a pathological condition over the years and following consistent observations the case of africa seems to have defied every cure and healing strategies attempted so far due to deep rooted infection and crossinfections through the institutionalised colonialism and neocolonialism which have operated covertly over the years and evaded the comprehension of the african nations and their leaders however the growing interest by african indigenous researchers who appreciates home grown methodological approaches in the recent times has unveiled the possibilities of healing the african system through the customization of academic disciplines as well as other social institution as trajectory of institutionalizing decolonization for effective and innovative outcome as such the possibility of healing africa from her current pathological condition as a result of deeprooted colonial and neocolonial infections is in sight with the promising power and engagement of african social scientists and social workers in particular who are more deeply involved in all aspects of social institutions and areas of life in african system the aforementioned is the focus of this paper african pathological condition pathological condition in clinical terms is observable disposition of a living thing showing unhealthy condition as a result of infection and the consequent diseases and decay in health and wellbeing in social scientific parlance this is a social condition showing the malfunctioning of the social institutions resulting to the general decay of the system and underdevelopment with daring impacts on the members of the society in question africa in history and the present historical epoch is in pathological condition and the symptoms of these conditions are observable in her different social institutions and socioeconomic life according to world bank africa is the destination of global poverty with majority of the global poor living in african countries despite the arrays of natural and human resources africa is the destination of the countries with the poorest public institutions in terms of provision of basic services to her population despite supplying the world with labour in various sectors this is visible in the health sector the economic sector educational sector leadership and services sectors africa is the most underrepresented continent in the united nations in terms of her interests and challenges in the current history despite having the highest number of membership in the organization across the global continents africa is the destination of the group of high ranking corrupt nations political instability religious crises high capital flights to europe america and asia as well as students and labour migration out of the continent africa in the current historical epoch exhibits all the symptoms and characteristics of what durkheim called a pathological society these ranges from the economy to the political system and the various public institutions established to manage the complex networks of human needs in the society the symptoms of pathological condition of the african nations can be captured in the social indicators of the basic human needs which are connected with the institutional structural existence of the states and regions for instance in the health sector virtually all african nations cannot boast of sustainable healthcare for the citizens especially in connection with the basic human health needs and emerging health complications yet the same african nations are the pool of human resources for the european american and eurasian health institutions worst still most of the basic pharmaceutical and health products sustaining the overseas health industries are obtained from africa however africa still remain the destination for substandard drugs and equally experience scarcity of pharmaceutical products a statistical irony about africa presently is that africa is the major pool for human resources for europe america and eurasian health institutions but is classified as one of the worst regions in terms of healthworkerspatients ratio population density majority of african indigenous health workers trained domestically and overseas end up serving in the american european and eurasian health institutions following the perceived poor service condition at home and other envisaged discomforts within the economy of virtually all african nations the principle of the more you look the less you see seems to be overriding the system following the corrupted structures either inherited from the colonialists or induced by the neocolonialists virtually all african nations have not less than 5 mineral resources serving the needs of the global communities and being exploited from overseas however the same african nations are on the top lists of nations depending on the britten wood institutions for survival via borrowing and aid from north africa to south africa and from east africa to central and west africa virtually all the nations within these regions are under different borrowing formula and aid assistance from the britten wood institutions united nations allied bodies and different colonialists and neocolonialist exploiters these borrowing and aids are systematically conditioned to enslave the economy of the receiving nations to the givers continue without end and sustain intergenerational domination of the economy of the receivers and these borrowing and aids by the former colonialists and neocolonialists are operating in virtually all the african countries currently in any case virtually all the economies of african nations are sick and struggling politically across african nations no nation can boldly make an independent policy from the united nations allied bodies and the league of colonialists and neocolonialists without being reprimanded the leaders of african nations are technically stooges of the colonialists and neocolonialists hiding under the cloak of britten wood institutions and the compromised united nations and her allied bodies this is exhibited in the continuous and widespread antiafrican socioeconomic policies by the leaders under the yoke of united nations globalization agenda covertly sustaining the interests of the former colonialists and neocolonialists interests across african nations the former colonialists and neocolonialists technically undermined by the united nations exploitation agenda are now using aids allies and diplomatic smokescreen to penetrate and influence socioeconomic policies among the vulnerable african nations all the public institutions established among the african nations such as education banking public health institution commerce and industries culture and public orientations etc are all patterned to accommodate and please the european american and eurasian colonialists and neocolonialists the pathogens of colonialism and neocolonialism in african system following the pattern through which colonialism and neocolonialism were institutionalised among african nations the lifestyle of the subsequent generations has been automatically sequenced to build on the faulty foundations of the colonialists and neocolonialists ostensibly designed to keep africa in perpetual dependence on the european american and asian nations while africans are being exploited this has resulted to selfhatred among the indigenous population of africa due to comparison with the colonialists and neocolonialists values african nations depending on the britten wood institutions for borrowing and economic aids africa building her socioeconomic policies around the colonialists and neocolonialists socioeconomic models maintaining public institutions that have no relevance to the indigenous people but aspires to meet the colonialists and neocolonialists global standard and political leaders in africa being handpicked by the colonialists and neocolonialists to represent their interest against the overall interests of the indigenous population by 14 th century the seed of colonialism and the subsequent neocolonialism had begun to germinate in the african region of the neoglobal map this began with the empire conquest and natural resources colony in proxy by the european nations such as spain portugal italy and britain who were exploring the world for natural and human resources for the emerging industrialization that has greeted the world via the european and american economies who have made breakthrough against the hitherto agrarian society and mechanical society as part of the enterprise of the american and european league of exploiters in legitimizing illegitimacy when it is a sure way of continuing unfriendly capitalistic tendency the proxy conquest and resources colony was graduated into full blown macro scale system of exploitation first as slave trade which received acceptance among the majority participating in the business in europe and america and latter into colonialism approved and accredited by the european league of nations the principle of the survival of the fittest which has become a norm among the european and american league of nations seems to have permanently guided every intra and international relationship they have maintained it was only a matter of compromising the image and intention of the activities involved in the relationship to capture whichever victim they came across as such the capitalistic tendency that pushed these nations to seek for materials and resources elsewhere compelled them to see the african nations at each stage as ripe for exploitation but by different strategies and approaches for instance during the era of conquest for empire and slave trade they simply appeared as helping the trapped victims with rejected products in the european and american markets as well as protecting the trapped population from the pseudo war they have invented this superficial view of the initial contact was soon contradicted by the subsequent impunity with which they exploited the populations including the local leaders who ignorantly entered into alliance with them against their subjects after the era of proxy conquest for empire and slave trade bowed to the prevailing moral pressure emanating from the selfinflicted injury the european and american did to themselves by activating the canon of human right consciousness colonialism which officially received the blessings of the european league of nations in 1884 in germany began to take off the stage in the disguise of civilization and protection of the vulnerable and already trapped african territories europeans having encountered resistance at the earlier stage of the colonial conquest while using force and weapons changed the strategy into deception of the population with the greek foil of friendship and civilization ostensibly to compromise the social psychology of the population to ignore the inherent dangers of selfenslavement orchestrated by the colonialists as such the policy of assimilation and that of association were introduced to eventually make the population vulnerable to selfhatred a situation that graduated to auto rejection and autoimmune among the african population till date colonialism itself was institutionalized via the social institutions public institutions and public orientations such that every aspect of african existence bowed to the infection of colonialism for instance the indigenous concept of security was transformed to modern institution so that the indigenous people were recruited to protect the interest of the colonialists the indigenous concept of family was transformed to the colonialists home grown family ideology promoting individualism and segregation in the communities indigenous concept of leadership was corrupted to promote the colonialists slave master ideology capable of sustaining the interest of the colonialists long after they have left the system cultural orientation was corrupted with the quest to promote the colonialist culture and self hatred among the colonized public orientation generally became a tool for the colonialists to subject the colonized to perpetual servantship to the colonialist system etc the neocolonialism enterprise took the trajectory of institutionalised colonialism but with slight changes to adjust into the system that has been tensed by the agitation against the colonialist after colonialism got superseded by the prevailing moral order in the historical epoch while the league of colonialists was within the wall of european nations the web of neocolonialists included the former colonialists covertly maintaining their domination over their former colonies and new entrants into the business of exploitation of the african and other nations who covertly used economic aids and other covert strategies to lure and tie down the vulnerable african nations social work as social health institution and social workers as social health workers social work as a profession and discipline emerged as reaction or rather counter measure to the observed and envisaged social dilapidated condition of the time in europe and america while the social dilapidated condition is perceived as a social scientific concept to capture the abnormality in the society affecting the population the social indicators were the visible suffering of the population in different areas of life as such social workers corporate social responsibilities which culminated into social work profession and specialized disciplines was the invention of the necessity of assistance to the poor masses lacking access to the basic social support and available resources for survival social work by its appearance in all areas of the socioeconomic life of the society can best be captured as social health institution with much emphasis on its responsibility in dealing with the pathological condition of the society while the pathological condition of the society exhibits the symptoms of diseases in different aspects of the societal life social work as social health institution appears as multifaceted institution specializing in dealing with the different diseases dealing with the society itself clinically there are different health condition and dimensions of health which warrant specializations in the medical profession this situation is obtainable in the social system warranting the different specializations in social work which deal with different issues in the society affecting the social wellbeing of the human beings in the society in the social scientific parlance the different challenges faced by the poor masses in the society which prompted the activities of the social workers are all social health issues requiring some professional training and understanding to deal with them in other to bring about social wellbeing for the population social work specializations which are numerous such as in the areas of management advocacy policy and planning public welfare social justice leadership etc are typically designed to bring solution and ensure wellbeing of the population in these different dimensions of human existence these different dimensions of human existence are supposedly social indicators of wellness and social pathology which required social health specialists to bring about wellness of the population this goes with the problem of colonialism and neocolonialism which are developmental and policy crises dealing with the african system in the current historical epoch while colonialism and neocolonialism are diseases and pathogens that have infected and continued to deal with the african system the symptoms are the indices of underdevelopment and system degeneration which we have continued to observe experience and complain about these are health and pathological conditions waiting for the social work health institution in the current history of africa social work came as a healing service to humanity but started mostly as affairs for the poor however with time the realities of the essence of social work services for the vulnerable such as the african population has gradually emerged as the specialization in the social work profession has begun to explore the strategic areas of african vulnerabilities before the league of global imperialists social work as social health institution implies that the activities of the social workers are geared towards healing the society from different diseases and health conditions including pathological condition as africa found herself currently the healing of africa from colonialism and neocolonialism can be achieved through the specializations in social work profession which tally with the different areas of african colonial and neocolonial problems such as in the areas of educating the youth public policy leadership social justice monitoring and management of foreign aid and the likes institutionalizing decolonization in africa the expected surgical intervention by the social workers unusual disease cannot be cured by everyday medicine colonialism and neocolonialism are not common developmental problems which the theory of sustainable development by the united nations can deal with owing to the fact that the phenomenon of colonialism and neocolonialism were properly designed perhaps by the same league of nations who designed the theory and agenda of sustainable development colonialism and neocolonialism were perfectly institutionalised to capture every aspect of african existence for continuous bondage from generation to generation as such there is a need to set up a counter institutional process to reverse the domination and manipulation of colonial and neocolonial imperialistic activities social work as social health institution is perfectly positioned to do this in africa decolonization agenda is more complex in application than they appear in concept and assumptions owing to the high level of intelligence behind the colonization and neocolonization processes colonialism and the subsequent neocolonialism did not just appear in african system and started ruining the system without a coordinated and high intelligent works by the colonizers and the neocolonizers who designed the game beginning from the era of conquest for empires to that of slave trade colonialism and the current neocolonialism strategies they were carefully crafted system of imperialistic mission with multiple dimensions to capture african population virtually in all dimensions of life while some of the dimensions of this imperialistic agenda were imported from the colonialists territory others were developed in the field of imperialistic mission following the principle of necessity is the mother of invention in any case the colonialists and the neocolonialists applied inductive and deductive strategies in managing their imperialistic mission in africa however the most complicated level of the colonialists and neocolonialists operation in africa was the institutionalisation of colonialism and neocolonialism in africa institutionalisation of colonialism and neocolonialism in african system followed certain processes and trajectories to capture and eventually enslaved the entire african societal system including the noncolonized territories who eventually were captured in the ongoing neocolonialism agenda the processes included the basic learning processes such as capturing of the attention of the population imbuilding the colonialists covert agenda in the memory of the population subversion of the indigenous languages for the colonialist and neocolonialists languages elevating the colonialists and neocolonialists logical order in the life pattern of the population subjecting the colonized and neocolonized to the writing pattern of the colonialists and the neocolonialists as well as enslaving the thought pattern of the colonized into the colonialists and neocolonialists agenda these basic learning processes are naturally occurring but are vulnerable to whoever wants to manipulate them for whatever agenda such that through these processes one can develop a population or a generation that will destroy itself in ignorance the colonialists and the neocolonialists utilized these learning processes to gradually and steadily enslave the african system to make a way for their imperialistic agenda in the socioeconomic life of the population they utilized the two major institutional and quasiinstitutional trajectories to actualize this among the african population during the colonial period and the ongoing neocolonial historical epoch these trajectories included the educational institution and the public orientation institutions such as the public media work situation orientation career orientation religion and other tertiary orientation avenues among the population through these trajectories the colonialists and the neocolonialists eventually developed an army of ignoramus who deliberately sustained the colonialists and neocolonialists agenda regardless of the disastrous consequences of the agenda on their side this system of colonialists and neocolonialists institutionalization of their imperialistic merchandise has lasted beyond the initiators and become a regular thing that has replicated the population of pro colonialists and neocolonialists interests in african system having observed the colonialism and neocolonialism as pathogens and diseases in the african system and how these pathogens and diseases found their way into the system there is a need for sustainable strategies by the social health workers to heal the system the surgical intervention by the social workers in dealing with the current pathological condition of african system as social health workers begins with the understanding of the processes and sustainable factors of colonialism and neocolonialism and how to reverse these factors in the system however for sustainable effects whatever workable strategies to be adopted they must be institutionalized institutionalisation of decolonization is the process of regularizing sustainable strategies in public counter measures against colonial and neocolonial orientations among the victims of colonialism and neocolonialism the surgical intervention by the social workers as social health workers in healing the african system from its present pathological condition spans across the areas of specializations in social work discipline in any case social workers can use their professional specializations which touch all social institutions of the society and virtually all aspects of life to penetrate and sanitize the african system these include the creating of avenue and establishment of sustainable educational program within the educational institutions to regularize counter colonial and neocolonial orientation among the youth and the users of educational resources and services among african population capturing the public orientation institutions such as public media career orientation process work situation etc through advocacy to sustainably reverse the thought logic of colonialism and neocolonialism among the population penetrating the policy initiation and implementation processes with afrocentric orientation and counter colonialists and neocolonialists orientations building and popularising teams of afrocentric leaders at various levels of leaderships among the new generation leaders in order to phase off the already muddled leadership system in africa capturing and reversing micro and macro scales foreign aids from colonialist and neocolonialist intension into indigenous african resources for genuine and sustainable development activities conclusion the african system captured as the social economic cultural and political lives of the african nations has been subjected to sustainable attacks by the so called developed nations and even emerging economies in a manner best understood and expressed in this paper as pathogen attacks resulting to pathological condition these attacks have basically come from the league of the former colonialists and neocolonialists who covertly entrench themselves into the systems of the african nations via britten wood institutions economic aids and vertical bilateral relationships with the vulnerable african nations over a century scholars political elites and even the common masses have tried in different times strategies and dimensions to liberate african nations from this illicit engagement however there has been some level of complications invariably making it difficult to ordinarily deal with the situation the complications have virtually hanged on the fact that the whole issue of colonialism and neocolonialism was a system institutionalised beyond one individual group or nation but operated across regions time and fluidly interwoven with the life system of the colonized and the neocolonized meanwhile unusual disease can only be cured by unusual medicine this is applicable to the current condition of the african nations the unusual medicine for the pathological condition of the african system is domicile with the social workers who are exceptional in dealing with social problem social workers are perfectly positioned with their strategic relationship with the poor mass across african nations who are in the majority of the population analysis of african existence and also are more vulnerable to the impact of colonialism and neocolonialism this they can achieve exploiting the multidimensional approach to societal social wellbeing captured in the specializations in social work profession

africa conceptually geographically politically economically religiously and socially is in bondage and this bondage is summarized as pathological condition the pathological condition of africa is the outcome of cumulative of the attacks by the empire builders slave traders colonialists and the neocolonialists the attacks and their consequences on the african system have resulted to the continuous failure of the socioeconomic political and institutional lives of the african system with such symptoms and social indicators like political dependence on the colonialists and neocolonialists dependence on foreign economic aids and borrowing galore social segregation and selfhatred among the african population modern slavery by willingness political instability religious exploitation etc over the years scholars political elites and other categories among african population have tried to deal with the pathological condition of the african nations however the situation seems to have defied every strategy this defiance of the pathological condition of the african nations to almost every effort to reverse it lie in the way and manner the adventure of colonialism and neocolonialism was designed and implemented colonialism and neocolonialism were institutionalised and eventually sustained using the indigenous population as such decolonization can only be successful if it is institutionalised and operated by the elite class with deep knowledge of the problem and deep relationship with the african population hence the social workers with their multidimensional discipline and profession as well as deep interaction with the population are strategically handy in mounting and sustaining decolonization agenda in the 21st century africa the aforementioned is the focus and interest of this paper

introduction studies of culture change have paid attention to the change in the level of national values but few studies have been conducted on the relationship between the change and health of residents we argue that change in the sociodemographic conditions would undermine individuals psychological health because whereas human wellbeing is a function of habituated behavioral tendencies fitted best to accustomed context change will bring alterations to the requirements of the external environment we believe such process is apparent across national boarders in this study we focus on the typical case of sociodemographic change which took place in japan after the economic crisis known as the collapse of the bubble economy 1 japan has witnessed increasing societal problems and this has led to investigations on the relationship between culture change and health in this study we take the perspective that japanese culture especially its sociodemographic context is becoming more nontraditional and the change in context from 1990 to 2010the two decades of extremely low rate of new employment opportunities spread of new liberalism and market 1 a surge in the market caused by speculation regarding a commodity which results in an explosion of activity in that market causing vastly over inflated prices the prices are not sustainable and a bubble is usually followed by a crash in the affected sector in the japanese case land prices first inflated and then crashed globalization would negatively explain the health of japanese adults the worldwide tide of change the world shift toward gesellshaft or sociodemographic condition common in individualistic societies is one of the largest contextual changes surrounding recent human ecology starting from economically developed countries urban population internet users one person households divorce and national affluence are increasing throughout the world conceptually we regard these changes as indicating the change toward increased gesellshaft sociodemographic condition figure 1 shows a world summary of the changes summarized from the database of oecd united nations economic commission for europe and world bank from 1990 to 20102 across the nine indicators average ecological correlation with time was r 094 suggesting that these variables are changing worldwide with time the change stimulated national development in many countries fulfilling our needs of the modern life style however during the same period many developed countries have also been caught up in waves of recession leading to disparity in the population during this period worldwide economic stagnation occurred in east asian countries in early 1990s and in european countries during the late 2000s there were some serious health consequences for marginalized group such as unemployed uneducated or poor individuals during the time however economic turmoil may also affect the health of population at large via the change in peoples sociodemographic conditions psychological consequences of change historically the sociodemographic change toward gesellshaft secured free market and wealth leading to material possession and happiness however since sociodemographic change by definition takes place first in the external environment it always precedes psychological change because human cultural adaptation is built even at the level of automatic behaviors learned in accustomed daily activities change in the sociodemographic context would impose an implicit challenge to the efficiency of acquired pattern of behaviors if acquired behaviors were rendered useless to pursue valued goals in life our wellbeing would be compromised in other words our health is usually sustained by the culture we live in diener draguns andtanakamatsumi andtriandis but for this very reason sociodemographic change undermining the original can cause mental health problems in the population by creating unaccustomed mandates if the transition had been carried out smoothly involving wellstructured institutions and formal education that supports people to catch up with the new requirements the change into gesellshaft socioeconomic condition may foster independence and also preserve healthy social relations however when the transition is rapid imminent allowing no choice but to engage in global competition to survive general population would fail to adapt further if the original culture was encouraging interdependent ways of life rapid change into gesellshaft sociodemographic condition might require extra mental effort for the residents possible disadvantages due to such change may range from psychological to social aspects of their health specifically their general health might be compromised because their working conditions become worse in response to economic stagnation during this period fulltime employees were required to oblige by meeting an intensified workload and they faced a doubled unemployment rate their life satisfaction might be lowered because subjective wellbeing can be compromised when valued life domains fail to satisfy individuals due to economic turmoil if rapid change requires the members to be alone and exercise new selfways to be accepted change might compromise ones selfworth or the fundamental motivation to belong and ones achievementacceptance of socially desirable self perceived social support might also be compromised as change may increase ones need to relocate and be mobile in the new context isolated from supportive others ones perceived social support may decline in east asian countries the outcome of the change has been observed as a decrease in average psychological health for example in japan people have traditionally regarded interpersonal harmony as their central meaning of happiness now they have to leave their close families elder parent or friends in order to attain new position or decent job sometimes they are involved in an aggressive competition or candid quarrel against their colleagues in order to compete for status and limited wage otherwise they may give up making new family out of inflated partner choice and economicbusiness reasons these events might increase the likelihood of interpersonal concerns or disharmony especially for those having interdependent self the change might undermine their wellbeing or severely limit the fulfillment of the motivation to belong given these disadvantages stemming from the glitch at sociodemographic level some people may survive the influence using specific forms of positive strength as one of such strengths we focused on interdependent happiness3 interdependent happiness is a collectively shared concept of happiness among the members of interdependent cultures according to the previous studies japanese compared to european american counterparts share the meaning of happiness as relational whereas this type of happiness is held central to the subjective concept of happiness among certain cultural members the conception of happiness as relational is considered common across all human being because interdependent happiness involves relational harmony quiescence and ordinariness these positive meanings would be more central to residents wellbeing in the gemeinshaft societal condition if the change is an avalanche toward gesellshaft sociodemographic condition then the traditional interdependent happiness would be a positive buffer against the trend therefore among the traditionally gemeinschaft societal members the strength of preserving harmony among close others may find the negative influence of change particularly in japanese case interdependent happiness will predict health positively while the change will not aftermath of recession in japan during the 1990s japanese companies faced a collapse of the collectivistic working style together with the collapse of the real estate bubble economy in the workplace companies abandoned the lifetime employment and seniority system in exchange for thrift management4 the push for globalizing economy transparency international competition and global communication increased even after 2000 the aftermath of this decade and further economic depression delayed japans economic recovery even more tragic was the fact that although such change was apparent formal education continued to encourage generalists allarounders capable of managing multiple roles in a single company thus best functional under the longlasting employment system 5 and the major companies preferred naïve freshmen over slightly older professionals as their main labor force coinciding with such tension was an increase in health problems the decades after 1990s are marked as a time when japan showed unprecedented deterioration in mental health statistics following the bubble collapse over 30000 workers per year committed suicide specifically the suicide rate of working men in their 30s and 50s increased the number of outpatients diagnosed with mood disorders doubled between 1990 and 2010 the number of working adults suffering from depression increased with more people suffering from depression than cancer or diabetes from the late 1990s to 2010 applications for insurance compensation to workers were dominated by requests from patients with mental disorders and industrial safety and health issues became focused on regulating overwork given this situation the ministry of health labor and welfare listed mental disorders as one of the big five diseases among japanese adults in 20116 the decades after 1990 were a time when the lack of fit between traditional interdependence and the requirements of the new liberal global economic individualistic environment became apparent with critical consequences for japanese health kitanaka vividly portrays these adverse psychological profiles of japanese workers and a society in distress through narrative data hypothesis what are the psychological consequences of economic stagnation accompanying demographic changes away from the traditional way of life in this study we used a national case approach and focused on japan as a country where people have traditionally lived in gemeinschaft sociodemographic condition but now caught up in a rapid change as a consequence of the 1990s specifically we hypothesized that among those working adults who underwent large change toward individualistic sociodemographic condition their psychological health would be more compromised than those who underwent small change we tested this hypothesis by comparing different regions that systematically differ in the amount of change dependent variables we measured adults health according to the indicators of general health life satisfaction selfesteem and perceived social support we hypothesized that the change would negatively predict general health also change will negatively predict life satisfaction selfesteem and perceived social support we divided social support into support provided from ones community and support provided from out of ones community in order to explore the possible difference between these two finally interdependent happiness would positively predict psychological health independent variables in this study we use the term change to refer to a set of changes in sociodemographic variables related to societal level individualismcollectivism such as family size or divorce specifically the change is captured as a crosstemporal change during 19902010 and a change which took place at the level of sociodemographic condition therefore we operationalized change as the difference in scores between two or more fixed points in time we examined change using ecological correlations between our indicators discussed below and time we measured sociodemographic conditions both at the meso and micro levels and used change at those levels as additional contextual explanatory variable in order to compare groups of japanese adults varying in their degree of change we used prefecture difference yamawaki measured at japanese prefecture 7 level the japanese collectivism scale the jcs is a sum of standardized scores of divorce to marriage ratio percentage of households with three generations living together percentage of elderly people living alone percentage of nuclear family households and percentage of people living alone in 2006 communities also vary by how people make living within their ecologies and they show sizable group differences we considered worthwhile to examine the impact of change at smaller levels than prefectures from the viewpoint of communitybased policy making we created a jcs city level variable 8 by aggregating the jcs indicators at the city level 9 7 prefectures in japan are the officially defined local governments that support citizens efficient political administration and development of an area they originate from the boundaries between local warlords during the edo era that lasted for 300 years until late 19th century they are treated as inclusive geographic regions that have distinctive natural and unique historical aspects such as resources main industries or dialects 8 based on the argument by na et al andhofstede et al we expected systematic differences in the reliabilities of jcs and jcscl using various behavioral measures that replicated japanese and european american differences na et al found these measures to be uncorrelated with each other within nation but correlated at the national level demonstrating a crosslevel difference in the reliability hofstede et al also used his value survey module in a survey of brazilian states and poorly replicated his crossnational level factor structure at the crossstate level if these studies are showing that national level indicators do not always hold at lower levels of analysis collective behaviors such as percentage of people living with parents or divorce rate may be strongly correlated with each other thus reliable at most at the national level but once the same societal behaviors are collected at the lower prefecture or city level the same indicators may lose their reliability accordingly because of the loss in appropriate level of analysis therefore if we calculate jcscl at the city level we should expect even lower reliability and validity than yamawaki s jcs based on this reasoning we tested the reliability and validity of jcs and jcscl hypothesizing that the former would be larger than the latter 9 cities in japan are officially the most basic individual unit of local government and their range is defined by population size and concentration of residences normally a city is led by a mayor and each unit has its own board of education to administer formal schooling while prefecture is rooted in a historical and geographical divide the city is one of the closest and most rooted living units for residents in japan traditionally neighbors sharing the same city had specific as well as unwritten norms to oblige and help each other on ceremonial occasions such as marriages and funerals in exchange for a daily commitment to district matters through assigned roles for each house even today households often have some assigned roles in city affairs such as gatherings or athletic meetings and people interact facetoface with their neighbors and most children are formally educated at local schools located within each city we evaluated societal level explanatory effects after controlling for basic individual difference variables for those we controlled for personality traits gender age and income in the analysis as for income considering the gender distribution of labor altering the income opportunity of adults in japan we measured own income independent of partners income and controlled these two in the analysis in order to test our model we first calculated the extent to which each prefecture and each city have changed using archival data we then used those change scores to explain the health of residents living in diverse areas in japan using social survey study 1 measurement of prefecture and city level change first we examined how jcs changed between 1990 and 2010 second jcscl and their changes were measured we tested reliability and validity using criteria that are both available at the city level because the change after 1990s should have affected both urban and rural regions during this special period of economic disaster and globalization we expected change in both urban and rural prefectures method prefecture change we collected archival data on five indicators of the jcs for 47 prefectures in japan from japans official census statistics site at 1990 1995 2000 2005 and 2010 we used jcs at 2010 as a prefecture level individualisticcollectivistic sociodemographic condition score in this study10 the five indicators included divorce to marriage ratio percentage of households with three generations living together percentage of elderly people living alone percentage of nuclear family households and percentage of people living alone a total of 1175 data points were collected we calculated internal consistencies for every sampled year we aggregated the standardized subtraction scores of each indicator between 2010 and 1990 as an indicator of change city change five indicators of jcs were collected at the city level from the same archive 11 we tested reliability of the jcscl by calculating internal consistency for every sampled year we evaluated validity of the jcscl using correlations with the city level variables of taxable income percentage of adults working in primary industry percentage of adults working in tertiary industry movein rate and moveout rate following past research then we calculated crosstemporal change of jcscl results and discussion reliability of the jcs the reliability of the jcs indicators in each sampled year was marginal to acceptable as in the original study 12 changes of prefecture sociodemographic condition the first column of table 1 shows the correlation between sociodemographic indicators and time at prefecture level in four out of five indicators their changes were in the direction of increased individualistic sociodemographic condition however for percentage of nuclear family the trend showed reversed tendency indicating marginal change toward collectivistic sociodemographic condition closer examination revealed this reversed correlation to be limited to urban prefectures this indicator change may be related to the population increase in urban areas however in this study we followed yamawaki to use this as an indicator figure 3 shows representative change for each indicator the urban and rural groupings were made based on the number of households and gross domestic prefecture income within that variation the top four urban and rural prefectures that are located apart within each group and have closely located pairs across groups were selected and their jcs scores were averaged in 1990 and 2010 respectively both urban and rural prefectures showed trends toward individualistic sociodemographic condition except for percentage of nuclear families in urban areas the jcs and its change score correlated positively indicating prefectures with collectivistic sociodemographic condition showed more change during this period in figure 4 a bar describes the sum of standardized change across indicators for one prefecture or the degree to which a prefecture changed into individualistic sociodemographic condition in comparison to others the rate of change differed across prefectures 13 reliability and validity of the jcscl as in yamawaki the jcscl also showed geographic similarity between the neighbors for example those cities located around the sea of japan coastal area are generally collectivistic pointing to the possibility that city level sociodemographic condition is clustered geographically the reliability of the jcscl was lower than that of the jcs in every sampled year similar to the jcs there was also a declining trend of the reliability over time the validity coefficients were r 011 with income r 011 with workers in primary industry r 044 with workers in tertiary industry r 036 with movein rate and r 040 with moveout rate all in expected directions these indicate reasonable relationships between criteria variables and the jcscl yet they show lower validity coefficients than those of the jcs 14 changes of city sociodemographic condition the second column of table 1 shows the correlation between sociodemographic indicators and time at city level all indicators changed in the direction of increased individualistic sociodemographic condition with percentage of nuclear family showing weaker correlation than other indicators the changes in the jcscl scores also varied between communities 15 the jcscl and its change score were very weakly correlated or in other words city level sociodemographic condition was weakly related to its change during this period 13 akita toyama or tokushima prefectures that had large population and had neighboring prefectures that were more urban seem to have changed greatly during the period in turn okinawa and kagoshima the most southern prefectures in japan showed smallest change in addition tokyo and kanagawa two of the most modern prefectures showed the least change during the period 14 validity coefficients of the national cultural indicators might greatly attenuate at lower levels such as cities a similar case was found when national level indictors were collected to examine city level difference in uk however such low level of reliabilities throughout different years would indicate that either the concept of individualismcollectivism is not best applicable to describe city differences or measurement error is unavoidable when locating city level ic using this specific set of indicators and we need to come up with different indicators at lower levels 15 for example the largest change toward individualistic sociodemographic condition took place in rishiri town at the northern island of hokkaido prefecture where single living increased from 10 to 40 within two decades in turn the largest collectivistic change was observed in aguni village in okinawa prefecture where the percentage of elders living alone decreased from 2723 to 1667 within the period in study 1 we measured sociodemographic indicators by prefecture and city and have observed variation in change utilizing this variation as a comparison ground we conducted study 2 to examine if japanese subjective health would differ significantly depending on the degree of change study 2 explaining adult health from change prefecturecity sociodemographic conditions and individual differences we surveyed japanese adults living in various prefectures in japan and tested the hypothesis model method measures for the explanatory variables we used the interdependent happiness scale which consists of 9 items asking whether participants experience happiness in their interpersonal relationships items included statements such as i believe that i and those around me are happy or i feel that i am positively evaluated by others around me participants responded using a 5point likerttype scale the regression weight for this scale score on health measures would respond to our hypothesis 5 we used the temperament and character inventory to measure the personality difference because of limited space for questions in the joint survey we used 2 or 3 representative items that have shown high loadings in the past japanese study to tap each of the 4 dimensions of temperament examples of tci items were i like to use money rather than save it or i often get nervous or worried when doing new things i am not familiar with participants responded using a 4point likerttype scale we also asked about participants annual income including the annuity from both the self and the partner as a measure country therefore the results should not be understood to cover full range of prefecture variation in japan despite this limitation a wide age range from working to retired adults who had been working during 1990 to 2010 were obtained which is valuable for the purpose of this study of economic condition because japanese adults have large gender differences in working roles we asked these two separate questions and analyzed by controlling for gender we asked participants to choose one option from 0 no income 1399 million yen 2 4599 million yen 3 6799 million yen 4 8999 million yen 5 more than 10 million yen separately for themselves and their partner if they were married to test our hypothesis 1 we used the general health questionnaire examples of items from this questionnaire are i couldnt sleep well because i had worries or i was able to have more fun in my daily life than usual participants rated how they feltexperienced each day using a 4point likerttype scale to test hypothesis 2 we used the 5item satisfaction with life scale as a measure of subjective wellbeing the swls consisted of items such as i am satisfied with my life as a whole and participants responded as to whether they would agree to each statement using a 7point likerttype scale to test hypothesis 3 we used 2 indicator items tapping selfliking and selfcompetence aspects of selfesteem as a measure of global selfevaluation participants rated how the items applied to themselves using a 5point likerttype scale to test hypothesis 4 we asked about ones perceived social support both in and outside of ones community since working and retired adults might have significant others in or outside of the area in which they lived the question was to what extent do you have friendsacquaintances whom you can help or talk to each other we asked them to rate separately friendsacquaintances in the community and friendsacquaintances out of the community on a 3point scale before analysis scores of ghq and social support were reversed so that a higher score means better health for the rest of the scales higher score indicates better health descriptive statistics and reliabilities of the scales are listed in table 2 except the four tci subscales which showed marginal reliabilities other measures showed acceptable levels of reliability explanatory variables were weakly correlated with each other analysis for each of the dependent measures we used the same set of explanatory variables in the model the first level explanatory variables were age gender four temperaments and interdependent happiness second level explanatory variables were the 53 jcscl scores assigned for available communitiescities and the degree of their change from 1990 to 2010 third level explanatory variables were the 17 jcs scores assigned for available prefectures and the degree of their change from 1990 to 2010 first and second level explanatory variables were group mean centered the higher level explanatory variables were modeled to explain the intercept of their lower level therefore the model tested would be described as follows level1 model health measure p0 p1 × p2 × p3 × p4 × p5 × p6 × p7 × p8 × p9 × e level2 model p0 b00 b01 × b02 × r level3 model b00 g000 g001 × g002 × u because each participant was nested within prefectures and cities we first examined how much variation in our dependent variables would be accounted for by group differences per se using intraclass correlation we used the had program to calculate the icc and conventional f ratio comparing the variance within and between the prefectures for each of the dependent variables separately for prefecture and city given the fact that the typical icc in applied research is around 002022 there was very little group difference between prefectures or cities this would indicate that when using selfreported health data among japanese adults there are almost negligible differences between prefectures and cities compared to the individual variation within them with these small effect sizes in mind we conducted hierarchical linear modeling using hlm7 results and discussion the results show strong and stable relationships between individual difference variables and health and small but significant effects of change this indicates that japanese health is explained largely by individual level factors and to a lesser extent by the temporal change of sociodemographic conditions at both prefecture and city levels in addition to such a general association there were differences in the combinations of these societal variables affecting specific healthrelated variables contrary to our hypothesis 1 general health was not explained by change but was explained more by individual age gender harm avoidance and reward dependence and interdependent happiness supporting our hypothesis 2 satisfaction with life was low among those who live in changed prefectures but city level change did not show the same weight supporting our hypothesis 3 weakly selfesteem also tended to be low in changed prefectures negative weight of jcscl on selfesteem might reflect a relationship between collectivism and low selfesteem however these predicted effects were smaller than the individual differences in harm avoidance persistence and interdependent happiness suggesting that subjective wellbeing and positive selfregard are largely predicted by individual emotional predispositions and interdependent happiness if withincountry difference is concerned as for hypothesis 4 social support in ones community was not explained by change but tended to be higher among collectivistic sociodemographic prefectures and high among such communities social support out of ones community was negatively explained by prefecture change suggesting deterioration of distal support during this period collectivistic sociodemographic prefectures but not cities showed lower support from outside of ones community again individual level factors predicted social support significantly and harm avoidance and reward dependence as well as interdependent happiness were the significant predictors of social support supporting our hypothesis 5 in all health measures examined interdependent happiness showed positive explanatory weight this is an indication that interdependent happinessrelational harmony quiescence and ordinariness among japanese adultsis an integral part of their health independent of change during this period general discussion in this study we examined the relationship between sociodemographic change and health using japanese adults living in various prefectures and cities we tested whether the change pertaining to the increase of individualistic sociodemographic condition is related to health during 19902010 when the japanese economy and culture was undergoing massive economic turmoil as a result most of our hypotheses were supported and some were not that is hypotheses 2 regarding the negative prediction of life satisfaction was supported and hypothesis 3 on selfesteem was weakly supported also hypothesis 5 which stated the positive prediction of interdependent happiness onto health measures was supported regarding hypothesis 4 which stated the negative impact of change onto perceived social support showed mixed results that is change at the prefecture level did relate to less perceived social support out of ones community but did not relate to that of inside of ones community finally hypothesis 1 with regard to the negative prediction of change onto general health was not supported considering the overall pattern of results the consequences of economic turmoil might be related to selfevaluative and the social domain of health pancultural implications the present findings support the argument that rapid sociodemographic change can be related to psychological difficulties we may be able to extend such argument by focusing on the sociodemographic change and consider adult health also the result suggests the importance of cultural wellbeing as a psychological strength and basic individual difference in sustaining the health since the best predictors of health were interdependent happiness and personality17 if individual differences are in turn sustained by the larger national culture then both personal and social explanations may need to be used together to explain adult health future studies will need to clarify more concrete processes of this contextual aspect of our health such as how and what events surrounding the individual would mediate this crosslevel impact on health implications for japanese culture current results showed that the sociodemographic change which took place during this period was negatively related to the japanese wellbeing specifically in more changed prefectures such as akita tokushima or toyama prefectures adults are more unsatisfied with their life tend to have lower selfesteem and less social support from out of ones community compared to adults in other prefectures that underwent smaller amounts of change additionally prefecture and city level collectivistic sociodemographic condition was positively related to social support in ones community our study also resonates with the findings on community strength in japan in that both types of research focus on societal level resources above and beyond the individual that in turn sustain residents health future studies need to disentangle the correlates between the sociodemographic condition we used and other societal resources in japan limitations of the study in order to disentangle the relationship between change and health one step further more effective research design would include collecting crosssectional data measuring a set of health and personality variables from the same as well as agediverse participants over time because our individual data came from a single shot survey the results may differ when withinsubject data are used to control for participants past health as well as past individual level values or personality by using a large data set involving cohort design we would be able to evaluate the effect of change on the deterioration of health in individuals in our analytical model we assumed forcefully that individuals had not lived in different prefectures or cities which is probably not the case in the joint survey we used in study 2 we additionally measured individuals original prefecture defined as the prefecture participants had lived longest before reaching 15 years old the results we found for the living prefecture did not emerge when participants are grouped into their original prefecture even though japanese do not relocate as often as americans on average residential moves strongly affect how individuals construe the self and positive affective experience regardless of country it is vital for future research to disentangle the factor of residential moves from what we found regarding prefecture and city sociodemographic conditions and test if our findings are robust after controlling for individual moves in doing so it might also be wise to take into account age at the time of the move as well as the specific combinations of the locations of moves further considering the time span of change in the sociodemographic condition in japan one can also argue that japanese health problems might have had roots long before the 1990 locating the temporal cause may be extremely difficult without the guide of any theory but finding an auto correlation between variables or comparing the same set of variables across different time periods might be an interesting investigation it must be noted that our analysis contained prefecture scores that showed negligible icc especially our city level sociodemographic condition showed low reliability and this may question the reliability of our final outcomes we note that removing city level factors from the hlm model did not alter our overall findings for other levels if we were able to find different dimensions that successfully describe crossregional differences in health it might override the effect of individual differences we observed in this study it could also be the case that simply applying national level cultural dimensions to lower level sociodemographic conditions may not be useful to describe health national level explanations and their lower counterparts may better be kept separate so that we can theorize and search for more reliable prefecture or city or even lower dimensions of subcultures that provide successful contextual explanations that are open to therefore more suitable to describing practical problems and considering remedies finally we did not model interactions between different levels in our analysis that is there still remains a possibility that the explanatory effects of individual level variables on health are systematically different across regional contexts such interactions can be hypothesized when we are able to deduce intricate hypotheses regarding correlational differences across regional as well as temporal contexts summary in this study we started from the research question what are the psychological consequences of economic stagnation accompanying demographic changes away from the traditional way of life based on this we prepared five hypotheses testing negative relationships between prefecture and city level change toward individualistic sociodemographic condition from 1990 to 2010 with five variables of individual health the results overall suggest marginal to significant weights of change on life satisfaction selfesteem and social support out of ones community we also found positive effects of prefecture or city level jcs on perceived social support in ones community as well as large weights of interdependent happiness and temperament at the individual level future studies should discern further which time period of change or level of sociodemographic condition would truly affect our important life outcomes using crosssectional and more representative samples and taking into account the mobile nature of recent japanese life supplementary material the supplementary material for this article can be found online at 01221abstract 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

today countries around the world are caught in the tide of change toward gesellshaft or individualistic sociodemographic condition recent investigations in japan have suggested negative impacts of change on emotional and motivational aspects of the japanese self norasakkunkit et al 2012ogihara and uchida 2014 building on previous findings in study 1 we measured sociodemographic change toward individualistic societal condition during 19902010two decades marked by great economic recessionat the levels of prefecture and city using archival data in study 2 we tested whether japanese adults general health satisfaction with life selfesteem and perceived social support were negatively predicted by the change using social survey results of hierarchical linear modeling showed small but unique negative effects of the change on several health measures suggesting that this change had an impact on health above and beyond individual personality traits and demographics additionally interdependent happiness the type of cultural happiness grounded in interdependence of the self hitokoto and uchida 2014 showed an independent positive relationship with all aspects of health examined implications for health studies in changing sociodemographic condition are discussed in the context of japanese society after economic crisis

introduction psychological distress refers to the symptoms of strain on mental health and includes anxiety depressive symptoms and stress 1 previous studies have found that demographic social and personal factors such as age gender marital status and socioeconomic status have been associated with psychological distress 1 2 3 4 psychological distress has been negatively associated with age but it increases among the elderly which has been associated with less social support 2 among individuals with higher education higher income and married individuals the risk of psychological distress is lower 2 women have a higher likelihood of psychological distress than men some authors explain these differences through biological psychological and social risk factors 5 6 7 biological factors involve eg hormonal changes 6 while social risk factors include the role in society and expectations for women and men in a business and family environment as well as the challenges in combining them 5 marriage has been found to be associated with better mental wellbeing in both sexes compared to widowhood and divorce becoming widowed has more farreaching consequences among men than among women 5 financial problems are a risk factor for mental disorders 58 it is not just poverty that causes psychological distress but also the stigma associated with receiving public assistance 59 various studies have found an association between smoking substance use and mental health 10 11 12 lifestyle factors such as smoking heavy alcohol intake and drug use are risk factors associated with an increased risk for psychological distress 1112 the strength of these associations depends on the substance type the pattern of their use and sociodemographic characteristics 10 another factor that was shown to mediate the relationship between substance use and psychological distress is the age at which the first use of substances was initiated 13 it is essential to understand the factors that lead to psychological distress and affect the population especially the workingage population to avoid mental physical and emotional difficulties and exhaustion associated with illness and inability to work the inability to work among the workingage population has multiplied individual consequences and numerous social familial and economic consequences related to the absence from work previous periods of uncertainty and challenges affect not only the person but also society this is especially evident in times of pandemics or other social unrest and it could lead to an increased need for interventions for preventing mental health problems especially for highrisk groups 14 our study could help policymakers to implement effective countermeasures and prioritize interventions for highrisk populations the aim of this study was to examine the association between social characteristics substance use and psychological distress in the national representative sample of adults in serbia materials and methods the study was a secondary analysis of the data from the national survey on lifestyles of citizens in serbia substance abuse and gambling 2018 15 the national survey on lifestyles substance abuse and gambling 2018 in serbia was a crosssectional study that included a total of 2000 participants aged 18 to 65 and recruited from the general population in serbia the quota nonprobabilistic sampling was used as a method for sampling two categories were used to determine the stratum the type of settlement and the region the households in which the respondents were surveyed were chosen at random with respect to defined quotas any member of the selected household could be interviewed if it corresponded to the quota sample plan given to the interviewer in advance 15 trained interviewers conducted data collection via tablet the facetoface computerassisted personal interviewing method was applied the questionnaire was developed for the national survey on lifestyles in serbia substances abuse and gambling 2018 based on the european model questionnaire developed by the european monitoring centre for drugs and drug addiction the questionnaire contained 158 items the study was conducted between november and december of 2018 the response rate was 90 participants gave informed consent after being given a written description of the study process and aims individuals excluded from the research were incarcerated individuals patients in hospitals or therapeutic communities homeless individuals and individuals in elderly homes or homes for children as well as individuals living in illegal settlements the study was approved by the ethical committee of the republic institute of public health of serbia dr milan jovanovic batut no 62961 on 26 october 2021 the study included a total of 13 variables these variables were age sex residence marital status education selfrated health subjective financial status antianxiety medications in the past 30 days binge drinking in the past year smoking status alcohol consumption any illicit drug use and psychological distress psychological distress was measured using the kessler sixitem questionnaire kesslers sixitem questionnaire was used to measure distress based on a question about anxiety and depressive symptoms experienced in the most recent fourweek period 16 answers were given on a 5point likert scale ranging from never to always participants were classified into three categories corresponding to the score on this scale the first category was no risk of distress the second category was a moderate risk of distress and the third category was a high risk of distress 16 marital status was defined with the question what is your marital status we merged the categories of divorced never married and widowed into single selfrated health was defined with the question how would you describe your health we then merged the categories of very good and good into one good and the categories poor and very poor into the category poor subjective financial status was defined with the question how would you describe your financial status we merged the categories of very good and good into one good and the categories poor and very poor into the category poor the use of antianxiety medications in the past 30 days was defined with the question have you used any of the medications for calming down in the past 30 days with answers yesno alcohol consumption was defined with the question how often in the past 12 months have you drunk beer wine spirits or any other alcoholic drink even in small quantities eg a glass of beer wine or spirits consumers were all those who declared that they had consumed alcohol at least once in the last 12 months binge drinking in the past year was defined with the question how often in the past 12 months have you consumed 60 or more grams of alcohol on occasion which is eg 15 l of beer or 06 l wine or 018 l of spirits drinks or any other combination we merged the categories of every day 56 times a week 34 times a week 12 times a week 23 times a month once a month 611 times a year 25 times a year once a year into yes and not in the past 12 months into no the question have you ever smoked tobacco was used to assess smoking status and participants were divided into current smokers and nonsmokers the exsmokers were classified as nonsmokers any illicit drug use was assessed with the question have you ever used cannabis ecstasy amphetamines cocaine heroin and opiates lsd and hallucinogenic mushrooms new products that mimic various substances and volatile solvents with possible answers yesno we merged the categories of cannabis ecstasy amphetamines cocaine heroin and opiates lsd and hallucinogenic mushrooms new products that mimic various substances volatile solvents into any illicit drug statistical analyses were performed using descriptive and analytical statistics differences between the categorical variables were examined using the chisquare test the differences in means in numerical variables were examined using univariate anova all the variables which were shown significant were entered into two models of the multivariate logistic regression analyses in the first model the outcome variable was a high risk of psychological distress compared to no distress and in the second model the outcome variable was a moderate risk of distress compared to no distress all statistical analyses were performed using the statistical package for social sciences 220 results the study included a total of 2000 participants 945 were male while 1055 were female the average age of our participants was 3783 ± 1361 years the prevalence of a high risk of psychological distress was 52 while the prevalence of a moderate risk of psychological distress was 152 there were significant differences between the participants with no risk of psychological distress with a moderate risk of distress and with a high risk of psychological distress in average age sex residence education selfrated health subjective financial status use of antianxiety medications in the past 30 days binge drinking in the past year smoking status and lifetime illicit drug use the characteristics of the participants are presented in table 1 multivariate logistic regression analysis showed that being male having poor selfrated health having poor subjective financial status binge drinking in the past year and lifetime use of any illicit drug was associated with a higher likelihood for having a high risk of psychological distress the results of the multivariate logistic regression analysis with a high risk of psychological distress as an outcome variable are presented in table 2 multivariate logistic regression analysis showed that being male having poor or average selfrated health having poor subjective financial status using antianxiety medications in the past 30 days binge drinking in the past year being a nonsmoker and lifetime use of any illicit drug was associated with having a moderate risk of psychological distress the results of the multivariate logistic regression analysis with a moderate risk of psychological distress as an outcome variable are presented in table 3 discussion the aim of this study was to examine the association between social characteristics substance use and risk of psychological distress in a national representative sample of adults in serbia in this crosssectional study we found that several factors are associated with the risk of psychological distress we have shown that one in six adults in serbia has a high risk of psychological distress while one in twenty has a moderate risk our analysis showed that being male and perceiving your own financial status as bad having poor selfrated health binge drinking in the past year and lifetime use of any illicit drug were associated with a higher likelihood of having a high risk of psychological distress and point towards a need for a stronger focus on these population subgroups earlier studies have shown similar evidence regarding sex differences and psychological distress 5 viertio et al 5 showed that psychological distress is a quite common problem where 11 of women and 88 of men in the nationally representative finnish working population had psychological distress moreover a large survey in the united states reported 151 of moderate psychological distress and 31 of severe distress over the 20012012 period 5 the authors stated that with the different rating scales and cutoff scores used in previous research the given prevalence figures of psychological distress are not correctly correlative between countries 5 matud et al also showed that women scored higher than men in psychological distress 2 previous studies have likewise found that financial difficulties constitute a notable risk factor for psychological distress 91718 one previous study found that being a man with a low household income was associated with psychological distress which is consistent with findings from our research 18 through different mechanisms poor material living conditions may affect mental health including poor social networks and restricted access to health care services 18 when comparing the risk for experiencing common mental disorders among sexes men and women seem different when classified by income category in all other categories except the lowest one womens risk is higher than mens risk but financial difficulties in covering household costs seem to have equally harmful effects on mental health in both 5 in line with previous research binge drinking and the use of any illicit drug were associated with more psychological distress 111219 in a populationbased study of adolescents they found that alcohol use and all specific combinations of substance use were significantly associated with medium and high psychological distress moreover they noted that according to their analyses the associations between substance use and psychological distress differed across regions in particular substance use was not associated with psychological distress in the eastern mediterranean region 19 in previous studies on the serbian population psychological distress was associated with smoking status 10 and problem gambling as outcome variables 20 while there was no association between psychological distress and binge drinking 21 additionally sexspecific role expectations and norms such as associating drinking alcohol with masculinity may be related to the male preponderance of drinking 2223 while alcohol could be used to reduce anxiousness in some individuals heavy alcohol consumption leads to anxiety distress and depression which in turn can lead to higher levels of alcohol consumption leaving the person caught in a dangerous circle 21 a crosssectional study of nationally representative samples of the united states national survey on drug use and health individuals age 12 showed that adults with substance use disorders who smoke cigarettes experience more than twice serious psychological distress compared to those without substance use disorder who do not smoke cigarettes 24 these results add further evidence for the cotreatment of substance use disorders and mental health problems in some studies psychological distress was associated with feelings of loneliness symptoms of insomnia and consequential anxiety and even suicidality 1925 however many previously conducted studies on the association between psychological distress and substance use examined only specific populations commonly adolescents and people with substance use disorders or examined only the use of one specific substance such as marijuana 131926 according to the information provided by the national institute of mental health online in the substance use and cooccurring mental disorders section individuals with substance abuse disorders may also have other mental health disorders individuals with mental health disorders may also fight substance use while pointing out that individuals can have a substance use disorder and a mental disorder this does not mean one caused the other the studies so far demonstrate three probable modalities that could describe the coexistence mechanism of these problems 27 one previous study investigated the genetic correlation pleiotropy and causal relationships between substance use and psychiatric disorder suggesting that common risk factors such as specific genes and environmental factors may be risk factors that contribute to both substance abuse and mental disorders 2829 many individuals with additional mental health conditions such as anxiety and depression may use substances as selfmedication which can make symptoms worse over time and can lead to severe mental illness and cause substance disorders abuse 30 vice versa substance use and substance use disorder can cause the appearance of other mental disorders due to changes in brain structures and functions 2728 the main strength of the present study is the high response rate additionally our study is the first analysis to assess the association of social characteristics substance use and psychological distress in the adult population in serbia on a large nationally representative sample of the workingage population to the best of our knowledge no study has yet been committed to the topic of the association between social factors and psychological distress either in serbia or in the western balkans using data from a nationally representative sample while most studies conducted in new zealand australia and the united states examined only distress as one of the independent variables in relation to other outcome variables 31 the main limitation of our study is the crosssectional design which does not allow us to determine the direction or causality of the associations furthermore data were obtained using a selfreport questionnaire therefore we did not obtain detailed information eg about mental disorders selfreporting bias such as social desirability and recall bias could affect the results other limitations related to individuals excluded from the research were incarcerated individuals patients in hospitals or therapeutic communities homeless individuals individuals in elderly homes or homes for children and individuals living in illegal settlements our findings do not apply to these individuals and some settings may show a higher frequency of substance and alcohol use than the sample from the population used in this study as well as a higher frequency of psychological distress a limitation might be the participants lack of desire to share information with the researchers a possible limitation could be that some participants may have given socially desirable answers to some questions regarding substance abuse conclusions one in six adults in serbia has a high risk of psychological distress while one in twenty has a moderate risk our analysis showed that being male and perceiving ones own financial status as bad having poor selfrated health binge drinking in the past year and lifetime use of any illicit drug were associated with a higher likelihood of having a high risk of psychological distress and point toward a need for a stronger focus on these population subgroups therefore this study contributes to reducing the gap in knowledge about the association of social characteristics substance use and psychological distress in the adult population the findings of our study can help direct future research in developing and implementing an integrative program for people suffering from psychological distress and people with alcoholand drugrelated problems more intensive cooperation is needed between the experts dealing with different aspects of substance and alcohol use and experts dealing with preventive activities data availability statement data can be made available upon request

this study examined the association between social characteristics substance use and psychological distress in a national representative sample of adults in serbia it was a secondary analysis of the national survey on lifestyles in serbia substance abuse and gambling 2018 the study included a total of 2000 participants aged 18 to 65 from the general population in serbia psychological distress was examined using the kessler 6 questionnaire there were a total of 945 male participants 473 and 1055 528 female participants the average age was 3783 ± 1361 years the prevalence of a high risk of psychological distress was 52 1032000 while the prevalence of moderate risk of psychological distress was 152 3032000 multivariate logistic regression analysis showed that being male having poor selfrated health having poor subjective financial status binge drinking in the past year and lifetime use of any illicit drug were associated with a higher likelihood of having a high risk of psychological distress one in six adults in serbia has a high risk of psychological distress while one in twenty has a moderate risk the findings of this study urge targeted actions to protect and improve the health of people in psychological distress and drug and alcohol users

formal care and their intersection and applicable across care settings drawing on existing critiques of research on informalformal care intersections we examine care relationships using the convoy of care model past research and conceptual models such as cantors hierarchical compensatory model the substitution model and litwaks task specificity model address care complexity but treat formal and informal care as separate spheres or overlook surrounding social economic and structural contexts kemp et als model extends kahn and antonuccis convoy model of social relations which conceptualizes individuals as embedded in convoys of close personal relationships that evolve over time and are vehicles through which social support is distributed or exchanged the modified model incorporates formal caregivers and suggests that longterm care recipients are situated within care convoys defined as the evolving community or collection of individuals who may or may not have close personal connections to the recipient or one another but who provide care… multilevel contexts influence care including policies and resources at the federal state and community levels and those factors operating within care settings networks and relationships assisted living for example is regulated at the state level and is a setting where most care is provided by unlicensed care aides home health and hospice services are a growing presence assisted livings social approach to care relies on resident selfcare and informal caregiver contributions which are vital to meeting residents needs typically family members and friends provide socioemotional support assistance with instrumental activities of daily living and care oversight assisted living research identifies informal care networks with a primary person and those with shared responsibilities little else is known about how informal caregivers organize themselves over time in the context of formal care but research reveals some general informal care patterns within families studies show for example that families range from individualistic to collectivist in their approach to caregiving and that high withinfamily consensus about care recipient behaviors influences family dynamics and perceptions of burden research also shows caregiving responsibilities within sibling networks can be unevenly distributed by employment and family status proximity and gender and highlights distinct caregiving approaches by gender corcorans research among individuals caring for a family member with dementia demonstrates distinct caregiving styles facilitating balancing advocating and directing this typology incorporates the dynamic and complex nature of caregiving through an examination of intentions and strategies but not how care is experienced by multiple caregivers within care networks existing research provides important insights into care but no known research involves entire care convoys studied systematically over time seeking to advance knowledge of care relationships and processes our goal is to obtain indepth understanding of residents care convoys in assisted living we seek to understand care convoy patterns including their structure and function and identify how and why convoys vary and with what resident and caregiver outcomes design and methods we present analysis of data collected for the qualitative longitudinal study convoys of care developing collaborative care partnerships in assisted living the overall goal was to learn how to support informal care and care convoys in assisted living in ways that promote residents ability to age in place with optimal resident and caregiver quality of life an indepth consideration of our methods appears elsewhere the study was guided by principles of grounded theory methods which involves a constant comparison approach whereby data collection hypothesis generation and analysis occur simultaneously building cumulatively on previous grounded theory research the convoy of care model provided sensitizing concepts and a place to start not end for our study for instance the model conceptualizes care as a process influenced by multilevel factors and calls for a holistic and longitudinal approach to studying care we report on data collected between september 2013 and october 2015 in four assisted living communities purposively selected to maximize variation in size location ownership resident characteristics fee structure and availability of a dementia care unit georgia state university s institutional review board approved the study for anonymity we use pseudonyms for sites and participants settings and sample our first site hillside familyowned and rural was licensed for 11 residents all white garden house had a separate dcu and was familyowned in a small town and licensed for 54 residents the majority were white feld house foundationrun and licensed for 46 residents almost all jewish was suburban and had an extra care area but no dcu oakridge manor licensed for 92 residents all african american was corporately owned and had a dcu prior to entering sites we distributed letters to residents families and staff and posted flyers with researcher names and photos across sites we recruited 28 focal residents purposively selected to provide informationrich cases that reflected variation in personal characteristics functional status and health conditions factors expected to influence convoy structure function and adequacy residents ranged in age from 58 to 96 years with a median of 85 the majorities were women white and widowed and had some college or a college degree formal and informal caregivers were selected based on their involvement in and knowledge of resident care we enrolled as many individuals as possible resulting in 114 convoy participants including 5 assisted living executive directors and 24 staff 20 external care workers and 65 informal caregivers all executive directors were women between 38 and 59 years most had some college education staff included nursing or resident relations personnel care aides activity personnel and maintenance and transportation workers they were between 24 and 72 years the majority were women with some college over half were african american external care workers included medical doctors hospice workers nurses therapists and a private care aide threequarters were women over half were white all had at least some college informal caregivers were residents family and friends including spouses children siblings grandchildren other kin and friends and volunteers most were women and white 79 had a college degree 66 were married and 46 were retired or unemployed data collection investigatorled teams of trained gerontology and sociology researchers collected data during the first month we began participant observation and conducted indepth interviews with executive directors to learn about the community next we began recruiting focal residents and convoy members convoy member recruitment was ongoing over the 2 years we used national institutes of health guidelines to assess residents informed consent capacity for those unable to consent we used proxy consent from legally authorized representatives and assent procedures all interviews occurred at a time and place of participants choosing and except for a sibling pair and three married couples were conducted oneonone interviews ranged from 30 to 330 min with a mean of 98 resident interviews lasted longer than other interviews with a mean of 168 min indepth interviews with residents typically occurred over multiple sittings and addressed their lives relationships past and present care needs and arrangements including selfcare and experiences convoy member interviews inquired about relationships with the resident care roles responsibilities and experiences site visits occurred one to three times weekly depending on home size to capture the full range of care activities we varied visits by time and day of the week participant observation took place in residents rooms with permission and in common areas and during mealtimes and activities we made 809 visits and logged 2225 observation hours all recorded in fieldnotes after completing formal interviews with focal residents and staff researchers followed up weekly collecting data prospectively we attempted twicemonthly followup with at least one informal caregiver per convoy to assess changes in care needs and arrangements facility record review provided data about diagnoses medications care plans service agreements doctor visits and orders and adverse events analysis we used nvivo 10 to store manage and facilitate coding and analysis of all qualitative data initially we coded data with broad concepts driven by research aims we used intercoder comparison queries to achieve consistency as data collection and analysis occurred simultaneously all 18 researchers engaged in data collection coding and analytic discussions the higherorder analysis described in the following paragraph was conducted by the authors an indepth account of our analytic processes appears elsewhere following corbin and strauss we used a threestage coding process first we examined the data for concepts based on our questions about convoy patterns through open coding initial codes included for example primary informal caregiver shared responsibility collaboration leadership and consensus through axial coding we related initial and other categories using a paradigm denoting conditions actionsinteractions and outcomes we created analysis charts that noted for example connections between residents receipt of timely and appropriate care and staff external worker informal caregiver and resident influences and convoy properties finally we refined and integrated concepts into a conceptual scheme through selective coding organized around our core category maneuvering together apart and at odds evoking images of navigation in our data the core category links subcategories in our explanatory scheme to characterize the dynamic and variable patterns and processes associated with care convoys results maneuvering together apart and at odds represented in figure 1 our core categorymaneuvering together apart and at oddsreflects the variable ways convoy members navigated the care landscape and negotiated care needs roles relationships and arrangements in an ongoing way and during times of crises figure 1 presents the care process as organized but as our data show the realities of care were not always so orderly care convoys varied in structure function and adequacy across and within convoys over time each had a trajectory unique in direction and duration marked by stability and change related to resident and convoy members involvement and punctuated by the timing and sequencing of events transitions and turning points in the care process as figure 1 shows the ways convoys maneuvered were influenced by convoy structure and function including leadership effectiveness and responsiveness of convoy members and levels of consensus collaboration and communication within convoys all of which were shaped by the intersection of regulatory community assisted living setting convoy and individual factors how convoys maneuvered influenced residents ability to age in place and care quality and their own and caregivers quality of life the three ways of maneuveringtogether apart and at oddsalign with three types of care networks identified in the data cohesive fragmented and discordant we discuss each below in the section convoy types but first we explain care convoy composition and care roles as both influenced how convoys maneuvered while navigating the care context and negotiating care processes and relationships care convoy composition and care roles the 28 focal resident care convoys were made up of varying and often fluctuating numbers of informal and formal members who provided a range of care activities also changeable over time figure 2 shows the types of caregivers identified across convoys residents as the center of their convoys were part of the care process although children participated in 21 of the 28 convoys 4 focal residents had no children and 3 had uninvolved children other family caregivers included spouses siblings grandchildren nieces nephews and daughters and sonsinlaw nonkin convoy members were friends neighbors ministers fraternity and sorority members volunteers and fellow residents in what follows we examined the contributions of each convoy member type to enhance understanding of how care convoys operate in assisted living and with what outcomes over time resident involvement the selfcare ability of focal residents varied widely determined by their changing health status care needs functional and cognitive ability care preferences support from caregivers access to assistive devices and the structure of physical environment the majority of focal residents needed help with three or more adls and iadls and with medications most reported their health as good or fair 82 used an assistive device including a walker wheelchair or both 33 had cognitive impairment although most performed some selfcare residents ranged in abilities from naomi a hillside resident with substantial cognitive impairment who could carry out none to ethel at oakridge manor who as the only focal resident who led her own convoy assumed primary responsibility for care provision oversight and coordination informal care informal caregivers were integral members of almost all convoys and based on our interviews and observations were knowledgeable about or directly involved in resident care on an ongoing basis for respite or during crises although 65 were formally interviewed data collection yielded information on 210 informal caregivers as with resident selfcare informal support varied and typically included most iadl and occasional adl assistance care monitoring and coordination and socioemotional support executive directors characterized informal involvement as a spectrum from daily to minimal garden houses owner noted all families are different one fellows just got his daughter and shes pretty much the primary caregiver some folks have multiple children that visit generally some kids live out of town and they visit when they can informal convoys varied in size and configuration we distinguished between convoys with a primary caregiver who provided all or most informal care and those with shared responsibilities sixteen focal residents had convoys with a primary caregiver 12 were children one spouse one sibling one niece and one friend most lived locally and had other convoy members who provided periodic regular support or intermittent respite in 12 convoys informal responsibilities were shared shared convoys tended to be larger and more diverse than those with a primary caregiver and included the largest with 26 informal members half had nontraditional caregivers generally shared convoys partly because of size were more likely fraught with challenges for residents and convoy members especially assisted living staff and administrators sharing of responsibilities though could lessen caregiver burden formal care assisted living staff furnished the typical services of adl and medication assistance monitoring and oversight housekeeping nutrition and activity programing three residences offered transportation to medical appointments for a fee one provided shopping services all four had a point person who supervised and coordinated resident care oakridge manors care director explained the importance of this position its a very difficult decision to move into assisted living so helping residents and families navigate and maneuver through assisted living coordinating with third party providers so whether its hospice or home health knowing when its time to coordinate my job entails that complex health care called for convoy members capable of understanding and managing multiple care components formal caregivers from the external community provided care onand offsite privately paid care aides used infrequently largely because of cost enhanced aging in place and quality of care and life health care providers including physicians nurses dentists podiatrists xray technicians and various home health and hospice professionals visited all homes for 15 focal residents across all sites virtually all health care occurred inhouse a nurse practitioner who visited feld explained for some people we truly are now their primary care provider eleven focal residents received almost all care offsite two had a mixture offsite care required greater effort arranging appointments and transportation tasks typically shared by residents informal caregivers and assisted living staff the majority of focal residents were hospitalized during data collection 12 multiple times 4 were in rehabilitation facilities and 20 had home health services garden houses director described a common pattern following a residents hospitalization angela ended up in a rehab unit when she comes back theyll have home health physical therapy and probably occupational therapy hospice services were used by five focal residents and across settings at hillside most residents including all three focal residents received hospice convoy trajectories stability and change care convoys were marked by stability and change in membership and in type and level of care resulting in unique convoy and care trajectories residents health changes triggered temporary or permanent modifications in selfcare and the nature amount and sources of support utilized some transitions were anticipated some were not changes in informal caregivers lives initiated temporary or permanent transitions in convoy structure function and adequacy four informal caregivers died during the study creating notable voids in residents lives travel employment health and other family responsibilities were frequent with effects reverberating within convoys as noted changes in residents health status also caused shifts in formal convoy members and often temporary relocations to other care settings all convoys experienced change convoy types care roles and structures provide an important entry point for understanding care but do not account fully for convoy function and outcomes our analysis identified components consequential to the function and adequacy of care networks over time levels of consensus surrounding care plans and goals degree of collaboration to achieve goals leadership effectiveness communication quality and responsiveness we classified convoys as cohesive fragmented or discordant based on the pattern that dominated each care network over the 2year study period yet reflecting the reality dynamism and complexity of care arrangements and relationships types were not mutually exclusive for example some convoys were cohesive for the majority of time but had periodic or situational fragmentation or discordance resulting from health or convoy transitions and led to a temporary lack of coordination or disagreement about care needs goals and plans cohesive convoys we categorized 22 of the 28 convoys as cohesive in cohesive convoys the most supportive for residents and caregivers care partners had clearly defined care goals unified efforts and maneuvered the care process together identifying and achieving goals required agreement collaboration and effective communication among convoy members setting goals involved a formal or informal member initiating dialogue garden houses care coordinator noted my new thing is getting residents to think about their goals for their time here is it to live as long as possible or is it to live with the best quality of life with the time you have left cohesive convoys possessed welldefined informal leadership responsive members and clear directives for health and financial matters hillsides owner described a common pattern in cohesive convoys collaboration and cooperation were successful mainly through ongoing open and effective communication hillsides owner observed about families for the most part especially if theyre here a lot they see what we see and so were always on the same page naomis daughter who shared responsibility with her siblings in a cohesive convoy said we are 100 percent in agreement on all of mothers care naomi remained at hillside despite significant decline in part because of shared and continuous family involvement and convoy cohesiveness the majority of cohesive convoys had a primary informal caregiver who assumed the leadership role although this configuration typically fostered cohesiveness and good outcomes for residents and caregivers other factors could intervene for example carl whose mother had high physical and emotional need had minimal support from his wife and one outofstate brother initially carl often managed daily visits with minimal burden but a job change with travel decreased his involvement and his mothers satisfaction shared responsibility offered more options opinions and potential for conflict but felds resident services director emphasized that if roles were clear cut then its easy but if its not decided amongst them then its harder when convoy members were mutually responsive to requests and cohesive shared convoys functioned effectively and had good outcomes with residents feeling supported and able to age in place and caregivers experiencing support and satisfaction with their roles in ethels informal convoy the largest with 26 members her leadership enhanced cohesiveness fragmented convoys fragmented convoys had some consensus about care goals but minimal communication collaboration or cooperation among care partners we categorized 4 of the 28 convoys as fragmented one had a primary caregiver in three informal responsibilities were shared among multiple members because fragmented convoys typically lacked informal leadership the assisted living point person often assumed care coordination for ernest a resident at oakridge manor whose informal care was shared among a niece who lived out of state and 14 nonkin members the resident director helped coordinate medical appointments convoy member responsiveness and resident involvement also could help overcome informal leadership deficits in fragmented convoys with wellestablished roles fragmented convoys generally could meet residents needs including a garden house resident fred whose children all help one way or another yet because they lacked close relationships his children did not coordinate or communicate regularly illness hospitalization or a change in caregiver availability could strain these potentially fragile convoys often impacting care quality health crises though sometimes led to temporary collaboration as illustrated by feld resident susan whose fragmented convoy consisted of her three children who interacted only on holidays and had unilateral care roles with susans hospitalization for pneumonia communication increased as one daughter explained we are in a lot of communication when she has a crisis we are always filling each other in on what the latest is occasionally care was overlooked as happened in ernests fragmented convoy where one person ordered medication and another paid the bills a staff member noted issues with the pharmacy holding the medication because they were waiting on payments discordant convoys discordant convoys 2 of 28 lacked agreement about care goals including appropriate roles and behaviors convoy leadership particularly among informal caregivers was either absent unclear or contested disagreement occurred within informal networks and with assisted living staff or other caregivers relative to cohesive and fragmented predominately discordant convoys typically had the most negative outcomes for residents and caregivers hillsides owner described feuding siblings if the sibling who is not the poa is not agreeing to the schedule then the other person can just take them because theyre not wanting the other one to see them its not our place by law to tell the other person to leave if theres not any order against them being here the causes of discord included family dysfunction offtime caregiving and an inability or unwillingness to balance care with competing demands predominately discordant convoys were the least supportive of residents ability to age in place and frequently led to frustration and dissatisfaction among residents and caregivers the three convoy types we identified were not mutually exclusive or constant for instance two convoys at garden house experienced marked change in type during the study described in the case examples section one predominately cohesive convoy with a primary caregiver experienced a temporary period of discord and noted earlier one fragmented shared convoy became cohesive during the residents health crisis another fragmented shared convoy temporarily transitioned to discordant when a residents friend became a romantic interest and assumed an increased care role a transition unwelcomed by some family members this discord was problematic for the resident and his convoy members the fluidity of types reflects the stability and change that defined convoy trajectories case examples we provide two examples to illustrate convoy function adequacy stability and change these cases contain elements of all three types demonstrate accompanying resident and caregiver outcomes and highlight key factors that shape how convoys maneuver through care processes over time illustrated in figure 3 alice a garden house resident widowed and in her 90s had a predominately cohesive convoy with a temporarysituational episode of discord and a trajectory with numerous health and convoy changes physically frail with cognitive impairment alice used a walker and later a wheelchair and received staff assistance with all adls some iadls medication management and oversight the nurse hired by the family to oversee her health care complimented staff saying i like the fact that they do get her out of bed and still keep her involved alices local daughter pam a health care professional was the primary informal caregiver her participation included health care management monitoring visiting and outings pam said i dont have any family or anyone else in the area who comes and visits her its about me my husband comes sometimes on sundays with me and we take her out to eat although she downplayed her husbands contributions he visited regularly and often took alice out pams outofstate sister caroline provided money management and visited caroline said i coordinate with pam what i try to do is give her a break about decision making she said pam would talk to me about it but i would absolutely defer to her recommendation both because of her experience with geriatric populations and because she has healthcare power of attorney generally staff described alices support system as great alice and her daughters were happy with care at garden house pam noted theyre pretty good to communicate with me when they notice a change alices decline prompted staff to recommend the dcu the daughters disagreed and fought the move for months creating additional care work and discord the care coordinator characterized negotiation as a tough tough battle explaining alice needs toileting because if shes left to do that alone theres a lot of clean up involved that was a very hard sell because the staff protected that for so long and wanted to protect her dignity so they didnt tell her family what was going on over time pams employment changes reduced visits and alices mobility challenges ended outings with continued decline convoy members and the homes owner collaborated with the goal of honoring alices request to stay here the rest of my life alice was placed on hospice and during her last week received aroundtheclock care hospice kept her comfortable and worked with staff and her daughters to help them understand alices progression along that endoflife spectrum alices cohesive convoy enabled her to age in place with quality care which enhanced caregiver satisfaction all positive outcomes in contrast deborah who moved to feld house at age 62 8 years after developing earlyonset alzheimers disease had a convoy with shared informal responsibilities that was fragmented with limited coordination and escalated to discord deborah had memory speech vision and mobility deficits and high blood pressure and cholesterol anxiety and depression as figure 4 illustrates deborah performed limited selfcare staff provided help and cueing with all adls medication management and oversight deborah divorced had two daughters in their twenties ruth and nancy and a son keith in his thirties who were her health care decision makers sisters diane and sheila though were deborahs most involved informal caregivers according to sheila it was a balancing act with diane visiting weekly and handling most iadl tasks the children visited maybe once a month if that and filled in for urgent things deborahs boyfriend lester in his 80s visited when in town for medical appointments and sometimes stayed overnight in deborahs room they talked daily by phone with help from staff convoy members lives were complicated by jobs and health issues their relationships were rocky then and in past sheila termed the family fractured and dysfunctional stating the kids had trouble growing up and lacked knowledge of how to interact in a loving family communication was emergencydriven usually by email and text occasional facetoface meetings addressed future care in the face of dwindling finances sheila noted here youve got disparate people with disparate lives and goals and things to do i feel like diane and i are like the jiminy cricket on pinocchios shoulder with the kids this is what she needs were trying our best to cobble together something thats functional for deborah communication with staff was similarly lacking services coordinator alexis described deborahs family as very difficult to get a hold of and their fragmented roles and unresponsiveness challenging if i need something financially its diane if we need something medically its the kids so like she just had a couple issues recently and you leave messages and they call back but not necessarily as quickly as we might need and they dont communicate to us about what we can do to make that easier diane welcomed staff support but noted there is still so much to navigate it would be nice for people to point the way deborahs decline also was emotionally draining keith explained on one hand you want to celebrate that your mother is still there on the other hand all you see is how much you have lost this dichotomy has become a dark cloud hanging over our entire family deborahs cognitive decline led to relocation to the extracare wing increasingly aggressive behavior triggered temporary stabilizations in a psychiatric hospital and finally discharge according to alexis deborah totally destroyed her room and physically attacked three residents the family remained very uncooperative very unhelpful that night nobody answered except for keith it was like 2 in the morning and he was like what do you want me to do to alexis families like deborahs can definitely get in the way keith does not believe that mom is capable of doing the things that we said she was doing we see her every day we are not making this up so its communication ultimately deborahs discordant convoy failed to meet her care needs and support aging in place and left convoy members frustrated and burdened discussion we depart from conventional approaches to studying care by emphasizing intersections of formal and informal care and focusing on entire care convoys studied qualitatively indepth and over time the process of maneuvering together apart and at odds with the accompanying model and convoy typology illustrate the complexities and dynamics of care experiences patterns and influential factors previously undocumented in the care literature especially in assisted living and over time in what follows we discuss our findings and their implications for care research and practice findings confirm that care recipients are care partners residents participated in selfcare and care management based on ability willingness and extent of convoy support existing work documents the importance of selfcare for autonomy and independence which are threatened by safety and convenience in some assisted living settings optimizing care recipients involvement requires greater caregiver time patience and willingness and has implications for wellbeing and quality of life and must be prioritized in any care setting doing so requires communication practices that include care recipients in their own care decisions and activities insofar as possible our work extends ball et als distinction between primary and shared informal caregiving by incorporating variation in the structure and dynamic of care convoys and including multiple members primary informal caregivers sometimes overlooked the support they had from others for example pam minimized her husbands contributions which enhanced alices care and pams respite opportunities family members in assisted living report greater burden than those in nursing homes likely owing to greater involvement and are apt to benefit from respite reinforcing the need for respite and creating opportunities for meaningful caregiver support through policy and practice can promote resident and caregiver quality of life and care findings shows that shared informal networks have the capacity to distribute responsibility across individuals and enhance access to informal assistance especially during crises as in prior research on family caregiving challenges arose in the absence of clearly defined roles or consensus both consequential to care outcomes regardless of convoy size and composition network size was a complicating factor in our data and noted in gaugler reese sauld pilot work our data also show that although convoy factors were highly influential resident caregiver facility and communitylevel factors could have equal and interactive importance convoys in our study demonstrated the advantages of care planning and goalsetting most states require service planning based on periodic assessment of residents health and functional status but our work shows that goals are not always established or agreed upon within and across care networks underscoring the need for effective communication we recommend ongoing discussions that include care recipients and informal and formal convoy members and developing care plans and roles that support established goals case management may be beneficial particularly when care recipients and informal caregivers are vulnerable or need help navigating the landscape some of this responsibility was assumed by assisted living staff especially care directors zimmerman and colleagues point to the potential value of social workers despite lack of standard regulations governing social services in assisted living quantitative assessments indicate interpersonalconflict between staff and family members in assisted living are rare but suggest room for improvement fragmentation and discord within convoys including among and between informal and formal caregivers were not uncommon even within cohesive convoys underscoring the potential value of social services in longterm care settings our data show the potentially negative outcomes for caregivers and recipients when there is withinconvoy disagreement over time inclusion beyond a primary person provides a more comprehensive understanding of care than previously existed as illustrated parent care frequently is shared among siblings and network changes are common implying the need to shift caregiving research from individual and crosssectional approaches to dynamic and systemic analyses findings illuminate the contributions of nontraditional informal caregivers who lack normative obligations governing spouses or children these convoys require further scholarly attention as many individuals now and in future will rely on nontraditional helpers data affirm the consequential nature of informal care for individuals quality of life and care and ability to age in place formal providers compensated to varying degrees for lack of informal leadership and responsiveness but this arrangement was not sustainable especially with limited resident involvement for example although deborahs shared informal convoy included traditional members none assumed responsibility and collaboration was absent complicating the dysfunctional family context caregiving occurred offtime for her children who were unable or unwilling to respond the care context including care recipients needs and caregivers capacity to provide care is highly consequential and renders certain convoys and hence care recipients more vulnerable and less supported relative to others our work confirms the value of considering informalformal care intersections assisted living staff provided most handson care and essential emotional support this lowpaid workforce is in need of greater recognition and remuneration escalating resident frailty in assisted living means a growing number of formal care partners and calls into question how best to deliver health care we provide insight into how care is accomplished yet this area warrants closer examination as the industry struggles between social and medical care models family and friends were consequential to resident care particularly during decline or crises as others note informal caregivers frequently are advocates and important decisionmakers sharpp and young found for instance that in absence of licensed nurses and training strong family involvement was essential to preventing unnecessary emergency room transfers for assisted living residents with dementia engaged informal caregivers and convoy consensus communication and collaboration differentiated alices ability to age in place and deborahs discharge care convoys were unique yet all had trajectories shaped by care relationships and contexts and multiple multilevel factors due to the complexity of the research design we are able to identify more complex models of care than existing research all convoys experienced stability and change but the ability to successfully navigate the latter was not universal our case examples also highlight key factors affecting how convoys maneuvered in assisted living and point to those factors that facilitate and constrain quality of life and care analysis confirms certain factors identified in the convoy of care model at the regulatory level medicare reimbursement for rehabilitation home health and hospice services and state assisted living regulations shaped care options and access and affected aging in place the size and location of a homes surrounding community influenced options for health care staffing and volunteers equally influential were assisted living residence factors including aging in place philosophy and policies care planning staffing practices training turnover and resources among caregivers attitudes beliefs strategies knowledge resources and availability affected care quality and quantity finally residents cognitive and physical function communication strategies material and social resources and relationships affected convoy structure function and outcomes limitations and future directions although we believe our research is innovative it has limitations first we formally interviewed multiple informal convoy members and gathered data directly or indirectly for most members but were unable to formally interview everyone certain convoy data are more complete than others second we selected residences that represent the range found in the united states but the present analysis only uses data from four sites future analysis of data from additional sites will build on and extend our present findings next the majority of residents and informal caregivers in our sample had some college or a college degree our previous research shows that education an indicator of social location and access to resources shapes care options care relationships and care experiences our ongoing data collection involves participants with rather limited resources and will expand the range of care experiences represented in the present sample finally in order to delve deeply and understand the complexities of convoys our sample size is limited and we rely on qualitative data and methods future research might consider using larger samples mixedmethods and interventions targeting communication consensus and collaboration to strengthen convoys despite limitations our design shows the value of a comprehensive approach to studying care relationships and illuminates the path to holistic understandings of care and creating collaborative care partnerships in assisted living and other longterm care settings conflict of interest we have no conflict of interest to declare

objectives frail and disabled individuals such as assisted living residents are embedded in care convoys comprised of paid and unpaid caregivers we sought to learn how care convoys are configured and function in assisted living and understand how and why they vary and with what resident and caregiver outcomes method we analyzed data from a qualitative study involving formal indepth interviews participant observation and informal interviewing and record review we prospectively studied 28 residents and 114 care convoy members drawn from four diverse assisted living communities over 2 years results care convoys involved family and friends who operated individually or shared responsibility assisted living staff and multiple external care workers residents and convoy members engaged in processes of maneuvering together apart and at odds as they negotiated the care landscape routinely and during health crises based on consensus levels and the quality of collaboration and communication we identified three main convoy types cohesive fragmented and discordant discussion care convoys clearly shape care experiences and outcomes identifying strategies for establishing effective communication and collaboration practices and promoting convoy member consensus particularly over time is essential to the creation and maintenance of successful and supportive care partnerships

introduction around the world population ageing creates challenges for human and financial resources individual health and quality of life as well as equity and wellbeing in society 1 now more than ever as the covid19 pandemic increases isolation and ageism 2 the importance of social interactions and participation is widely recognised but this presents new challenges in terms of security and roles 3 4 5 at the beginning of the pandemic one in three older canadians reported concerns about maintaining social ties 6 for most older canadians opportunities for social interactions were and still are very limited based on a scoping review of the definitions of social participation in older adults which included articles up to 2009 social participation could be defined as a persons involvement in activities that provide interaction with others in society or the community 7 as a health determinant enhanced social participation helps older adults to be active and in response to concerns about population ageing 8 that inspired public policies is a key proposal of the world health organisation following the uk minister for loneliness appointment several countries in europe considered officialising efforts to combat loneliness 10 against which social participation has a known protective effect 11 social participation is also associated with a reduced risk of mortality 12 13 14 and morbidity 15 greater functional independence 16 greater satisfaction with life 17 and shorter hospital stays 18 when social participation is optimal 19 older adults might have a sense of purpose and contribution and their engagement benefits society as well as themselves 20 for example volunteering encourages values such as altruism and also fosters the feeling of being valued and respected in ones community which in turn increases resilience in response to stress 21 and can lead to positive mental health outcomes including less loneliness 22 social participation should be seen as encompassing involvement not only in nonprofit and public organisations including volunteering but also in many other aspects such as social and leisure activities and informal support between families and neighbours by participating in society according to their needs desires and capacities older adults reduce their risk of social exclusion which is a process through which individuals become disengaged from mainstream society depriving people of the rights resources and services available to the majority 23681 and increases as they grow older lack of access to material resources such as income and housing or to healthcare restricts social participation 24 and increases inequalities which could be attributable to the combination of population ageing ongoing economic instability and situations of vulnerability 25 many factors such as being over 80 years of age having a low income 26 belonging to a racial ethnic or linguistic minority presenting one or more disabilities or identifying as belonging to a sexual or gender minority 27 can interact and increase the risk of marginalisation and social exclusion 25 it is thus essential to promote older populations social participation using processes that enable their inclusion such processes include giving them a voice providing meaningful opportunities and improving access to proximity resources while respecting their rights 2428 fighting systemic ageism 29 and reviewing policies on participation in ageing 3031 promotion of social participation should consider a variety of life experiences foster structural and cultural access to participatory settings and offer spaces supporting new identities including ageing with disabilities to expand the study of social participation and better understand encourage and value older adults contribution to society it is important to adopt a consensual and current definition of the concept although a previous review contained a content analysis of definitions and proposed a synthesis 7 a qualitative study presented results according to dimensions 32 and a concept analysis was carried out 33 many researchers still define this concept in their own way 34 which only exacerbates the confusion surrounding the meaning of social participation moreover a recent study of the current generation of older adults reported a lack of alignment between their aspirations concerns and participation opportunities especially for women 35 as witnesses to or being involved in societal advances in social civil and political rights this generation is diversified and generally reaches older age in better health and living active lives searching for freedom wishing to start new life projects and advocating for selfdetermination and a greater citizen presence 36 they also report needing spaces to contribute and do their activities regardless of their health and without worrying about being productive and useful 3738 todays ageing generation wants to participate and be recognised and active not necessarily in roles valued by society or liberal policies based on contributing and volunteering but in ways that reflect their own interests and capacities empowered older adults can describe their own experiences and reality 39 moreover in keeping with approaches involving personalisation 40 and reablement 41 older adults should be involved in revisiting the definition of social participation ie given a voice in the conceptual work this paper provides an updated inventory and synthesis of definitions of social participation in older adults based on a critical review by content experts and knowledge users a consensual definition is proposed methods following prisma guidelines 42 including collaboration between researchers and knowledge users 43 and validation by a documentalist the methodological framework for scoping studies 4445 was used to synthesise current knowledge concerning definitions of social participation in older adults papers retrieved were published between february 2009 and march 2020 in four databases with relevant keywords and websites were also searched conceptual definitions were extracted from each paper by mlt and él and contentanalysed using seven predetermined interrogative pronouns who how what where with whom when and why 7 these pronouns identified critical dimensions of the concept of social participation 46 themes emerging from this condensation were deductively organised and renamed according to the human development modeldisability creation process a model of human development and disability 47 similar to the international classification of functioning disability and health 48 in terms of approaches objectives and elements of the models components 49 the hdmdcp illustrates interactions between personal and environmental factors and participation three of the researchers independently performed the content analysis with an interrater agreement before discussion of 969 it was then validated by the principal investigator all discrepancies were resolved through discussion between at least two members of the interdisciplinary research team with final decisions approved by the principal investigator to enrich and validate the results of this first step as is often done in scoping studies 43 the dimensions identified with the seven interrogative pronouns provided the starting point for a 90minute workshop conducted by the principal investigator this workshop aimed to reach a consensus on key elements of the definition of social participation and identify participants perceptions of related challenges and concerns the workshop involved 32 content experts and knowledge users ie 11 researchers 8 partners 7 collaborators and 6 students from an interdisciplinary emerging partnership on older adults social participation 5051 while workshop participants were mainly academics who conducted research on social participation partners and collaborators came from community organisations working directly with or representing older adults all dimensions identified were discussed not just the commonest the workshop began with testimony concerning social participation from three older adults and to validate the main ideas finished with a synthesis of the proposal the workshop was audiotaped and a research professional took notes mainly on a clipboard the workshop also included a 15minute powerpoint presentation summarising preliminary results followed by a 60minute discussion on which key elements to retain during this discussion older adults primarily shared their views while some of the researchers briefly raised points from their own studies to stimulate debate the notes and audiotape were considered throughout the content analysis of the definitions and when proposing a consensual definition by revisiting the definitions three times ie synthesis and workshop and triangulating these perspectives the authors of the present paper corroborated the analysis and a consensus on the definition was reached this work was supported by a social sciences and humanities research council emerging partnership 89020120034 results of the 2326 papers retrieved through electronic searches almost half were duplicates and 936 did not meet the inclusion criteria based on titles and abstracts of the remaining 314 more than two fifths were excluded since they did not provide a definition of social participation nearly half were eliminated because they referred to another source ultimately 54 original definitions 15 of which were added because of extended search strategies were extracted and contentanalysed year of publication of the papers containing an original definition ranged from 1987 to 2020 almost three quarters were published after 2010 with the most productive year being 2019 a majority of first authors were from north america and europe principally working in healthcare and social services and gerontology or geriatrics with nearly onetenth from rehabilitation only a limited number of the definitions came from the psychology sociology education and social work literature most papers specifically concerned older adults and used the term social participation or social engagement a majority reported empirical results mostly from quantitative crosssectional or longitudinal studies onefifth of the papers were more conceptual with the majority from reviews definitions according to the content analysis based on the seven interrogative pronouns dimensions related to how and what were found in most definitions dimensions concerning who and where and with whom were present in ability to take advantage of opportunities for social interaction nursing home residents involvement in the social and recreational life of the facility social participation 54415 individuals levels of participation in both social and civic affairs civic engagement 55236 ways in which citizens participate in the life of a community in order to improve conditions for to others or to help shape the communitys future social participation 56283 person takes part in the activities of formal and informal groups as well as other activities in society social engagement 57331 the extent to which individuals participate in a broad array of social roles relationships and activities social participation 581811 ability to participate in work and education social participation 595 collective activities that individuals may be involved in as part of their everyday lives this might include being a member of a community group a tenants association or a trade union supporting the local hospice by volunteering and running a study group on behalf of a faith organisation social engagement 601189 a psychological thought process and a conscious behaviour that shapes all forms of social relationships and by which social ties and social networks are derived this includes both relationships that are a source of social support and those that are less supportive social engagement formal social engagements and social interactions with other friends and relatives social engagement 72549 participation in activities that involve interactions between or among people capturing a broader array of social interactions and intensity of interaction that may contribute to greater social integration community participation 73772 active involvement in activities that are intrinsically social and either occur outside the home or are part of a nondomestic role social participation 747 interaction that older adults have with other members of their community and the extent that the community itself makes this interaction possible social participation 752 persons involvement in social activities social engagement 76939 contacts or connections between individuals that include some element of socioemotional exchange that is flows of interactive utilitarian and affective elements social participation 77657 formal voluntary commitment to community organisations on a regular basis social participation 7882 engagement in daily social activities social engagement 79642 participation in social activities and socialisation with others social participation 801 participation in civic groups that an individual can join regardless of occupation or family situation 83334 carrying out meaningful social roles through activities embedded within social relationships social participation 1125 attending external activities such as social clubs or volunteering social participation 84976 accomplishing an attempted life habit without difficulty social participation 85555 persons engagement in social groups social participation 86133 peoples involvement in social activities community participation 871161 involvement in local economic political cultural and voluntary activities social participation 882 form of social interaction that includes activities with friends family andor other individuals social engagement 891062 participation in social activities such as community events volunteerism or providing support to older people social participation 90801 respondents social group involvement community integration 91526 community involvement and interaction with social networks social participation 923 involvement in society had occurred the aspects were public meeting attending a club participating in society or other meetings etc social engagement 93156 interaction with neighbours and participation in social activities including attending religious services social clubsorganisation meetings sportscultural activities and civicpolitical organisations social participation 94317 both aggressive participation and passive participation in social interactions social engagement 95187 taking part in events meetings and activities within a local community social participation 961959 two categories •formal participation through membership of an organised association •informal daytoday activities initiated by older people themselves without an organisation social participation 976 various activities in which the older adults participate in their neighbourhood including five styles volunteer works selfmanagement and mutual assistance activities lectures and reports recreational and sports activities and interest groups social participation 3368 conscious and active engagement in outdoor social activities leading to interacting and sharing resources with other people in the community and the person has a personal satisfaction resulting from that engagement social participation 98 participating in activities of a social nature ie nurturing meaningful relationships being part of a community and participating in group volunteer or paid work activities social engagement 992 to engage in both individual and societylevel activities also called social participation or social involvement forms the basis of social relationships or participation in a community and provides a sense of belonging social identity and fulfilment social involvement 1002 •informal relationships with people from ones social network such as family and friends and focuses on useful interactions that entail provision of support in which adults are needed and beneficial •formal activity in formal organisations such as volunteering civic engagement 10139 psychological attentiveness to social and political issues civic participation 10139 action on social and political issues behavioural in nature activities conducted individually or within a group or organisation civic activities may primarily aim to help others solve a community problem or produce common good with no manifest political intention or may explicitly seek to influence political outcomes almost half the definitions dimensions related to when and why were found less often no definitions specifically targeted instrumental activities or responsibilities current and satisfaction of needs or survival but one definition newly focused on educating most definitions focused on people involved in activities providing interactions with others in society or the community following is a detailed description of the dimensions identified in the definitions for each interrogative pronoun whoalthough one paper in five defined social participation from an individual perspective most definitions took a population perspective howsocial participation was mostly defined as involvement ie taking part and included participation connection contribution or integration of the person while engagement referred to a stronger commitment and was mostly emphasised by public health performance focused on actions and ability to take advantage of opportunities or participate whatsocial interactions and activities were mainly found in the definitions and generally came from the field of 1 5 15 17 20 25 30 36 41 49 10 how 2 involvement 16 8 11 1418 22 23 25 2932 34 37 38 4048 50 51 54 16 20 21 28 36 49 51 54 8 3 performance 2 7 13 19 35 54 6 what 4 activities 1 5 6 8 10 1416 19 22 23 30 33 34 35 39 4648 50 52 54 22 50 41 social activities 1 3 8 11 12 14 19 25 29 37 40 42 44 46 4851 54 8 14 18 19 27 35 38 40 48 50 52 11 412 community activities 3 8 14 19 34 40 4244 46 48 53 54 13 42 recreational activities 12 18 44 48 4 43 daily activities 28 47 51 3 44 instrumental activities 5 social roles 1 5 6 17 20 21 27 32 33 47 52 11 51 responsibilities 6 social interactions 2 6 9 10 1115 17 18 21 22 24 26 29 33 39 42 44 45 5052 1 4 5 1113 15 17 19 23 38 41 43 46 48 4952 54 gerontology and geriatrics papers referred to life situations or different kind of activities other external individual collective various formal informal paid or voluntary for one definition 62 social engagement specifically involves formal social relations as opposed to informal ones that include ties to family and friends scoping study of definitions of social participation wheresocial participation was more commonly defined as happening in the community or society especially in the public health literature but also occurred in organisations mostly related to gerontology and geriatrics no definition specifically mentioned virtual participation with whomdefinitions mentioned that social participation involves family friends neighbours or other individuals especially in gerontology and geriatrics and also groups or associations mostly in the public health field five definitions described how others or groups are involved namely by offering social and emotional support having a reciprocal relationship or making the interaction possible whenaccording to two definitions social participation takes place regularly whyfinally and mainly from the gerontology literature approximately one definition in four mentioned that social participation involves development mainly personal but also social or meaningfulness such as helping others meaningfulness is based on older adults interests and what gives them a sense of belonging or fulfilment or contributes to their identity only one definition considered social participation as including support from others or being educated coconstruction of an interdisciplinary consensual definition according to content experts and knowledge users and based on previous results and testimony from three older adults social participation can be defined as the action of being involved in community life socially or politically and structured by the environment which places can be shared and which are significant participating socially is a conscious free choice not an obligation and it takes various evolving but significant forms according to available time social participation is highly personalised ie based on individual priorities motivations and interests and involves social interactions and relationships with others while it can be achieved for oneself and simultaneously for community wellbeing and development social participation gives life meaning based on the literature review and to better represent older adults social participation can be defined as a persons involvement in activities providing interactions with others in community life and in important shared spaces evolving according to available time and resources and based on the societal context and what individuals want and is meaningful to them discussion this paper provides an updated inventory and synthesis of 55 definitions of social participation in older adults enriched by a discussion with content experts and knowledge users based on these findings social participation can be defined as a persons involvement in activities providing interactions with others in community life and in important shared spaces evolving according to available time and resources and based on the societal context and what individuals want and is meaningful to them a consensual definition is important in order to better communicate develop or select measuring instruments intervene develop policy or analyse research results 7 although it shares similarities with the previous synthesis 7 this new definition emphasises the where when and why one conceptual analysis of social participation also emphasised the importance of communitybased activities interpersonal interactions sharing of resources active participation and individual satisfaction 33 the why of the current definition is also globally related to all dimensions of social participation identified by raymond and colleagues 32 which were developing significant relationships enjoying pleasant group activities engaging in a collective project assisting and supporting each other sharing knowledge and being empowered in decisions concerning themselves these dimensions provide clear examples of what older adults want and what contributes to their development and is meaningful to some of them however this does not constitute a norm and may differ from societal expectations an important point that cannot be overemphasised linked to the key elements of the mobilisation process 32 the dimensions also highlight the involvement and even the engagement of older adults compared to involvement engagement indicates a contribution that can be more demanding and sustained 7 this appeared more often in recent definitions finally the number of original definitions increased compared to the previous synthesis this may be attributable not just to the longer period but also to the greater importance of this concept in the last decade or to the persistent lack of agreement given the importance of active ageing and the contribution of older adults to society socioeconomic and personal development benefits for older adults and society selfactualisation and goal attainment also emphasising the why the influence of some international health policies must not reinforce normative standards or societys expectations and stigmatise older adults who choose not to be or cannot be involved in some social activities older adults can participate socially without being involved in an organisation such as by doing activities with their grandchildren or helping neighbours family friends or others or even during everyday activities such as shopping or going to the hairdresser while ageing personal and environmental resources that are mobilised to participate socially can change 47 and might necessitate assistance from community organisations and health and social professionals 102 to encompass a broader perspective of social participation professionals who work with older adults might also help them to use relevant resources and promote their autonomy and connectedness with the community 98 social participation must be recognised as a personal choice and human right and health policies should include actions to facilitate involvement in activities or interactions meaningful to people especially older adults with disabilities or insufficient personal or environmental resources compared to the previous synthesis 7 recent definitions referred less often to where social participation takes place based on the workshop community is important as is community life which highlights the importance of social interactions and activities that take place in the neighbourhood and other public spaces during the covid19 pandemic and despite sanitary measures using public spaces generated anxiety in older adults and most people worried about infecting family members or friends through social interactions 103 which greatly increased the risk of being socially isolated 104 to foster physical distancing and restrict propagation of the virus the size and ventilation of these public spaces and building materials used must be rethought friendliness and safety of neighbourhoods are also important factors associated with social participation that have been emphasised not only in policies but also in empirical studies synthesised in a review 105 sometimes the environment itself can cause social exclusion 25 like stairs for people with limited mobility with advancing age life space can be even more restricted and the neighbourhood becomes a central element in the social participation of older adults 106107 including interactions between neighbours 108 time was also mentioned less often in this new synthesis yet evolution of the concept over time is an important dimension which was reported in this studys workshop and documented in previous studies 109 110 111 112 113 114 115 for instance scoping study of definitions of social participation when interviewed about their neighbourhood participation new zealanders aged 85 and over reported holding onto everyday life as participating and being concerned about maintaining their capacities while ageing 116 evolution can occur not just in individuals but also between generations 35 justifying the need to revisit the concept over time especially when important societal changes occur such as increased use of social media or a pandemic the workshop also raised the issue of the time available to participate socially a dimension linked to optimal participation being the fit between an individuals reality governing how social activities are done and expectations about them 19 although the why and more specifically reference to meaningfulness were added after the workshop fewer definitions in the recent literature included this dimension compared to the previous synthesis 7 a finding that may concern the baby boomer generation which values freedom new life projects selfdetermination and greater citizen presence 36 in addition older adults may feel they contribute to society and fulfil a role when they help others such as by volunteering babysitting or caring for family members 117 the importance of meaningful activities and purposeful life has been highlighted especially in the occupational sciences 118 and there are emerging interventions that empower older adults to develop their own routines fostering their health and making life more fulfilling for example lifestyle redesign 119 a preventive occupational therapy intervention has been shown to improve health be costeffective 120 and has been adapted to many contexts including quebec canada 121122 while it is important to prevent loneliness and isolation social participation should not only be a way for older adults to stay active it should also increase their wellbeing feeling of being valued and sense of purpose finally rather than being an obligatory contribution to society including economic activities meaningfulness should have a more central place in health policies according to the content experts and knowledge users in this study thus to improve health promotion these policies should increase their scope to specifically include informal and meaningful participation which would encompass a broader spectrum of the ageing population strengths and limitations expanding upon a previous synthesis and using a rigorous innovative procedure a methodological framework for scoping studies and content analysis using interrogative pronouns this study presents an indepth review of many original definitions of social participation found in various multidisciplinary databases this procedure involved at least two people analysing the content of definitions and a workshop with content experts and knowledge users from an emerging interdisciplinary partnership on social participation among its limitations this study did not include the concepts of participation societal participation handicap disability meaningful activities and occupation which generated too many unrelated results although some papers using these concepts might have been relevant moreover retrieving original definitions was occasionally challenging as papers sometimes define the concept implicitly or mainly for operationalisation purposes finally although they might reflect an evolution in the definitions or different perspectives in the group opinions from two groups of authors 8590101 might be overrepresented in the analysis as two original definitions were extracted for each group conclusion this scoping study provides an updated inventory and synthesis of definitions of social participation in older adults enriched by a critical review involving content experts and knowledge users although the literature mostly defined social participation as peoples involvement in activities providing interactions with others in society or the community content experts and knowledge users emphasised the importance of community life and shared spaces moreover social participation should be seen as evolving with available time and resources and based on what individuals want and is meaningful to them 123 and the societal context as the pandemic clearly showed social participation and interactions are essential for peoples wellbeing to enable community organisations healthcare providers and decisionmakers to encourage social participation on the ground and in policies a deep understanding of its conceptualisation is needed as it evolves with virtual communications and respect for social distancing in their studies researchers must provide a definition of social participation and choose a measuring instrument accordingly future studies should involve older adults family members and professionals working with them and examine how social participation is operationalised and measured to make it easier to compare research results the aim should be to achieve a consensus regarding a single definition and a measuring instrument declaration of conflict of

background considering the importance of social participation for quality of life and active ageing in older adults it is an important target of social and health professionals interventions a previous review of definitions of social participation in older adults included articles up to 2009 new publications and changes in the social context eg social media and the covid19 pandemic justify continuing this work objective this paper provides an updated inventory and synthesis of definitions of social participation in older adults based on a critical review by content experts and knowledge users a consensual definition is proposed methods using a scoping study framework four databases medline cinahl ageline psycinfo were searched with relevant keywords fiftyfour new definitions were identified using content analysis definitions were deconstructed as a function of who how what where with whom when and why dimensions results social participation definitions mostly focused on peoples involvement in activities providing interactions with others in society or the community according to this new synthesis and input from content experts and knowledge users social participation can be defined as a persons involvement in activities providing interactions with others in community life and in important shared spaces evolving according to available time and resources and based on the societal context and what individuals want and is meaningful to them conclusion a single definition may facilitate the study of active ageing and the contribution of older adults to society socioeconomic and personal development benefits for older adults and society selfactualisation and goal attainment

introduction infertility represents a major reproductive health issue with substantial clinical humanistic and economic burdens alongside demographic repercussions it is defined as a disease of the female or male reproductive system characterized by the failure of achieving clinical pregnancy after engaging in regular unprotected sexual intercourse for 12 months or more 12 with the staggering global lifetime prevalence reaching approximately 176 of the adult population based on world health organization estimates for 2022 infertility may have a profound and devastating impact on contemporary society and affected individuals 2 the magnitude of this public health concern hindering the attainment of several united nations sustainable development goals underscores the need for a comprehensive and multifaceted agenda targeting policy formulation and advocacy research efforts and educational activities concomitantly with the provision of reliable accessible and equitable fertility care services 3 addressing the infertility in a responsible and coordinated manner is of paramount importance for fostering sexual and reproductive health and rights and subsequently the overall physical and mental wellbeing the intricate and heterogeneous pathogenic landscape of infertility challenges both its epidemiologic and causative analysis although the interaction between partners determines the fecundity it is estimated that pure or combined malefactorassociated infertility is present in approximately 50 of all the couples experiencing undesired childlessness 4 the etiology of male infertility encompasses a broad spectrum of pretesticular causes testicular disorders and posttesticular conditions the underlying mechanisms may be traced to disrupted spermatogenesis gonadal and extragonadal endocrine disorders congenital or acquired anatomical defects functional urogenital anomalies immunological and geneticrelated causes sexual dysfunction infections certain chronic illnesses environmental exposures and lifestyle determinants 56 nevertheless in 3040 of primary testicular failure subjects the etiology remains elusive and these cases are referred to as idiopathic male infertility 7 despite reasonable limitations regarding the assessment of the overall spermatozoal fertilizing capacity intraindividual variability in relevant parameters over the course of time and analytical standardization issues conventional semen analysis remains fundamental and often the most informative component of the infertility evaluation in men 8 nevertheless quantitative and qualitative semen parameters complying with reference values do not necessarily equate to normal fertility as some men may have latent health impairments or fertility disturbances conversely abnormal semen analysis results do not unavoidably indicate infertility 9 all men facing conception difficulties should receive a comprehensive medical assessment to identify and address any modifiable risk factors compromising their reproductive potential the implementation of a structured multidisciplinary clinical care algorithm featuring reproductive endocrinologists andrologists and general urologists supports the streamlining of the diagnostic process and treatment planning eventually resulting in better procedure coordination and enhanced patient care by leveraging the expertise of these specialists a collaborative practice model fostering a holistic and personalized approach establishes a dynamic platform for a seamless and wellorchestrated exchange of knowledge insights and resources thereby facilitating the pursuit of targeted and tailored interventions leading to superior patient outcomes furthermore accumulating scientific evidence suggest that infertile men may have increased susceptibility to cardiovascular diseases certain oncopathologies and phychoemotional disorders underscoring the importance of appropriate screening and counseling 1011 the inability to meet personal desires and public expectations of male procreation is often recognized as a threat to the traditional perception of masculinity and may be related to social stigma and significant impacts on the quality of life of men and their partners 12 in men who regard fatherhood as an important element of their male identity the inability to become biological parents may trigger profound psychological distress featuring an array of negative emotions including the feelings of shame guilt and inadequacy by acknowledging the fertility issue and engaging in activities related to treatment some men are forced to deconstruct and reframe the embodied notions of their manhood 13 regardless of the rising prevalence trends in male factor infertility this topic largely remains taboo at least partially due to the societal norms discouraging men from disclosing their struggles and openly discussing their vulnerabilities furthermore there is a notable gender imbalance in the current literature on infertility as most studies have focused on the female position thus often leaving the male perspective overlooked or underestimated 1415 hence it is essential to expand the breadth and depth of the scientific knowledge base regarding the qol of infertile men to gain a deeper insight into their needs and to inform the development of effective interventions aimed at enhancing their overall health and welfare 16 the objective of this study was to investigate the qol and emotional distress of men undergoing infertility treatment in serbia using a multidimensional approach featuring validated selfreport questionnaires physical measurements and medical records to provide a holistic perspective of the complex interplay between psychological and physical factors in mens experience of infertility particular emphasis was placed on the exploration of the impact of the treatment duration on the qol and psychoemotional disturbances as well as the sequence of relationships between these constructs materials and methods study design and participants this observational crosssectional study recruited a sample of patients attending the clinic of urology university clinical center of serbia for infertility treatment from january to may 2018 the recruitment protocol included four consecutive stages identifying potential participants and screening against the predefined criteria approaching the selected men and proposing their inclusion in the current research project providing all the relevant information regarding the purpose of the study responsible entities and a detailed description of anticipated activities and specifying the protection procedures applied for ensuring personal data privacy and confidentiality prior to finally seeking ethically valid and scientifically appropriate consent in order to limit participants burden and avoid additional clinical appointments that may compromise the overall recruitment rate both data and sample collection were organized within the individuals standard outpatient care schedule all the recruitment activities were performed by trained healthcare professionals ie 4 responsible urologists serving as members of the core research team acknowledging the possibility of intentional andor unintentional bias introduced by socalled gatekeepers 1718 the selection protocol and conditions were clearly articulated and formally approved by the internal clinics professional board and the initial screening stage was performed concomitantly by two independent researchers eligible participants were adult men of 18 years and older willing to join the study experiencing at least one year of primary or secondary malefactorassociated infertility confirmed by a specialist in accordance with the european association of urology guidelines on male infertility 19 with an absence of cognitive disability precluding the capacity to provide responses to study questionnaires independently and accurately the exclusion criteria were as follows compromising mental illnesses or severe functional impairments a history of alcohol andor drug abuse that may distort the validity of the obtained results present psychiatric disorders requiring treatment and limited languagecommunication capacities a total of 118 men undergoing infertility treatment were approached over the course of the recruitment process and screened against the predefined eligibility criteria among suitable subjects 102 voluntarily agreed to participate in the study nevertheless due to failure to adhere to the research protocol and provide all the required data prior to study completion 4 men were disqualified and thus excluded from further analysis furthermore 2 decided to withdraw their consent yielding a final sample of 96 male individuals and an overall response rate of 8136 ethics statement this nonincentivized study was conducted in accordance with the ethical principles and standards of medical research involving human subjects expressed in the declaration of helsinki the protocol was approved by the ethics committee faculty of medicine university of belgrade all research participants provided written informed consent for data collection semen sample provision and the subsequent analysis data collection general and medical history data participants sociodemographic lifestyle and medical data were collected with a purposefully devised questionnaire in a standardized manner via structured facetoface interviews conducted by trained healthcare professionals by maintaining a professional and objective attitude the interviewers aimed to establish an atmosphere of trust thus ensuring that each subject was treated respectfully and with dignity general information included age residential region education occupation prior paternity and selfperceived socioeconomic status the compilation and presentation of the highest attained level of formal education were performed in compliance with the wellestablished international standard classification of education reference framework 20 whereas the patients professional profile was indicated based on categories proposed by the international classification of occupations 21 furthermore the questionnaire addressed relevant lifestyle determinants and diverse environmental factors associated with an adverse impact on male fertility 22 comprehensive medical data including present acute and chronic conditions past medical and surgical history and family history were retrieved from personal health records anthropometric assessment the anthropometric assessment was performed in a clinical setting during the physical examination by skilled medical staff participants body weight in light clothing and without footwear was measured using an electronic platform scale with tarring capacity calibrated to 01 kg height was recorded with an accuracy of 01 cm with a mobile stadiometer body mass index was calculated as a ratio of weight and standing height squared based on bmi subjects were allocated to normal weight overweight and obese categories 23 physical activity evaluation patients physical activity estimates were based on the internationally acknowledged and broadly applied selfadministered international physical activity questionnaireshort form 24 the instrument referring to the 7day recall period captures vigorous and moderateintensity physical activities walking and sitting all undertaken across a wideranging set of domains including occupationrelated activities transportation domestichousehold chores and leisure time featuring seven short response items the ipaqsf imposes minimal respondents burden thus implying negligible survey fatigueinduced bias 25 following the questionnaire scoring manual and the compendium of physical activities coding scheme 26 the activity scores were converted into metabolic equivalents in minutes per week such a measure introduced to facilitate and promote the interstudy comparability of coded physical activity indices is presented in both absolute values as well as in the form of 3level categorical scores the sedentary period was not included in energy expenditure calculations but is presented as a separate informative entity the threshold for excessive sitting was set on 540 min per day 27 evaluation of psychoemotional disturbance the participants level of psychoemotional distress was evaluated with the depression anxiety stress scales 42 questionnaire 28 this survey tool represents the tripartite construct characterized by a low positive effect anhedonia life devaluation avolition inertia and hopelessness specific to depression physiological hyperarousal apprehension and general distress pertinent to anxiety and persistent irritability impatience agitation nervous tension and chronic nonspecific arousal corresponding to stress 29 a substantial research corpus featuring dass42 provides robust evidential verification of the questionnaires good psychometric properties reliability and validity in both community and clinical populations dass42 encompasses fortytwo selfreport items divided into three subscales referring to distinguishable yet moderately intercorrelated negative emotional symptom clusters 30 the instruments reference period is the past week and each item is rated on a 4point likerttype severityfrequency scale ranging from 0 to 3 domainspecific scores are summed for the respective scales with higher scores indicating more pronounced distress and a higher prevalence of the syndromerelated symptoms given that dass42 is based on the underlying assumption that emotional disorders intrinsically display a continuum of severity this tool provides quantitative rather than categorical measures without the ambition to assign respondents to discrete diagnostic entities postulated by the conventional morbid taxonomic classificatory frameworks dass42 scoring and interpretation guidelines propose cutoff values for percentile scores defining mild moderate severe extremely severe labeled categories for each subscale healthrelated quality of life assessment the 36item short form survey was employed for the assessment of the healthrelated quality of life 31 accommodating the diversity of major dimensions and operational definitions of health and acknowledging the potential and utility of wellconstructed standardized shortform assessment tools sf36 is a patientreported generic multifaceted eightscale instrument the comprehensive conceptual structure of the questionnaire encompasses the following spectrum of health domains physical functioning role physical bodily pain general health vitality social functioning role emotional and mental health following the introductory tool familiarization and filling out instructions the questionnaire was selfadministered in the presence of research staff no proxies were allowed by the study protocol and the completion time averaged 1015 min in order to minimize the desirability bias and interviewerrelated confounding effects researchers adhered to a standardized script aiming to communicate with respondents in a neutral nonsuggestive nonjudgmental manner the computational analysis of the sf36 was performed as a multistep procedure resulting in eight subscalespecific numerical scores first the predefined likerttype values were recoded and linearly transformed per the weighted percentagebased scoring key subsequently items pertaining to the respective health domain were averaged to create eight summary measures ranging from 0 to 100 whereby lower values represent less favorable outcomes and more intensely perceived disability semen examination semen processing and analysis were performed by an accredited laboratory following standardized procedures compliant with the internationally acknowledged world health organization manual 32 ejaculates were obtained through masturbation after 37 days of sexual abstinence in a private room on clinical premises into a specialized sterile graduated widemouthed testvessel made of spermatozoa nontoxic material men were provided with a detailed information sheet and precise spoken instructions concerning the appropriate protocol for semen sample collection in order to prevent the adverse impact of sample exposure to temperature fluctuations and ensure a proper assessment of liquefaction the specimen containers were placed in an incubator preset at 37 • c within 5 min after the collection routine macroscopic evaluation volume determination and preparation of dilutions and smears for the assessment of quantifiable features and spermatozoa qualitative attributes were performed in the following 3060 min patients were allocated to appropriate categories based on semen parameters the lower reference limits for the semen volume sperm concentration total spermatozoa motility and progressive motility were 15 ml 15 × 10 6 spermatozoa per ml of ejaculate 40 and 32 respectively patients presenting with a reduced sperm concentration were further classified into 3 subgroups severe moderate and mild oligozoospermia sperm motility findings not meeting the defined criteria were considered asthenozoospermia patients with less than 4 of morphologically normal spermatozoa forms according to the papanicolaou staining procedure and an observation with brightfield optics in oil immersion at 1000× magnification were diagnosed with teratozoospermia the estimated presence of leukocytes determined by the peroxidase activity assay in concentrations exceeding the consensusbased threshold value of 10 × 10 6 per ml of ejaculate was labeled as pyospermia statistical analysis statistical analysis was performed using ibm spss statistics for windows version 280 and opensource jasp software version 0172 33 continuous data were summarized with the appropriate measures of the central tendency complemented by measures of dispersion whereas categorical data were presented in absolute numbers and frequencies the normality of the variable distribution was explored with the kolmogorovsmirnov test differences between sample subgroups were assessed using the mannwhitney u test or the chisquare test in accordance with the variable type spearmans rank correlation was employed to evaluate the strength and direction of associations between dass42 and sf36 scale scores in conjunction with the conventional frequentist statistical approach bayesian inference was adopted with an aim to enhance the effect of the robustness estimation and credibility of the conclusions therefore alongside frequentist statistical metrics the bayes factor is reported as a quantitative indicator of the relative predictive performance of the two rival hypotheses such a hybrid approach fosters a more comprehensive and rigorous analysis enabling wellinformed and reliable interpretations of study findings while acknowledging and managing the inherent advantages and disadvantages of each statistical paradigm deviation from bf 10 1 which indicates equal support for the null and the alternative hypothesis represents the degree of evidence in favor of either h 0 or h 1 consensually bf 10 values greater than 1 are supportive of h 1 while a bf 10 lower than 1 favors h 0 3435 the mediation analysis was conducted in order to elucidate the role of depression anxiety and stress in the relationship between the sf36 role emotional domain and infertility parameters ie the sperm concentration category and the duration of infertility treatment specifically we aimed to assess whether the effect of infertility on sfre was direct or mediated by the levels of psychoemotional disturbances results the overview of the descriptive characteristics of enrolled patients stratified by treatment duration is summarized in table 1 with the average height weight and bmi of 18158 ± 703 cm 9265 ± 1801 kg and 2772 ± 401 kgm 2 respectively the majority were overweight or obese whereas the rest were allocated to the normal weight category respondents were predominantly employed residing in the urban setting of the capital city region childless and had selfperceived middlelevel socioeconomic status current habitual cigarette and alcohol consumption was present in 2917 and 5625 of the studied samples respectively according to the ipaqsf assessment threequarters of the studied men were categorized as active and the cohortlevel estimated total energy expenditure was 426259 ± 442525 metminutes per week on average the contributions of vigorous moderatelevel intensity and walking activities were 171125 ± 277718 106854 ± 161575 and 148277 ± 139510 metminutes per week respectively the selfreported daily sedentary period featured a broad range from 30 to 960 min and reached the average value of 37412 ± 18824 min excessive sedentary behavior ie sitting for 540 min or more per working day was recorded for 15 men although not reaching the statistical significance threshold subjects allocated to the low physical activity category had a higher bmi compared to the moderate and high activity groups among respondents fewer than 10 reported repetitive and prolonged exposure to occupational and environmental factors with a postulated detrimental impact on fertility a review of personal medical records revealed a history of sexually transmitted infections in 13 patients whereas 9 were previously treated for nongonococcal urethritis in total 15 participants had prior urological surgery including inguinal hernia repair and varicocelectomy the overall burden of chronic nonmalignant diseases was relatively low with hypertension being the most prevalent condition followed by allergies diabetes and respiratory diseases in addition four subjects were cancer survivors based on participants report six had a family history of male infertility in the analyzed cohort the infertility treatment duration ranged from 12 to 180 months with an overall average of 3480 ± 3361 months the reported period pertains to the time dedicated to diagnostic and therapeutic procedures aimed at achieving successful pregnancy treatment modalities included a spectrum of the available armamentarium including the promotion of lifestyle modifications sexual dysfunction management treatment of urogenital tract infections targeted endocrinologic interventions surgical procedures and most commonly application of assisted reproductive technology treatments patients may have undergone different procedures either concomitantly or one after another as the treatment evolved over time based on individual circumstances surgical approaches may be categorized into four main groups interventions aimed at enhancing semen parameters surgeries to optimize sperm delivery procedures for diagnostic purposes and interventions for the retrieval of sperm specifically for in vitro fertilization no statistically significant differences were observed between the subgroups of patients treated for less or more than two years regarding the anthropometric indices selfreported lifestyle determinants physical activity prior urological pathologies and the general comorbidity burden including allergies and cardiovascular respiratory hematological gastrointestinal and rheumatic diseases neurological and psychological disorders dermatologic conditions endocrine and metabolic disturbances hepatitis and cancer semen analysis revealed the complete absence of spermatozoa in the ejaculate of 10 patients sperm concentrations below the who lower reference limit either isolated or present in conjunction with motility andor morphologyrelated spermatozoa deviations were found in 45 subjects it is noteworthy that the majority of patients presenting with oligozoospermia had a severe form the concomitant existence of multiple semen abnormalities ie oligoasthenozoospermia asthenoteratozoospermia oligoteratozoospermia and oligoasthenoteratozoospermia was detected in 25 27 31 and 23 men respectively poor sperm motility was more pronounced among active smokers and men experiencing fertility issues for a longer period of time accordingly among individuals with infertility treatment exceeding two years there was a significantly higher prevalence of asthenozoospermia 12667 p 0001 oligoasthenozoospermia 10682 p 0001 asthenoteratozoospermia 10299 p 0001 and oligoasthenoteratozoospermia 11159 p 0001 teratozoospermia was detected in 33 subjects and was always associated with other seminal alterations fewer than 10 of the study participants had an abnormally elevated concentration of leukocytes in semen samples and the majority had an ejaculate volume within the reference range the overall average scores based on the dass42 psychosocial distress evaluation were 452 ± 498 389 ± 415 and 1078 ± 783 points for the depression anxiety and stress negative emotional dimensions respectively a visual inspection of the distribution plots revealed right skewness for all the subscales and the significant deviation from the normal distribution was confirmed through kolmogorovsmirnov tests a summary of the obtained results featuring each scale central tendency and variability measures conservative frequentist probability and bayesian inference metrics along with further sample stratification based on conventional ratings from mild to extreme severity are provided in table 3 as presented score discrepancies between patients undergoing infertility treatment for less or more than two years were not statistically significant based on a mannwhitney u test with the bayes factors indicating moderate strength of evidence in favor of the null hypothesis for the anxiety and stress domains and weak for the depression subscale although it is important to reiterate that particulate domain scores should be primarily regarded as dimensional rather than categorical the prevalence of subjects surpassing a priori defined cutoff points for depression anxiety and stress was 13 11 and 22 respectively confirming the established pattern of an absence of statistically significant differences between men treated for less or more than two years 1118 p 0290 anxiety subscale χ 2 2122 p 0145 and stress subscale χ 2 0050 p 0824 strong positive correlations between subscales corroborated conceptually related underlying constructs score distributions across eight healthrelated quality of life conceptual areas comprised in the sf36 questionnaire are presented in table 4 component summary scores ranged from 4900 ± 625 for the mental health dimension to 9016 ± 1775 obtained in the physical functioning subscale expectedly correlations between scales were positive and with a limited number of exceptions statistically significant the ceiling effect was observed in physical functioning role physical and social functioning domains when assessed against the infertility treatment period the betweengroup difference reached the threshold value of statistical significance only for the role emotional concept patients with a longer treatment duration scored lower in this health domain indicating a less favorable state a significant correlation with the negative direction and moderate magnitude was confirmed with the analysis featuring the treatment period as the continuous variable 0270 ipaqsfbased estimates of physical activity expressed as metminutes per week correlated inversely with the bodily pain subscale 1361 patients presenting with semen abnormalities did not differ from their normospermic counterparts regarding the results attained in any of the sf36 health dimensions not surprisingly significant positive correlations were observed between the scales encompassed by dass42 with depression vs anxiety showing spearmans ρ 0544 depression vs stress with spearmans ρ 0540 and anxiety vs stress exhibiting spearmans ρ 0623 while inverse associations were found between dass42 scores and sf36 health domains a heatmap plot as the graphical representation of the correlation matrix indicating both direction and magnitude of the observed associations between these instruments is presented in figure 1 individually constructed mediation models for depression anxiety and stress entailed estimations of both direct and indirect effects the mediation model pertaining to the dassanxiety symptom cluster indicated a statistically significant direct effect of both the sperm concentration grouping and the timeextent of the infertility treatment based on sfre while significant indirect effects were observed only for the treatment duration entity the mediation model for dassdepression yielded lessconvincing results with direct effects demonstrating marginal significance for sperm concentration categories and no significant effects for the treatment duration additionally the model did not reveal any significant indirect effects similarly the mediation model for the dassstress cluster yielded results with only the direct effects of statistically significant levels for the sperm concentration class the direct effects for the infertility period as well as indirect ie mediation effects were all bellow the statistical significance threshold total effects of the sperm concentration category and infertility duration based on sfre were both significant this implies that sfre is directly affected by the explored infertility parameters and that the effect of the treatment duration is partially mediated by socioemotional distress expressed in the form of anxiety figure 1 heatmap correlation matrix presenting associations between the depression anxiety stress scale and 36item short form health survey questionnaire domains pfphysical functioning rprole physical bpbodily pain ghgeneral health vvitality sfsocial functioning rerole emotional mhmental health p 005 p 001 p 0001 the colors used in the heatmap are designed to convey specific information about the correlations red indicates a negative correlation blue represents a positive correlation between two variables while the color intensity reflects the magnitude of the correlation coefficient a stronger correlation whether positive or negative is depicted by a darker and more saturated color while weaker correlations are shown with lighter shades discussion the experience of infertility diagnosis and treatment imposes a complex and mu faceted burden on affected individuals encompassing not only physical and medical pects but also a plethora of psychological social and emotional factors involuntary ch lessness may instigate a broad spectrum of negative feelings including guilt embarr ment reduced selfesteem grief anxiety and depression along with strained interp sonal relationships and social isolation 36 furthermore the impact of infertility m extend beyond the personal domain and affect the couples bond sexual functioning communication 437 the current literature on infertility displays considerable gen discussion the experience of infertility diagnosis and treatment imposes a complex and multifaceted burden on affected individuals encompassing not only physical and medical aspects but also a plethora of psychological social and emotional factors involuntary childlessness may instigate a broad spectrum of negative feelings including guilt embarrassment reduced selfesteem grief anxiety and depression along with strained interpersonal relationships and social isolation 36 furthermore the impact of infertility may extend beyond the personal domain and affect the couples bond sexual functioning and communication 437 the current literature on infertility displays considerable gender asymmetry with a predominant focus placed on the female position 3839 thus a more comprehensive and genderinclusive approach in the evaluation and management of infertilityassociated distress and its underlying determinants is essential to promote the overall wellbeing and qol of those struggling with conception by employing a multimodal assessment featuring validated selfreport questionnaires physical measurements and clinical records the present study sought to shed light on a nuanced interrelationship between physical and psychological factors affecting infertile men in serbia thereby addressing the dearth of research on the underrepresented male perspective in this domain the investigation yielded diverse semen abnormalities in the study cohort with notable associations between a prolonged treatment duration and reduced sperm motility among the participants 1354 surpassed predetermined thresholds for depression based on the dass42 questionnaire while 1146 and 2292 experienced elevated anxiety and stress levels respectively the summary scores from the sf36 questionnaire demonstrated a broad spectrum ranging from 4900 ± 625 for the mental health dimension to 9016 ± 1775 for the physical functioning subscale additionally patients with longer treatment durations exhibited lower scores in the role emotional domain indicating a less favorable emotional state as expected inverse correlations were observed between the sf36 mental health score and the dass42 subscales although occasionally supplemented by advanced and more sophisticated sperm function tests the routine analysis of semen exploring the vital parameters such as the concentration motility and morphology retains its indispensable role as a cardinal procedure in the assessment and treatment of male partners in couples experiencing infertility accordingly in conjunction with a thorough investigation of the reproductive and general medical history and rigorous hormonal and physical examinations physiologically aberrant spermatozoa remain the primary target of meticulous scrutiny throughout the infertility management 40 within the study sample a remarkable proportion of subjects was observed to manifest severe malefactor infertility encompassing the conditions of severe oligospermia and azoospermia 41 as advancements in the comprehensive evaluation of male reproductive function and diagnostic methodologies continue to unfold these conditions remain a formidable challenge in the realm of infertility treatment 42 the complete absence of spermatozoa was found in the ejaculate of 10 patients constituting 1042 of the study cohort these findings corroborate the current epidemiologic estimates of azoospermia indicating a prevalence of approximately 1 among the general male population and notably higher ranging from 10 to 15 among individuals diagnosed with infertility 43 historically men diagnosed with azoospermia were categorized as unambiguously infertile with sperm donation being the primary consideration for achieving parenthood however contemporary medical literature and practice have significantly advanced the understanding of azoospermia revealing that many underlying causes of this condition are potentially reversible thus offering new options as prospective avenues for restoring reproductive potential 44 the advancement of knowledge and subsequent paradigm shift in the management of severe malefactor infertility hold the potential of positively influencing the overall qol experienced by affected individuals this biomedical evolution not only contributes to the improvement of their psychological wellbeing but also acts as a catalyst in alleviating feelings of despair and cultivating a more positive and empowered perspective as they navigate the intricacies associated with confronting such health challenges 45 this is echoed by the findings of the present study given that no significant differences were observed regarding the overall healthrelated qol or psychosocial wellbeing between azoospermic or oligospermic participants compared to their normospermic counterparts as measured by the sf36 and dass42 respectively with accumulating evidence at the confluence of urology and reproductive biology a general understanding has evolved to recognize that the functional capacity of spermatozoa extends beyond their mere fertilization potential but rather includes their ability to orchestrate a normal course of embryonic development via diverse genetic and epigenetic mechanisms these spermborne imprints are influenced by multiple paternal variables such as the genetic makeup advancing age and certain modifiable riskfactors 46 one of the most significant phenomena with adverse effects on sperm quality features is the excessive generation of reactive oxygen species which may be related to a range of pathologic conditions environmental exposures and lifestyle determinants 47 asthenozoospermia present in approximately onethird of study participants can arise from structural abnormalities or functional impairments of spermatozoa as well as the deleterious effects of seminal plasma or due to the synergistic interplay of these detrimental factors 48 apart from intrinsic causes such as protein structural defects and genetic disorders contributing to deficiencies in sperm motility certain physiological processes occurring over the course of sperm maturation and ejaculation may also exert effects via intricate molecular alterations and cellular signaling events perturbation of these occurrences and their intensification beyond regulated levels lead to the exacerbation of negative impacts on sperm movement capacity 49 within our sample cigarette smoking emerged as a particularly prominent deleterious contributor among factors associated with oxidative stress and exposure to harmful chemicals evidenced by the significantly higher prevalence of asthenozoospermia observed among active smokers these findings are aligned with prior research including a comprehensive metaanalytical review that summarized published evidence regarding the adverse impact of smoking on semen parameters derived from more than 5000 men using the who criteria 50 the present study revealed a concerning observation regarding the excess weight prevalence among participants given that the significant majority exceeding twothirds were classified as overweight or obese a potential association between the escalating incidence of infertility and obesity at a global level has generated substantial interest and apprehension within both the scientific community and public health sectors 51 extensive research has been conducted to explore the impact of the detrimental synergy between an increasingly sedentary lifestyle and an unfavorable dietary regimen prevalent in western societies on the declining reproductive potential among males over the past halfcentury 52 the impact of obesity on semen quality and the reproductiveendocrine milieu has yielded conflicting findings and remains a topic of debate and uncertainty in the scientific literature 5354 to attain more objective insights on this issue it has been proposed that the research focus should be directed towards ordinary obese men rather than infertile individuals thus mitigating the potential confounding factors present in these patients 55 our findings underscore the need for clinicians awareness regarding both the direct and indirect effects of obesity on fertility a deeper understanding of the implicated physiological mechanisms and emotional disturbances and their dedication to the implementation of tailored interventions while additional investigations are required to fully ascertain the extent of efficacy and the precise role of each recommendation it is essential to motivate individuals encountering fertility difficulties to maintain a healthy body weight optimize their dietary habits restrict alcohol consumption engage in regular moderateintensity physical activity and cease smoking 38 it is recognized that the experience of involuntary childlessness may exert adverse psychological effects potentially giving rise to a paranormative crisis that detrimentally impacts mens selfesteem occupational functioning and personal relationships consequently heightening the likelihood of concomitant symptoms of anxiety and depression 56 the observed rates of men surpassing predetermined dass42 thresholds for depression anxiety and stress in the analyzed cohort were 1354 1146 and 2292 respectively when contrasting our findings with existing literature it is worth noting that the documented occurrence of psychological symptoms among infertile men exhibits considerable variation across diverse investigations a slovenian study involving 353 infertile men attending an outpatient infertility clinic documented anxiety traits in 199 of participants 57 similarly in a separate investigation encompassing 771 chinese men with infertility the prevalence rates for depression and anxiety were reported as 208 and 78 respectively 58 a polish study comprising 188 infertile men revealed rates above cutoff points for depression and anxiety as 156 and 479 respectively in contrast the observed prevalence rates in the swedish and italian samples were comparatively lower the swedish study reported major depression in 51 of males and various anxiety disorders in 49 of the sample 59 while the italian study documented anxious symptoms in 45 of men and depressive symptoms in 69 of the cohort 60 these discrepancies may stem from a multitude of factors such as differences in sample sizes variations in methodological approaches and the utilization of diverse measurement instruments moreover it is plausible to suggest that the reported psychopathological profiles are shaped by cultural nuances as well as the ethnic and demographic contexts in which these studies were conducted to gain a comprehensive understanding of these symptoms within specific population of infertile men further research is essential to unravel the intricate underlying determinants although the literature indicates that men are more resilient to psychoemotional disturbances imposed by an infertility diagnosis and treatment than women 61 our findings are comparable with those observed using the same instrument ie the dass42 questionnaire among infertile females in korea 62 this may be contextualized by the notion documented in previous research highlighting the importance of gender assignment of the underlying cause of the conception difficulties namely mens reaction to fecundity issues approximates to that of women when couple infertility has been attributed to a male factor regardless of the concomitant presence of a female factor 63 as per the who definition qol refers to an individuals subjective evaluation of their life considering their expectations objectives standards and concerns within the broader cultural and environmental context societal framework and personal value system this holistic concept encompassing both affective and cognitive dimensions conveys the need for a departure from the mechanistic paradigm in contemporary medicine in favor of integrating a humanistic element into healthcare practices 6465 accordingly the inclusion of psychosocial aspects alongside biomedical measures in addressing fertility issues has emerged as a pivotal factor in achieving favorable outcomes as perceived by both clinicians and patients 66 score distributions across conceptual areas of the healthrelated qol captured by the sf36 questionnaire in our study exhibited a similar pattern to the findings reported for male partners in large cohorts of italian 67 and iranian 68 infertile couples undergoing in vitro fertilization treatment notable discrepancy between our study and the aforementioned research lies in the lower scores observed specifically in the mental health domain within our cohort nevertheless our observations align closely with the investigation conducted by shindel et al among american couples experiencing fertility challenges where male participants demonstrated standardized scores with a mean value of 4760 based on the mental health subscale of the sf36 questionnaire 69 expectedly inverse correlations were found between the sf36 mental health score and those obtained from the dass42 depression anxiety and stress subscales such convergence across employed instruments indicates consistency and supports reliability thus enhancing confidence in the accuracy and the robustness of the observed findings while subjective health profiles may not differ significantly between individuals with and without infertility the duration of treatment appears to exert an influence on patients qol 70 however reaching definitive conclusions in this regard remains elusive as the existing literature presents certain contrasting findings underscoring the intricate nature of the relationship between the infertility duration and its impact on overall wellbeing in a study by ragni et al it was revealed that a longer period of struggling with infertility could have a detrimental effect on the physical functioning domain of the qol 67 conversely rashidi et al reported that neither the duration of infertility nor its underlying causes exerted a significant influence on the qol 68 our cohort exhibited a statistically significant betweengroup difference in the role emotional concept of the sf36 which provides valuable insights into how emotional problems may impact a persons ability to fulfill their daily roles and responsibilities effectively specifically patients with a longer treatment duration demonstrated lower scores in this domain indicative of a less favorable emotional state in line with expectations inverse correlations were found between the sf36 role emotional score and those obtained from the dass42 depression anxiety and stress subscales furthermore mediation analysis confirmed that the role emotional domain was directly affected by the explored infertility parameters and that the effect of the treatment duration was mediated by psychological distress expressed in the form of anxiety the role emotional scale within the sf36 questionnaire assesses a persons perceived limitations in their daily activities or work due to emotional challenges it explores three different aspects of these limitations if the individual felt compelled to reduce the time they spent on work or other regular activities as a result of emotional difficulties if the person felt that they achieved less in their work or activities than they desired due to emotional issues whether the individual noticed a decrease in the thoroughness or carefulness with which they carried out their work or activities because of emotional challenges these findings suggest that extended periods of treatment may contribute to emotional challenges and impede individuals functioning in their daily lives continued research in this area is crucial for a comprehensive understanding of the underlying factors and mechanisms involved ultimately guiding the development of effective interventions to enhance the qol of those facing infertility challenges investigations conducted across various european countries have reported dropout rates ranging from 17 to 70 among couples undergoing assisted reproductive treatment 71 and it is estimated that in approximately 23 of cases the premature termination may be attributed to the entailing emotional toll 72 hence it might be prudent for infertility programs to integrate comprehensive psychological vulnerability assessments and establish supplementary counseling services as part of regular protocols to alleviate psychoemotional distress that hinders both patients qol and treatment outcomes 73 enhancing resilience as a valuable psychological asset may serve as an effective strategy to mitigate the adverse consequences of psychoemotional disturbances related to infertility fostering resilience entails cultivating selfefficacy developing effective problemsolving skills and bolstering individuals ability to cope with the challenges posed by infertility by harnessing these qualities individuals are better equipped to navigate the emotional and psychological aspects of their fertility journey potentially optimizing their overall wellbeing 74 theoretical studies and empirical findings suggest that the perception and interpretation patterns as well as response trajectories in the reaction to health challenges including infertility are genderspecific considering the substantial discrepancy in both scientific and practical attention to psychosocial aspects of male infertility compared to the female position there is a concern that men known to exhibit a lower propensity for inquiring and engaging in medical consultations than women may be disadvantaged in terms of receiving appropriate strategies for managing their emotional disturbances given the prevailing research emphasis on masculinity as a determinant of mens engagement with medical assistance the exploration of male needs and the quality of support they receive throughout the illness continuum remains relatively limited accentuating the necessity for a more comprehensive understanding of these dynamics 75 although extensive measures were undertaken to mitigate bias and ensure meticulous data collection and analysis it is crucial to acknowledge the presence of certain limitations within this study a noteworthy constraint stems from the implementation of a crosssectional design which inherently impedes the establishment of the precise temporal sequencing of events and consequently precludes the derivation of causal inferences while the comprehensive diagnostic process involved a careful examination of the medical and reproductive history a thorough physical examination with particular attention to secondary sexual characteristics and genitalia as well as semen analysis followed by secondlevel examinations including hormonal evaluations and microbiological exams we made a deliberate choice to primarily focus on semen parameters as the cornerstone of male fertility assessments consequently the detailed elaboration of other factors remained beyond the scope of the present article due to the lack of baseline data on the qol and symptoms of psychoemotional disturbances among the studied individuals before the diagnosis of infertility the potential for protopathic bias cannot be entirely disregarded the singlecenter nature of this research and limited sample size may restrict the generalizability of the findings beyond the specific setting under investigation the recruitment of men from a specific participant pool within a particular clinical facility raises caution regarding the broader applicability of the results to diverse populations or alternative healthcare contexts notwithstanding the potential impact of selection bias the present study offers relevant evidence regarding the characteristics and experiences of infertile men seeking treatment at a major urology clinic in serbia thus contributing to the scarce knowledge base in this filed although the utilization of selfreported data brings attention to the potential influence of recall andor socialdesirability bias proactive measures were made to alleviate their impact these include the application of validated instruments standardized investigation procedures a clear indication of instructions provided by welltrained medical professionals and the maintenance of a nonjudgmental and supportive stance throughout the data collection process fostering an atmosphere of trust and openness the inclusion of diverse data sources such as medical records and clinician assessments further complemented the selfreport data providing a more comprehensive and objective perspective such an approach enhanced the robustness of our study and contributed to a more accurate understanding of the complex factors involved in male infertility and its impact on the qol conclusions while it is imperative to conduct further longitudinal and multicentric research to validate and expand upon our findings the present study offers valuable insights into the intricacies of qol and psychoemotional disturbances experienced by men undergoing infertility treatment in serbia by delving into the multidimensional nature of the distress faced by these individuals our research contributes to the limited body of knowledge in this area highlighting the necessity for comprehensive support strategies that holistically address their unique needs these findings may serve as a fundamental platform for future investigations enabling a deeper understanding of the complex dynamics between physical and psychoemotional factors within the context of male infertility such advancements hold great potential for the development of targeted interventions and the delivery of enhanced patient care ultimately striving towards improved outcomes and wellbeing for these individuals data availability statement the data supporting reported results can be found upon request in the form of datasets available at the clinic of urology university clinical centre of serbia institutional review board statement the study was conducted in accordance with the declaration of helsinki and was approved by the ethics committee faculty of medicine university of belgrade informed consent statement informed consent was obtained from all subjects involved in the study

the experience of an infertility diagnosis and treatment imposes a profound burden on affected individuals encompassing not only physical and medical aspects but also a plethora of psychological social and emotional factors by employing a multimodal assessment featuring validated selfreport questionnaires physical measurements and clinical records the present study aimed to explore the quality of life and psychoemotional distress of men undergoing infertility treatment in serbia thereby addressing the dearth of research on the underrepresented male perspective in this domain findings revealed diverse semen abnormalities among participants n 96 average age 3769 ± 572 with significant associations between longer treatment durations and reduced sperm motility the observed rates of men surpassing predetermined dass42 questionnaire thresholds for depression anxiety and stress in the analyzed cohort were 1354 1146 and 2292 respectively summary scores in conceptual areas comprised in the sf36 questionnaire ranged from 4900 ± 625 for the mental health dimension to 9016 ± 1775 obtained in the physical functioning subscale patients with a longer treatment duration demonstrated lower scores in the role emotional domain indicative of a less favorable emotional state expectedly inverse correlations were found between the sf36 mental health score and dass42 subscales by addressing the existing knowledge gap and highlighting the unique needs of infertile men the finding of this study may contribute to a more inclusive and holistic approach to infertility research and management

introduction the global scientific community has raced to develop effective and safe covid 19 vaccines yet vaccine development solves only half of the problem in dealing with the threat of the disease recent modelling suggests both high efficacy and coverage rates are essential 1 and a plan for rollout is crucial experience gained from seasonal and pandemic influenza vaccination 2 3 4 as well as routine childhood vaccination 5 6 demonstrates that building confidence and effective delivery is a science in itself an effective covid19 vaccination programme will allow societies to resume economic social and cultural function this project assists in fulfilling that goal as of 12 may 2021 there were 99 vaccines in clinical development as recorded on the who covid19 candidate vaccine landscape database 7 open access and paramedic services general practice respiratory clinics and covid19 testing facilities aged care and disability care staff and aged care and disability care residents 8 the next priority group included all other healthcare workers household contacts of quarantine and border workers critical and highrisk workers people aged ≥70 years aboriginal andor torres strait islander people aged ≥50 years and adults with an underlying medical condition or significant disability australias federal government developed the countrys covid19 vaccination programme 9 shaped by a number of health and government bodies key among them is the countrys national regulator the therapeutic goods administration which is responsible for assessing the safety quality and efficacy of vaccines including any covid19 vaccines the australian technical advisory group on immunisation also provides technical input for a covid19 vaccination programme tasked with identifying priority populations for vaccination the federal government and the governments of the states and territories share responsibility for programme implementation through national and local implementation plans australia has experienced relatively little community transmission since the pandemic began especially compared with culturally similar contexts like the usa uk and continental europe this is particularly the case in western australia which until early february 2021 had no community transmission of the virus for nearly 10 months 10 and has had very little community transmission since 11 the country and its states and territories have implemented strict border controls restricting visitors and enforcing 2week quarantines australia and wa within it is therefore a unique place to study the publics views on and acceptance of covid19 vaccination with relative safety for instance comes the possibility that people may delay or avoid vaccination this unique coronavax study is therefore necessarily sensitive to barriers and challenges to vaccination that may arise in australia and globally australians are generally highly supportive of vaccination with 87 believing that vaccines are safe effective and necessary 12 less than 6 of australians do not believe that vaccines are safe 13 however recent pandemic experience with influenza ah1n109 saw poor vaccine uptake one study found 26 of refusers were concerned about safety and 17 did not believe in the vaccine 14 studies conducted between april and june 2020 found between 65 and 86 of australians were likely to accept the covid19 vaccine 15 16 17 the who listed vaccine hesitancy as one of the top threats to global health in 2019 18 even before the pandemic hence implementing an evidencebased plan for covid19 vaccine rollout is crucial to facilitate an effective covid19 vaccination programme scholarship needs to inform covid19 vaccine communications and to help develop effective mechanisms of governance for a vaccination programme governments must understand what communities require and identify the factors enabling widespread vaccine acceptance a central aim of this project is therefore to facilitate communication between governments and members of the public communities are not homogenous and they will need different messaging encouragement and access based on their demographic features values locations and experiences of disease threat and lockdown 19 building and maintaining trust is central as mistakes can have lasting and devastating repercussions previous pandemic vaccine rollouts demonstrate this for example in france a challenging and rapidly implemented rollout of the influenza a h1n1 vaccine united a heterogeneous front of vaccinehesitant populations 20 engaging transparently and continuously with those who might undermine vaccination programmes through holding or disseminating negative views of vaccination is best practice in risk management and increasingly important in the age of social media 21 the project facilitates communication and ensures shared understanding between communities and governments during covid open access social media study design sample and analysis social media is increasingly important as a source of information and disinformation for the broader public the social media component of the study involves monitoring social media platforms used by local communities in order to stay abreast of realtime concerns or controversies this process will involve weekly searches for mentions of the covid19 vaccine in various social media channels and the collection of data based on those searches it is not expected that these searches will comprehensively collect all mentions of the vaccine on social media rather it is seen to be enough coverage to provide an overview of prominent and emerging concerns this broad data collection will provide the basis for more targeted research about the origin and spread of concerns and controversies about the vaccine and the evolution of vaccine sentiment over time the resulting data will be analysed using both discourse analysis and network analysis the type of data to be collected includes ► comments and posts made by social media users pages and groups ► interactions with these messages such as shares retweets and reactions ► basic demographic data shared publicly on social media such data may include location gender and age this aspect of the study collects data that may influence public sentiment we will only use data from the public domain and include only publicly available posts and comments the majority will be from search tools available to anyonespecifically twitter instagram tiktok youtube and facebooks search console google trends google search and boardreader there may be some use of curated data in order to make the search for relevant data easier for instance facebook have provided academic access to their crowdtangle application allowing researchers on this project access to data on the spread of information via facebook reddit instagram and twitter crowdtangle allows us to monitor discussions in facebook pages that are used by cultural and linguistic minority communities as well as information provided by advocacy organisations through that platform the data that facebook releases via this application are only that which are publicly available the access provided for this project collates data on posts with the highest number of public interactions this does not include private facebook groups or personal profiles accounts established on instagram twitter tiktok and youtube manually follow stories about the covid19 vaccine accessed weekly in order to assess and code what sort of information about the vaccine each platform algorithmically selects as recommended for these accounts we do this by coding the first 10 stories or posts in each feed the naming of these accounts makes it clear that they are research accounts and they only view and follow covid19 vaccination stories and posts the data collection schedule includes a weekly scrape of the top posts on each feed and platform nvivo 22 capture gathers data such as message content source and engagement which is then stored for analysis social media data is analysed in two ways 1 discourse analysis this involves looking at peoples comments and overall concerns frameworks that used to code data and analyse discourse include but are not limited to media type level of engagement stated concerns about the vaccine identifying where messages position themselves in terms of leask et this research has significant benefits in terms of monitoring and reporting the spread of information about covid19 vaccination programmes it will also help improve understandings of how information spreads through social media networks this knowledge will help guide public health communication during the rollout of the coronavirus vaccine as well as informing future public communication programmes and initiatives network data will be analysed using ucinet 24 and statnet 25 for r community interviews study design sample and analysis the project involves semistructured indepth interviews of approximately 1 hour with those living in wa as determined by the research team in collaboration with the wa department of health interviewees include those who need the vaccine first but also those who possess the capacity to undermine a vaccination campaign through holding or disseminating negative views of vaccination 26 open access 8 parentsguardians of children aged 518 years with comorbidities 9 parentsguardians who are hesitant about routine childhood vaccines 10 aboriginal and torres strait islander people in perth 11 adults in regional or remote areas of wa 12 culturally and linguistically diverse people 13 adults with comorbidities 14 service delivery organisations for especially vulnerable populations such as the homeless drug dependent and victims of domestic violence methodologies for engagement with these groups will be developed based on best practice including the use of translators and interpreters where necessary 15 pharmacists participants discuss their experiences and views of the pandemic and lockdown periods as well as their views regarding covid19 vaccination in wa participants answer additional questions depending on which categories they are in a number of participants may belong to one or more of the categories for instance interviewee x might be an adult working in aged care who has a child under the age of 5 years they would therefore receive generic adult questions with additional questions related to their occupation and being a parent to young child in order to ensure the sample includes the target groups and is as diverse as possible participants are prescreened using research electronic data capture software redcap is a secure webbased software platform designed to support data capture for research studies providing an intuitive interface for validated data capture audit trails for tracking data manipulation and export procedures automated export procedures for seamless data downloads to common statistical packages and procedures for data integration and interoperability with external sources 29 30 the prescreening survey first captures important demographic details that enable screening for particular types of participants in addition to providing contact details and preferences for interviews days and times participants then have the option of continuing to a followup survey in redcap or of answering these followup questions during their interview questions in the second survey capture important information about participants that are not necessary for the purposes of screening brochures posters word of mouth and media releases distribute the prescreening survey in the perth metropolitan area the design of posters and brochures was in collaboration with the telethon kids institute communications and graphic designer team recruitment also draws on investigators existing networks if recruitment through communitybased methods is insufficient there will be further recruitment through government and nongovernment workplaces and institutions a number of groups such as parentsguardians who are hesitant andor resistant to childhood vaccines may be difficult to access however ka has previously worked with such parents 31 they will be recruited through the channels described above at 22 with an emphasis on the use of personal networks maintaining confidentiality and providing distance from personal relationships open access information and consent materials for the project explain the researchs basis in improving vaccine uptake this provides transparency for participants who can take the opportunity to share their critiques and concerns through the research as they have through kas previous work research with aboriginal andor torres strait islander people should be led by aboriginal andor torres strait islander people and communities the research team must include aboriginal andor torres strait islander members and the priorities should be guided by the community with whom the researchers intend on recruiting within 32 thus to assist with recruitment and interpretation of the views of aboriginal people in perth an aboriginal cultural guidance advisor and researcher has been engaged with the recent awarding of additional funding we are employing an aboriginal researcher to undertake extensive community consultation and to later conduct interviews in a culturally sensitive fashion with this priority group for covid19 vaccination in australia 34 these interviews will be conducted with aboriginal people in perth this community predominantly uses english as their main language spoken at home 35 research with aboriginal people in regional areas remains in the project plan interviews may be conducted by video chat phone or in person for the bulk of participant groups facetoface interviews are the preferred method dependent on covidsafe policies and recommendations at the time of interviews for people less eager to participate in facetoface interviews or who face technological barriers alternative methods are employed thematic analysis of the data uses nvivo v12 software 22 this analytical process will be collaborative with inductive themes decided jointly by the research team based on research questions and then revisited throughout the analysis deductively with the emergence of new themes analysis will follow the steps outlined in the braun and clarke method 36 if postinterview clarifications or additional information is required investigators may followup with participants data collected in these followup conversations may be included in the project findings functional dialogues study design sample and analysis coronavax is centrally concerned with vaccine governance regular functional dialogues take place with relevant government departments and committees within wa and australia these study how policymakers understand and implement the tools available to best drive vaccine uptake ensure rapid dissemination of emerging insights from ongoing fieldwork to stakeholders in wa and federal governments and encourage stakeholders and the research team to shape fieldwork through collaboration investigators work with government partners to identify key individuals who have used or will use the emerging findings and can speak on behalf of their teamdepartment including in terms of providing feedback to inform the ongoing conduct of each coronavax component researchers from the coronavax research team are selectively included when discussing relevant findings or project components a facilitator from the research team leads each functional dialogue conversations follow a semistructured discussion framework giving time for research dissemination and indepth conversations between researchers and stakeholders while exploring stakeholders attitudes beliefs experiences roles and observations in detail meetings with local participants will be face to face or via online videoconferencing if it is not covid safe to meet face to face functional dialogues with federal participants are via videoconferencing this is necessary in light of current internal border closures and travel restrictions within australia open access mapping evidence uptake and use study design sample and analysis coronavaxs interest in vaccine governance will also focus on knowledge sharing by government stakeholders and policymakers to do so investigators will conduct a quantitative social network analysis of wa state government employees intrainter stakeholder informationsharing networks recruited through the functional dialogues social network analysis enables the research team to both visualise the structure of stakeholders and analyse the properties of these relationships this enables investigators to understand how evidence travels through government this has two benefits identifying blocks to communication and helping stakeholders to redesign their communication networks to achieve more effective working practices data collection is through a short nineitem structured questionnaire administered by hand and online using qualtrics survey software 37 themes in the questionnaire include knowledge understanding and use of coronavax findings internal colleagues with whom the participant discusses covid19 vaccine rollout and external colleagues with whom the participant discusses covid19 vaccine rollout data gathered through the questionnaire will be analysed using the specialist social network analysis software ucinet investigators will explore the overall structure of the communication network as well as the existence of any structurally important actors in the network part of the discussion will focus on evidencesharing networks using these suggested connections the research team will be able to snowball and identify relevant departmentsteams as potential respondents to the survey 38 patient and public involvement consumers have informed the projects design which has been undertaken with three main goals in mind 1 ensure the appropriateness and sensitivity of research questions and recruitment 2 ensure that the research priorities and design reflect the needs of the community 3 explicitly bring the consumer voice back to government as part of the functional dialogues involving advocates and trained consumer representatives and related organisations such as the immunisation foundation of australia and light for riley online vaccine advocacy campaign is central to the projects community engagement strategy consumers advise on the community interviews and contribute to all sections of the protocol this approach is supported by a network of consumer involvement experts from the tki and the consumer and community health research network including the wesfarmers centre of vaccines and infectious diseases community reference group this community reference group consulted on coronavax in september 2020 ethics and dissemination this project has ethical approval from the child and adolescent health services human research ethics committee under permit number rgs0000004457 the university of western australia hrec reciprocally recognised this approval under permit number 2020 et000339 and separately granted ethical approval for the federal functional dialogues under permit number 2020et000340 our protocol has undergone three amendments with more pending to include new community study cohorts for which we have attained additional funding these have been explicitly detailed above participants and their workplaces or institutions are given pseudonyms ensuring that their anonymity is respected in any communications and publications arising from this research publications and presentations will omit specific information that may identify participants participant data are manually reidentifiable and will only be accessed and analysed by the researchers identifying details collected in the prescreening survey of the community interviews are stored on redcap all audio transcripts created during the community interviews and functional dialogues are stored temporarily with otter and permanently deleted following transcription 39 audio files collected in the community interviews and functional dialogues transcripts evidencemapping survey data and any other nonidentifying information are stored under associated pseudonyms on uwas institutional research data store irds supports the requirements of researchers regarding confidentiality integrity availability security and ownership of data 40 investigators will keep the project data on uwa redcap and uwa irds all hard copy documents obtained during the research will be stored in a secure filing cabinet in the lead authors office investigators will securely destroy them at the time of electronic data disposal investigators anticipate publishing several articles from each coronavax component in peerreviewed journals that publish articles on vaccines infectious diseases medicine public health social sciences relationships family employment anthropology gender and health sociology project investigators will also share results more widely including with and through the media as well as by presenting at conferences and seminars contributors ka conceptualised the project convened and managed the research team and worked in collaboration with each component lead to design the project she also led the research funding applications and wrote the core sections of the protocol as well as editing and drafting this protocol manuscript sc was responsible for writing the core sections of the protocol collated and managed the contributions of coauthors to the protocol contributed to the writing of funding applications managed the hrec application process as well as drafting and editing this protocol manuscript jt wrote the core sections of the protocol designed the functional dialogues and evidence uptake and use mapping contributed to the development of the social media study and managed the ethics applications to uwa hrec application for functional dialogues with federal policymakers th wrote the core sections of the social media study and had input on the functional dialogues section he is the research team leader for the social media study lm led the design of the community interviews with ka and sc cowrote the relevant sections of the protocol and contributed to the editing of this manuscript lr assisted with the design of the community interviews and contributed to the editing of this manuscript including preparing the appendices mr contributed to the conceptualisation of the project with regard to the role of the government in vaccine rollout the development of the functional dialogues with jt and he assisted with the ethics application to uwa hrec dw provides institutional liaison with the department of health western australia and has contributed to the project design he contributed to the editing of this manuscript pe represents with the department of health western australia and has contributed to the project design from its inception ch contributed to the projects consumer involvement plan and provided consumer insight relevant to the protocol participant information sheets participant recruitment materials community interview questions and social media project vs an aboriginal woman and aboriginal cultural governance advisor to the wesfarmers centre of vaccines and infectious diseases telethon kids institute provided leadership and guidance to ensure this project addresses the needs of first nations families she continues to shape the teams culturally secure recruitment and engagement for its ongoing research programme ccb has contributed significant medical technical and research expertise to all aspects of this project he has led funding applications and provided resources engaged in highlevel conceptualisation of the project in its entirety and led key aspects of its stakeholder engagement he contributed to the writing of the protocol as well as the drafting and editing of this protocol manuscript all authors contributed to the editing of this manuscript funding funding for this project was provided by a wesfarmers centre of vaccines and infectious diseases 2020 catalyst research grant and the government of western australias department of health a subsequent future health research innovation grant from the government of western australia funds additional community subgroup interviews ka is funded by the australian research council of the australian government under dede190100158 she has previously received a speakers fee from merck disclaimer the funding providers organisations involved in the study and individual members of the research team have no financial interest in the outcome of the research government funding partners will contribute to the research question design and contribute to the functional dialogues although not to their research design all funders will also participate in the dissemination of research findings competing interests none declared patient consent for publication not required provenance and peer review not commissioned externally peer reviewed supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

introduction ahead of the implementation of a covid19 vaccination programme the interdisciplinary coronavax research team developed a multicomponent mixed methods project to support successful rollout of the covid19 vaccine in western australia this project seeks to analyse community attitudes about covid19 vaccination vaccine access and information needs we also study how government incorporates research findings into the vaccination programme methods and analysis the coronavax protocol employs an analytical social media study and a qualitative study using indepth interviews with purposively selected community groups participant groups currently include healthcare workers aged care workers first responders adults aged 65 years adults aged 3064 years young adults aged 1829 years education workers parents guardians of infants and young children 5 years parentsguardians of children aged 518 years with comorbidities and parentsguardians who are hesitant about routine childhood vaccines the project also includes two studies that track how australian state and commonwealth federal governments use the study findings these are functional dialogues translation and discussion exercises that are recorded and analysed and evidence mapping of networks within government which track how study findings are used ethics and dissemination ethics approval has been granted by the child and adolescent health service human research ethics committee hrec and the university of western australia hrec study findings will be disseminated by a series of journal articles reports to funders and stakeholders and invited and peerreviewed presentations

an alternative possibility is that ses differences in childdirected speech may be explained in part by broader contextual factors that exert influence on parenting behaviors in line with this perspective conger and colleagues have developed and tested the family stress model to explain how economic pressures affect family functioning and individual adjustment and consequently a broad range of child development outcomes 23 24 25 more specifically financial stress is posited to impact aspects of caregiving including warmth sensitivity and cognitive stimulationactivities such as reading aloud play and other interactions that involve childdirected speech and support childrens language development for instance nievar and colleagues 26 showed that lower income predicted reduced positive parenting behaviors such as responsiveness to infant vocalizations which then predicted childrens later cognitive outcomes in the first grade there is also evidence suggesting links from economic concerns to parenting stress and depression and in turn child language 26 27 28 29 moreover though initially conceptualized to explain family processes among lowses families evidence suggests that the family stress model applies to families across varying socioeconomic levels 3031 ponnet 31 hypothesized that although the nature of financial concerns may differ at different levels of ses the subjective experience of worrying about finances is likely to impact parenting and family functioning across families from a range of ses backgrounds indeed recent surveys suggest that americans across the ses continuum are financially stressed less than 4 in 10 americans state that they would be able to pay a surprise 1000 bill from their savings 32 and of individuals who make over 100000 a year over 30 regularly run out of money between paychecks 33 the idea that financial concerns impact parents capacity to interact with their children complements a growing body of research showing that specific structural sources of stress such as resource scarcity affect adults psychological functioning and cognitive processes 34 35 36 37 mani and colleagues 38 suggest that when a particular resource is scarce this taxes cognitive resources and individuals shift their attention to focus on the scarce resource at the expense of other issues that might require attention this can lead to counterproductive behaviors such as anxiety forgetting attentional neglect and poor decision making 39 40 41 for instance shah et al 40 conducted a laboratory study in which participants were given either rich or poor budgets to play a version of wheel of fortune after which they completed a task measuring cognitive fatigue participants with poor budgets demonstrated more cognitive fatigue suggesting that resource scarcity caused those with poor budgets to increase focus during the game which in turn resulted in reduced cognitive function on the later task additional findings from shah et al 36 speak to how financial concerns influence individuals everyday experiences through several experiments shah and colleagues showed that individuals who were not necessarily poor but had constrained budgets were more likely than higherincome individuals to think about financial concerns when contemplating daily events that involved an economic dimension were more likely to do so unprompted and found it difficult to suppress thoughts about the cost of common activities when instructed not to think about it complementary evidence suggests that reducing financial concern can improve cognitive function 3942 for instance ong et al 39 demonstrated that providing debt relief to individuals with chronic debt resulted in improvements in their inhibitory control abilities and reductions in anxiety financial strain is not experienced as a steady state for all families instead it varies over the course of the month due to timing in paydays distribution of public assistance benefits and when bills are due two recent studies by carvalho and colleagues showed that in the us paydays and other income sources are distributed 12 times per month and are most frequently paid at the beginning of the month 43 in the state of california where the present research was conducted public assistance benefits are typically paid within the first 3 to 10 days of each month and credit cards and other bills are frequently due at the beginning or middle of each month 44 45 46 this timing corresponds to families spending less on groceries and other goods later in the month when americans report that they are less financially secure 33 47 48 49 if parentchild interactions are impacted by financial strain as suggested by the family stress model then variation in financial strain over the course of the month should be linked to corresponding variation in parent and child behavior findings from several recent studies that have used the date of the month of an indicator of financial strain are consistent with this possibility for instance one study found that elementaryschool childrens disciplinary infractions spiked at the end of the month and this pattern of findings was most apparent in children whose families receive snap benefits which are distributed early in the month 50 in addition reducing financial strain at later points in the month via changes in benefit distribution is associated with reductions in crime and grocery store theft 51 finally the impacts of financial strain on cognitive load have also been linked to payday timing in a study by burlacu et al 52 priming financial worry among parents impacted their budgeting for immediate household needs as opposed to child learning products such as books despite the presence of subsidies for the child products these impacts were most pronounced among those who were furthest from their payday suggesting that the timing of financial concerns reduced their decisionmaking capacities building on this body of research ellwoodlowe and colleagues 53 recently proposed that the cognitive load imposed by resource scarcity could directly suppress parent talk if parents attention is occupied by financial concerns this leaves less attention to devote to childdirected speech they tested this hypothesis in two ways in one study scarcity was experimentally manipulated in a laboratory setting by prompting caregivers to reflect on times in the prior week when resources were scarce parents childdirected speech was then examined during a play session and compared to a control group that was not prompted to reflect on scarcity not all parents reflected on financial scarcity when prompted but those who did spoke less to their 3yearolds than parents who failed to reflect on financial scarcity and parents in the control group in a second study ellwood lowe et al examined corpora of daylong inhome recordings to test whether parents speech decreased near the end of the month which as noted previously is when americans report experiencing greater financial strain 3349 results showed that parentchild conversational turns tended to be lower in the last week of the month compared to earlier weeks though this finding only emerged in 1 of the 3 corpora examined the authors concluded that above and beyond individual characteristics of parents financial concerns may impact the tendency to engage in childdirected speech these findings from ellwoodlowe and colleagues 53 provide initial suggestive evidence for a link between financial concern and parents childdirected speech however there was limited variation in family ses in both studies in the first study the majority of parents were high ses the median household income was over 150 k per year and a third of the parents reported a household income over 200 k per year although the ses levels in the second study were somewhat lower and more variable than in study 1 the majority of parents were still from middleto uppermiddle class backgrounds moreover the single corpus where the effect of the week of the month was significant happened to have the highest reported family income and 50 of the mothers in this corpus had a graduate degree thus it remains unclear whether the impact of financial stress on childdirected speech is robust and whether it operates across ses levels as the family stress model would predict 25 the present study tested the claim that financial concern suppresses childdirected speech using two existing corpora of labbased parentchild interactions from socioeconomically diverse samples we examined whether parents speech to their children varied over the course of the month as discussed above americans tend to spend more money during the first and third week of the month and less in the last week of the month 47 and report greater financial concern later in the month 33 47 48 49 financial concern is likely to be particularly salient in the state of california where the present corpora were collected california is ranked second in the nation for cost of living and is home to 33 million families living paycheck to paycheck 5455 benefits in california are also paid early in the month and thus financial concern should be greater later in the month 4445 we therefore hypothesized that the quantity and diversity of the childdirected speech that parents produced during an interaction with their child would be negatively associated with the day of the month in which the interaction took place we reasoned that if this pattern emerged in a labbased interaction where it was salient to parents that their speech to their child was being observed this would provide particularly strong evidence that financial strain suppresses childdirected speech results participants were parentchild dyads from two existing corpora in which dyads completed an interactive picturebook activity interactions were recorded transcribed and coded for three measures of parent language number of utterances number of word tokens and number of word types we then examined whether these measures varied as a function of the day of the month that the lab visit and parentchild interaction took place four parents had utterance counts that fell more than 3 standard deviations above the mean for this measure excluding these dyads from the analyses of parent utterances did not affect the patterns of significance reported below so we retained them in the analyses there were no outliers for word tokens or word types six parents spoke spanish for a portion of the interaction all of the patterns of significance reported below remain the same if these dyads are excluded preliminary analyses revealed no significant effects involving child sex parent sex or ethnicity all ps 015 we therefore collapsed across these factors in subsequent analyses child race white 120 blackafrican american 4 asian 8 hawaiian or pacific islander 1 native american 1 more than one race 9 other race 14 na 9 child ethnicity hispanic or latino 83 nonhispanic or latino 80 na 3 highest degree completed by either parent highschool or less 36 associates degree 35 bachelors degree 53 mastersphdprofessional degree 42 zeroorder bivariate correlations revealed that as predicted the day of the month that the parentchild interaction took place was significantly negatively correlated with the number of parent utterances r 020 p 0011 word tokens r 019 p 0014 and word types r 016 p 004 to determine whether visit day significantly predicted parent talk after accounting for demographic variables and corpus a hierarchical multiple regression model was conducted for each parent talk variable in each model child age corpus and parent education level were entered at step 1 and visit day was entered at step 2 finally to test whether the effects of visit day varied across socioeconomic strata interactions between visit day and parent education level were entered at step 3 as shown in table 3 there were no effects of child age or corpus in any of the models the effect of visit day was significant in all three models and this effect did not interact significantly with parent education level thus parents who participated later in the month produced less speech and their speech was less diverse regardless of their level of education to facilitate comparisons with ellwoodlowe et al 53 we compared parent talk during the last week of the month to the rest the month for each parent talk variable we conducted an analysis of variance with visit week and parent education as betweensubjects factors these models revealed a significant effect of visit week on the number of parent utterances f 582 p 0017 η 2 004 and the number of parent word tokens f 423 p 0041 η 2 003 and a marginal effect of visit week on the number of parent word types f 366 p 0058 η 2 003 there were no significant effects of parent education 017 p 092 tokens f 033 p 081 types f 024 p 087 and no significant interactions of visit week and parent education 036 p 078 tokens f 096 p 041 types f 145 p 023 because time of the month was not a factor of interest in the original studies from which these data were derived the timing of study visits was not controlled appointments were scheduled on the day the parents chose this raises the possibility that visit day was confounded with other participant characteristics that could impact parent talk a final set of analyses indicated that visit day did not vary as a function of child sex parent sex ethnicity or corpus all fs 1 all ps 076 there was a marginal effect of parent education on visit day f 254 p 0058 η 2 005 examination of this marginal effect revealed that the visit day of parents in the high school or less group was somewhat earlier in the month than the visit day of parents in the although the reason for this sampling difference is unclear the direction of this effect means that the lower levels of parent speech observed on later visit days were not due to oversampling lowses parents later in the month as these parents tended to participate earlier in the month more critically all of the significant relationships between parent talk and visit day held after controlling for parent education and no interactions emerged between visit day and parent education in any of our analyses together these analyses suggest that the relationship between visit day and parent talk was not driven by any of the participant variables that were available in the data set discussion considerable evidence suggests that parents engagement in childdirected speech is related to a number of important aspects of child development and in particular language development 1222 it is therefore critical to consider potential sources of variability in parent talk in the current study we examined one possible source of variation that has been hypothesized to exert influence on parents use of childdirected speech financial concern 2853 we used existing corpora of labbased parentchild interactions and examined whether parents speech to their children varied over the course of the month we predicted that parents would talk less near the end of the month when financial concerns were likely to be greatest 33 47 48 49 consistent with this hypothesis results showed that the number of utterances word tokens and word types that parents produced were negatively correlated with the date of the month when they participated in the parentchild interaction these associations remained after accounting for child age corpus and parental education finally as one would expect if financial strain were highest at the end of the month parents who participated in the final week of the month produced significantly fewer utterances and word tokens and marginally fewer word types than parents who participated earlier in the month these findings provide the first evidence that the time during the month that a parentchild interaction occurs relates to parents use of childdirected speech in a socioeconomically diverse sample parents in the current study varied considerably in their level of education and they were drawn from a region where families tend to have lower socioeconomic status than other parts of the state or country the current findings therefore replicate those reported by ellwoodlowe and colleagues 53 who tested primarily middleto uppermiddle class families and extend them to a more socioeconomically diverse sample the fact that timedependent differences in childdirected speech emerged in a more socioeconomically diverse sample suggests that the impact of financial concern on childdirected speech is robust and operates across ses levels these findings suggest that above and beyond individual properties of parents broader contextual factors such as financial concerns exert influence on the way parents interact with their children our findings are consistent with the family stress model which posits that economic hardships such as low income or high debttoasset ratio increase economic pressures which negatively affect family functioning and parent adjustment and consequently child development outcomes 23 24 25 including language 27 28 29 although we did not directly measure financial strain we hypothesize that in the current study parents participating at days later in the month were more occupied with financial concerns which affected the speech they used in interactions with their child if this is the case then these results suggest that economic strain plays a role in parents capacity to interact with their children moreover our analyses revealed no effect of education on parents childdirected speech suggesting that families from highand lowses backgrounds were similarly influenced by the date the interaction took place as well as the potential corresponding economic pressure although families from lowand highses backgrounds likely experience financial strain very differently from one another the current findings suggest that financial strain can nevertheless have impacts on parental language across ses levels our results therefore add to the growing body of findings suggesting that these processes are not specific to families living in poverty 31 and that the family stress model applies to families experiencing financial concerns across socioeconomic strata the current findings also extend prior work by showing that parents childdirected speech was lower at later points in the month in a context where it was particularly salient that they were being observed parents were given instructions on how to interact with their child and then were left in a room where video recording devices were clearly visible the fact that parental talk varied across the month despite these cues and despite the potential urge to engage in high levels of childdirected speech due to social desirability bias is wellaligned with the hypotheses set forth by mani and colleagues regarding scarcity 34 35 36 37 in particular these findings complement laboratory and field research showing how financial concern operates in everyday life and that these cognitions can arise spontaneously and are difficult to suppress 36 in the case of the current study the influence of financial concerns surfaced even in the face of cues that might otherwise enhance parental talk our finding that parents engage in less childdirected speech at later points in the month is consistent with those reported by ellwoodlowe and colleagues 53 who examined daylong recordings collected in the home however this latter finding was only significant in one of the three corpora examined this pattern of results raises the possibility that the influence of financial concern on parent speech might be greater in laboratory settings than at home contrary to our suggestion that being observed might have enhanced parent talk one might instead argue that being in a laboratory could enhance effects of financial concern because parents experiencing more stress might be less able to perform under scrutiny if so then the impact of financial concern on childdirected speech might be less evident in home environments although possible prior research examining the speech used in parentchild interactions has revealed converging findings across laboratory and home assessments 125660 in particular recent work examining the association between ses and childdirected speech found that location of the assessment did not significantly moderate this relationship 12 this converging evidence across methods suggests that labbased measures of parent language such as the picturebook task used in this study tap into consistent patterns of behavior that are reflective of childrens everyday experiences we therefore think it likely that our findings reflect a more general impact of financial concern on parents childdirected speech that would also emerge in the home setting nevertheless it would be worthwhile to replicate the present findings in naturalistic settings to clarify in which contexts financial concern impacts parents childdirected speech a second question is whether the current findings would generalize to other participant samples the current findings and those reported elsewhere suggest that in the us the effect of financial concern on parentchild interactions is not specific to lower ses families however this effect might differ for very low ses families such as those living well below the poverty line notably some racial and ethnic minority groups experience higher levels of stress earn lower wages and are more likely to live in poverty 61 62 63 this also raises the question of whether our results would emerge across racial and ethnic groups in the us in the present study approximately half of the participants were hispanic or latino but we found no effects of ethnicity however we did not have information regarding parents immigration status country of origin or levels of acculturation which could affect parents childdirected speech 64 65 66 similarly we only examined the quantity of parent talk some research suggests that the style and content of parents language varies with ethnicity 67 it is therefore possible that other aspects of parental talk might vary by day of the month and ethnic background in terms of the broader global population outside the united states prior research has shown that the timing of paydays and harvest schedules that are likely to produce financial stress in nonwestern cultures correspond to changes in performance on cognitive tasks 35396869 these findings could indicate that scarcity impacts cognitive function similarly across cultures but it remains an open question whether this would also impact parent speech and in turn child language and other developmental outcomes in studies within the united states there is strong evidence showing associations between ses childrens language environment and childrens language development in contrast in other parts of the world such as in southern mexico and bolivia children are exposed to less childdirected speech and despite this achieve language learning milestones on a typical trajectory consistent with children in the united states 70 71 72 given the infrequency of childdirected speech it is possible that financial concerns may not impact parents speech or child development in these communities however scarcity might still impact other aspects of cognitive functioning that have implications for parenting our results cannot speak to these possibilities there is thus a need for further work examining whether and how resource scarcity relates to childdirected speech and caregiving behaviors more broadly in other socioeconomic and cultural contexts one key limitation in the current study is that we did not collect any measures of household income or parent occupation which have the potential to impact parents childdirected speech while some have argued that of ses indicators parental education is most predictive of parents speech 7 others suggest that different ses indicators represent distinct constructs with unique linkages to parent outcomes and hence they should not be used interchangeably 73 therefore future research examining how financial concern relates to parents speech should test whether additional measures of ses interact with parental talk a second limitation is that we lacked a direct measure of finances or financial concern in the current study we posited that it was financial strain specifically that contributed to timedependent differences in parents child directed speech none of the participant characteristics in our data set varied with visit day except for a marginal difference in parent education and our results held after controlling for that variable it is possible that other factors that vary with time could have impacted parental language however americans report that finances are their greatest source of stress 33 and this source of stress seems the most likely to vary with the time of the month in which parentchild interactions occurred we therefore conclude that financial concerns are the most probable factor that contributed to differences in parental language over the course of the month still the effect sizes in the present study were modest which could reflect our indirect measure of financial concern future research on this topic should include direct measures of perceived financial strain and family finances such as when parents were paid whether families were receiving public assistance or carrying debt in addition to providing direct evidence for the impact of financial strain on parent talk this might yield larger associations between financial concern and childdirected speech however collection of this information must be done with caution as prior work has shown that priming parents to think and talk about financial concern results in reductions in their childdirected speech 53 in conclusion our study indicates that parents talk less to their children at later points in the month when financial concern is likely to be greatest our findings thus suggest that efforts to improve child language outcomes might benefit from focusing on broader contextual factors such as reducing parents financial strain rather than solely intervening on individuallevel factors the present study contributes to a growing body of evidence that financial strain impacts a range of parent and child behaviors 50 51 52 53 together these findings suggest that reducing financial strain could have broad positive impacts on families above and beyond enhancing childdirected speech and child language outcomes method participants this study drew on two existing corpora of parentchild interactions that were part of larger labbased studies on childrens socialcognitive development 7475 these corpora were selected because the same labbased parentchild activity was used and both samples were socioeconomically diverse the dyads in the two corpora were recruited from birth records provided by the california department of public health and a database of parents living in merced county california who had previously expressed interest in participating in research studies with their children parents in the latter group were largely recruited at a variety of community events many of which focused on providing resources and support for lowses families these procedures have been used in several prior studies to recruit socioeconomically and ethnically diverse samples 67 76 77 78 dyads were recruited for a single lab visit and appointments were scheduled at parents convenience timing of study visits over the course of the month was not controlled because this was not a factor of interest in the original studies parents were not paid for their participation instead all children received a small gift of approximately 5 value for participating dyads who met the following criteria were included in the present study they completed the relevant parentchild interaction children had no known speech language or developmental delays and children were exposed to english at least 50 of the time the final data set consisted of 166 parentchild dyads demographic information for this sample is provided in table 1 the majority of children completed the tasks with their mother the remainder completed the tasks with their father on average children were exposed to english 95 of the time over 95 of the sample heard english at least 75 of the time information on race ethnicity and socioeconomic status was obtained via parental report socioeconomic status can be accessed via a variety of indicators including parents education occupation and income 737980 these existing corpora did not include measures of family income or occupation but did include a measure of parental education as can be seen in table 1 the highest degree completed by either parent was diverse ranging from completing high school or less to possessing professional or advanced degrees with a relatively even distribution across the education categories although income was not measured the participants were drawn from a region where families are generally relatively low in socioeconomic status the county where these participants were recruited has a poverty rate of 23 for children 18 years of age and under 81 which is higher than both the state and national level the median household income is also lower than those reported at the state and national level 81 procedure dyads participated in a single lab visit lasting less than 45 min children completed one or more social cognition tasks and then dyads completed one or more interactive activities the present study focused on a picturebook activity that was common across the two corpora dyads sat together in a chair or on the floor and viewed a wordless picture book that was adapted from prior research on parentchild mentalstate talk 82 the book contained color photos of children and adults engaged in a variety of activities the pages did not contain any words parents were instructed to go through the book with their child as they would at home parents were allowed to use whichever language they felt most comfortable with the experimenter then left the dyad alone to view the book the interaction was video recorded the length of the book and the duration of the activity varied across corpora in one corpus 75 the book was 23 pages and parents were encouraged to take as much time as they wanted in the other 74 the book was 10 pages and parents were told that the experimenter would come back after 10 min to conclude the activity for each interaction parent language was transcribed verbatim by trained research assistants who used a formal protocol based on prior language research to guide their work 5983 to ensure accurate identification of words and utterances all transcribers were trained to criterion before beginning the transcription process utterances were identified by grammatical closure intonation or pauses nonverbal sounds were not transcribed words that referred to sounds such as animal sounds were included in the transcription six parents spoke in spanish for a portion of the task for these parents the interaction was first transcribed verbatim by a native spanishenglish bilingual transcriber and then the spanish words were translated into english we then used the clan program 84 to calculate three measures for each parent number of utterances number of word tokens and number of word types descriptive information for these variables appears in table 2 we also calculated the total duration of each interaction this was defined as the time between the onset of the first utterance about the book to the offset of the final utterance about the book the average duration of the interactions was approximately 6 min despite differences in administration of the task the duration of the interaction did not vary significantly across the two corpora t 096 p 034 only 10 of the interactions had durations longer than 10 min ethical approval the right of the subjects who participated in our study were protected the research was conducted in accordance with the common rule guidelines established by the us office of human research protections the university of california merced institutional review board approved all procedures all parents provided written informed consent prior to participation data availability all data generated or analyzed during this study are included in this published article received 13 august 2021 accepted 18 may 2022 competing interests the authors declare no competing interests

socioeconomic status predicts the quantity and nature of childdirected speech that parents produce however the mechanisms underlying this relationship remain unclear this study investigated whether the cognitive load imposed by resource scarcity suppresses parent talk by examining timedependent variation in childdirected speech in a socioeconomically diverse sample we predicted that childdirected speech would be lowest at the end of the month when americans report the greatest financial strain 166 parents and their 25 to 3yearold children 80 female participated in a picturebook activity the number of utterances word tokens and word types used by parents were calculated all three parent language measures were negatively correlated with the date of the month the activity took place and this relationship did not vary with parental education these findings suggest that above and beyond individual properties of parents contextual factors such as financial concerns exert influence on how parents interact with their children research has shown that both the quantity and nature of childdirected speech is associated with numerous aspects of child development including receptive and expressive vocabulary development 12 language processing abilities 3 the lexical and syntactic diversity of the speech children produce 4 and childrens school readiness and academic success 5 given the broad body of evidence demonstrating the importance of childdirected speech it is critical to identify potential sources of variability in parent talk one factor that has received considerable attention is socioeconomic status ses research suggests that parents of higher ses engage in higher rates of childdirected speech than lower ses parents 6 7 8 the striking finding first published by hart and risley 6 showing large ses differences in childdirected speech became widely cited in popular press and academic journals and has since been described as the 30millionword gap although there has been some recent debate regarding the nature of this word gap 911 several recent metaanalyses have confirmed a relationship between ses and the quantity of language in childrens environment 1213 in addition to this quantity difference recent research has also shown ses differences in the nature of parents childdirected speech for instance parents with higher ses use more diverse and sophisticated vocabulary and produce more complex sentences and syntactic structures than lower ses parents 247 a question that follows is what might explain the relationship between ses and childdirected speech one approach that has been taken to answering this question is to focus on properties of the individual parent for instance parents with higher levels of education one dimension of ses tend to be more knowledgeable about child development 14 15 16 research has in turn shown that parents with less knowledge or skills related to child development engage in less childdirected speech 16 17 18 19 and that the relationship between ses and childdirected speech is mediated by parenting knowledge 1618 however there are several reasons to suspect that this individuallevel approach alone cannot fully explain ses differences in childdirected speech first interventions focused on enhancing parenting knowledge and skills are not always successful in increasing childdirected speech 20 second mothers with high and low ses view childdirected speech as equally important but still engage in childdirected speech at different rates 21 finally some research has shown that there is considerable variability in childdirected speech within ses strata 47822 suggesting that there may be external effects on childdirected speech that operate across levels of ses

introduction of protective and risk variables the development of mental health issues may be affected by both protective and risk factors both the presence and absence of risk and protective factors as well as the various combinations of these two categories of variables have an impact on the mental health of young people youth prevention and intervention efforts may benefit from a thorough analysis to lessen the negative effects of risk factors protective factors may be thought of as characteristics at the biological psychological familial or community level that are linked with a reduced chance of issue outcomes on the other side risk factors are characteristics at the biological psychological familial community or cultural level that precede and are linked with a greater chance of negative consequences in the table below we see instances of youth family peer community and societal protective and risk factors when you knowingly put yourself in harms path you run the chance of losing money or suffering some other negative outcome in the long run involvement in activities that put one at danger of bodily injury include examples of risktaking behaviors including drinking and driving binge drinking selfharm aggressive behavior hazardous sex cannabis usage and risky sports teens and young adults are more likely to participate in dangerous behaviors despite their awareness of the risks involved behavior that involves taking risks is not unreasonable teenagers seem to have a heightened receptivity to novel and difficult input adolescents are particularly drawn to experiences that push them to their physical and mental limitations taking risks increases the likelihood of gaining social acceptability confidence and experience rather of trying to reduce risktaking we should instead aim to lessen the damage that results from it literature review kelly wolfe etal this research was out to disentangle the roles played by risk attitude objective risk and numeracy in explaining age variations in participants propensity for taking risks during the recent coronavirus epidemic we investigated if older and younger persons varied in their willingness to take health risks associated with coronaviruses whether or not coronavirus risk risk attitude and numerical ability vary with age and how these factors relate to one another the research was observational and individuals completed the measurements at random risktaking objective risk risk attitude toward health and safety issues mathematical ability and risk perception in connection to the coronavirus were all reported by 469 participants our results suggest that younger persons take larger risks when it comes to coronaviruses and that higher levels of numeracy play a mediating role here but that objective risk and risk attitude play no role at all initial studies imply that changes in perceived risk between individuals of different ages contribute to the observed agerelated disparities in coronavirus risktaking the results of this research may shed light on the question of whether disparities in risktaking across age groups result from a natural decrease in capacities or from shifts in risk attitude during a pandemic james boylan etal when were bored its a catch22 because we want to do something but we dont want to do whats readily accessible we are all experiencing this tension to varying degrees during this time of social isolation in reaction to the covid19 epidemic and it is worsened when external causes put constraints on the variety of activities we may participate we surveyed 924 people throughout north america using the online mturk platform to see whether or not there was a correlation between selfreported boredom proneness and individual replies to questions concerning compliance with socialdistancing criteria during the covid19 epidemic our sample supported recent findings in the study of boredom such as an inverse association between boredom tendency and selfcontrol also we provide new evidence indicating those who are easily bored are more likely to take part in dangerous activities that put them at risk of being isolated from their peers moreover we demonstrated that the tendency to grow bored quickly mediates the relationship between selfcontrol and rule violation according to these findings susceptibility to boredom should be taken into account while trying to promote longterm social isolation takawira munyaradzi ndofirepi little details concerning the mechanism by which entrepreneurship education and training influences its desired consequences are known despite the common idea that educational opportunities like this help inspire future business owners this study set out to answer the question does education in entrepreneurship have a predictive connection with a persons desire to start their own business a crosssectional survey of 308 pupils at a zimbabwean vocational school allowed for this to be determined results show a favorable statistically significant correlation between entrepreneurship education and achievement motivation risk taking a belief in ones own ability to influence events and the ambition to start a business need for achievement risk propensity and an individuals sense of agency all contributed to a statistically significant variation in entrepreneurial ambitions only the drive for success acted as a mediator between the effects of entrepreneurship education on the intents of aspiring entrepreneurs and the other two personality traits the results have important implications for the future of entrepreneurial education david m lydonstaley etal core to dual systems theories of adolescent risk taking are the concepts of sensation seeking and impulse control using information from the national longitudinal study of adolescent to adult health researchers analyzed the correlations between ss and ic and both current and lifetime smoking adolescence saw the largest correlation between ss and either current or past 30day smoker status the highest link between ic and smoking was shown in those in their mid20s to early30s although it persisted regardless of age the findings provide new light on the complex relationship between smoking and the many factors that make up dual systems models jens o zinn todays civilizations are defined by their intense discussions and disputes about the pros and cons of taking risks unfortunately efforts to minimize peoples risktaking via legislation and tactics typically fail despite the availability of useful information professionals sometimes assume a lack of comprehension when they see the general public disregard sound counsel although this may be the case in many situations a growing amount of evidence demonstrates that individuals frequently have adequate understanding while taking risks rather than simple ignorance or misinformation the complexity dynamism and paradoxes of human risktaking are more understood thanks to the expanding corpus of study on the topic yet there havent been many efforts to organize this information this page provides useful information for such an endeavor it proposes differentiating between risktaking incentives degrees of control and many sources of socially embedded reflexivity risktaking is discussed in terms of its role in the formation and maintenance of a sense of selfworth the paper concludes that individuals take risks in order to form and safeguard an identity they value and that there is excellent evidence for the ways in which structural and cultural variables interact to affect risktaking in a variety of contexts experts may learn more about risk and encourage individuals to take less of it if they take the greater social settings and individual risk behaviors of daily life into account methods materials and procedure prior to any data collection the appropriate internal review board ensured that the studys approach was in accordance with ethical norms each participant filled out the survey online to guarantee that everyone experienced the same style and procedure throughout the research the redesigned dosperts 30item risktaking subscale was administered and participants were told that the research was exploring their perspectives on a wide range of life situations the dospert comprised six items total two each for ethics economics health leisure and society attitudes toward risk in the social recreational and health domains were assessed independently from those toward risk in the financial health and leisure domains on a scale from never to always participants were asked how often they would engage in each activity responses were tallied across all six questions in each risk category with higher scores indicating a more risktaking disposition statistical analysis cronbachs alpha was used to assess the degree of dependability within each domain of the dospert scale pearson r correlations were used to determine levels of intercorrelation on the dospert scale ordinal data on participants judgments of their comfort with various types of risk were analyzed using friedmans analysis of variance with the risk domain serving as a repeated measures factor to examine if there is a correlation between age and risk taking participants ratings of their own risktaking behaviors were analyzed using multiple regression there were two types of predictors used age and gender with an interaction term between the two included in the second stage model c is the result of replacing the interaction term with a quadratic term for age and then comparing the resulting r2 to that of model a age gender age2 gender by age and gender by age2 were all investigated as predictors in our fourth step of regression analysis model d this study showed no evidence of a statistically significant interaction between age and gender in any measure of risktaking model c was run separately for men and women and the r2 difference was compared to model a on a genderspecific basis if model bs interaction term between age and gender was statistically significant results according to table 1s cronbach values the dospert scale has enough internal consistency dependability across all five risk categories the intercorrelations for the dospert scale are also included in table 1 it was shown that the five risk areas were highly correlated with one another with the exception of the ethical and social risk areas table 2 displays the average groups risk perceptions which are greatest in the social realm then according to their value as a source of fun money health and morality our friedmans anova showed a significant impact of domain 2 102607 p 001 which persisted even after we subtracted the significantly higher social evaluations 2 17701 p 001 our research therefore supports the hypothesis that risktaking varies by domain after conducting a post hoc analysis with the wilcoxon signedrank test we found that there were statistically significant differences in risk attitudes between the social and recreational domains the recreational and financial domains the financial and health domains and the health and ethical domains weve recently been concentrating on the disparity in risktaking by age group table 3 displays the results of our tests for collinearity in each of our regression studies which included examining the variance inflation factor and tolerance levels of each of our regression models in the ethical economical health and recreational realms but not the social realm males were shown to exhibit much greater risktaking attitudes than women the individual causes of aberrant data were also looked at on a casebycase basis standardized residuals cooks distance average leverage and the mahalanobis distance let us identify an extreme case in the ethical domain and we have since removed it from all of our analyses in table 2 we see that men and women had different risk attitudes on average with the biggest gap in the financial area and the smallest gap in the social domain a typology of risk here risks are analyzed from an individual perspective and characterized as potential dangers to health happiness may be measured in several ways it includes not only material safety but also personal safety community safety and financial stability health in the full sense of the word including mental physical social and spiritual wellbeing is also included pathologies in the home such physical and sexual abuse and in the community like being a victim of crime pose serious risks to peoples wellbeing and safety some like smoking drinking and risky behavior are the result of individual decisions on how to live ones life there is a complex web of relationships between health happiness and social variables including housing employment and income as shown by the high rates of injury and sickness that i attribute to lifestyle choices the state of wellbeing is the end outcome of several interconnected factors in the actual world using information from recent studies conducted in new zealand table 4 categorizes and identifies key risks to young peoples health and safety noting whether men or girls are more at risk or whether the risk impacts both sexes to varying degrees pregnancy and other issues that solely affect one gender are not included in the table table 4 adolescent risks gender differences conclusion agerelated variations in risktaking were investigated in this research nonetheless there are a variety of ways to take risks although some theories attribute risktaking behaviors to a lack of selfcontrol others provide explanations based on sensationseeking and impulsivity taking risks is probably a complex concept especially within certain types of risks risktaking may be heavily influenced by ones ability to handle emotions and this ability evolves throughout life there may be changes in the way different age groups approach risktaking activities since older individuals show a preference for positive information at the expense of negative information hence investigating gender variations in behavior and sensitivity to risk factors is a promising field for future study with an emphasis on the youth and their families this should include considerations beyond gender such as socioeconomic and racial background recent attention has been focused on disparities between the sexes in terms of academic success and completion rates

our results suggest that risktaking inclinations in the financial sphere decline dramatically with older age in contrast social risktaking increases somewhat between the ages of 18 and 24 then declines considerably in later life whereas the decline in risktaking for recreational purposes is steeper between the ages of 18 and 24 than in later life taking risks with ones health and ones morals tends to decrease significantly with age later in life men but not women lowered their financial risktaking significantly whereas women reduced their social risktaking more substantially than men did risk variables are thought to predispose a person or group to some bad consequence and consequently to constitute a danger to wellbeing these elements may be human qualities or environmental ones inherent in the family community school or peer group environment

introduction the covid19 pandemic and its social distancing measures have resulted in dramatic changes to working life for many sectors and roles these include job insecurity job loss job changes andor reduced control over job roles and responsibilities as organisations pivot to different business models due to national lockdowns and other pandemic restrictions many individuals who typically worked in offices or other communal settings had to rapidly switch to teleworking from home despite the general flexibilities offered by telework the sudden shift to extreme teleworking in newlycreated home offices likely led to new and intense strains in job roles in the physical working environments and in the social context at home these sudden changes required new or different levels of resources and pose a likely risk to occupational health such as work fatigue work fatigue is central to job burnout theories model conservation of resources theory hobfoll 1989maslach et al 1997demerouti et al 2001shirom 2003 job burnout theories describe an energy depletionprotectionrenewal process through job demands and job resources demands require sustained effort that depletes energy resulting in emotional cognitive mental and physical work fatigue whereas resources can protect or renew energy interest in the drivers and consequences of work fatigue has risen in recent decades given its links to employee health motivation and performance work fatigue and burnout research during the pandemic has predominantly focused on specific occupations such as frontline healthcare workers and teachers as the pandemic has placed considerable psychological strain on members of these professions increasing attention is however being given to teleworker fatigue and burnout although relationships between job demands job resources and work fatigue in a nonpandemic context are established some emerging evidence suggests that prior knowledge cannot be readily transferred since pandemic working poses new issues and intensifies existing issues furthermore the impact of relevant job resources such as job control and job change management appears underexplored in pandemic teleworking research teleworking research during the pandemic has mostly examined the blurred lines between job and private domains specifically childcare and health consequences such as work fatigue comparatively little research has considered the impact of the physical teleworking environment on work fatigue however as pandemic research indicates homeworking environments varied drastically across countries and sectors resulting in privacyrelated issues and risking teleworkers health lack of privacy is a huge health and performance concern in office research we focus in this study on work privacy fit which is rooted in personenvironment fit theory and describes the congruence between the desired and the actual level of work privacy work privacy is defined as a socioenvironmental control process of information and social stimuli in the work environment workers attempt to achieve the best possible fit between their actual and desired levels of inputstimuli from their colleagues and output they make to their colleagues as outlined in the privacy fit theory workand healthrelated outcomes can be maximised if environmental characteristics can be organised in a way that supports individual privacy needs however work privacy fit and its predictors during pandemic teleworking has been almost neglected as prepandemic and pandemic studies have indicated separate relationships between job demands and job resources the home office environment privacyrelated issues childcare and work fatigue our study examined relationships together between these factors during the first covid19 lockdown in 2020 our study makes three key contributions to the existing literature 1 examines the relationship between the physical environment and privacy fit 2 examines the relative effect of psychosocial environmental and social working conditions on work fatigue 3 examines the interaction between environmental and social working conditions and work fatigue the conceptual model of our study is presented in figure 1 overarching theoretical approach socioecological framework we examine psychosocial environmental and social teleworking conditions during lockdown and their relationship to work fatigue through the theoretical lens of the socioecological framework on work context this theorybased framework suggests that health at work is influenced by factors across four nested levels individual determinants social environments built environments and 103389fpsyg20231155118 frontiers in psychology 03 frontiersinorg structural environments in this study we examined how factors across the levels of this framework influence work fatigue we also examined interactions between these factors starting at the fourth outer level the framework proposes that health at work is influenced by structural factors such as job design and teleworking policies we examined the role of psychosocial working conditions during lockdown telework as structural factors at the third level health is influenced by the built environment and its adequacy to meet individuals work needs we examined aspects of the home office as built environment factors at the second level health is influenced by the social network that operates within an environment we examined social family presence when teleworking specifically childcare duties as a social environment factor finally as health is also influenced by individuals demographic characteristics we included age and gender as individuallevel control variables we also included country of residence during lockdown as a structurallevel control variable structural environment factors psychosocial teleworking conditions and work fatigue job demands are job conditions that require sustained effort for example workload and responsibilities and are often the most important predictor of work fatigueburnout within the cor and jdr models studies have found links between high job demandsworkload during the pandemic and work efficiency productivity perceptions or higher work engagement in these pandemic studies links are mostly found when home environments had minimal distractionsinterruptions and were workconducive presumably in a pandemic context high job demand can also act as a motivational driving force under the right circumstances as shown in prepandemic research however a different stream of pandemic research indicates that job demands have changed in nature and intensity due to new pandemicspecific job demands such as teleworkingspecific tasks disruptive teleworking management tasks and telework never seeming to end high levels of job demand during pandemic telework have been associated with increased perception of stress emotional work exhaustionfatigue and burnout especially when adequate job resources were not in place and when compared to prepandemic work job control is defined as the perceived level of autonomy and influence workers have over when and how they work eg autonomy in scheduling work making decisions and choosing working methods prepandemic teleworking research indicates that teleworking is predominantly advantageous for job control with teleworking enhancing perceived job control in terms of when and where work is done and how it fits around other aspects of life in prepandemic research job control is consistently positively associated with wellbeing and negatively associated with indicators of burnout including work fatigue however there is still little evidence on the salience of this association in the pandemic teleworking context as studies have not tested associations with a global operationalisation of work fatigue but with related constructs such as emotional fatigue nonworkspecific exhaustion and wellbeing straus et al 2022 furthermore studies suggest that prior knowledge cannot be readily transferred as pandemic working poses new issues such as daily covid19 task setbacks andor intensified old issues such as familyworkinterference job change captures how well any organisational change is managed and communicated organisational change which may include changes to ones own job is associated with work fatigueexhaustion and burnout good management of organisational or job change eg highquality supervisor peer support or providing training is a resource that can help employees cope with changerelated stress and therefore avoid work fatigue since teleworkers often have reduced opportunities for support and feedback from colleagues they are at risk of negative outcomes arising from job change this risk was accelerated by the fast organisational changes due to the pandemic a large number of workers were suddenly primarily teleworking a shift that organisations and employees were largely unprepared for with more than half of workers in european union countries having had no prior experience with teleworking nonetheless very few studies investigated the role of job change in the pandemic teleworking experience some longitudinal evidence suggests that being satisfied with organisational communication about covid19 related work changes is an important resource to protect wellbeing during pandemic teleworking however overall the role of perceived job change management in work fatigue during pandemic teleworking has been rather neglected despite researchers having called for it in terms of the structural environment this study contributes to emerging evidence about pandemic telework by exploring relationships between job demands job resources and work fatigue during the first covid19 lockdowns in 2020 we propose that h1 individuals reporting higher job demand lower job control and poorer job change management during the covid19 lockdown will report greater work fatigue after controlling for all other predictors built environment factors privacy fit homeoffice characteristics and work fatigue work privacy fit 1 addresses the home office from a sociospatial level to determine its adequacy to fulfil work privacy needs work privacy fit is a multidimensional conceptualisation and operationalisation of work privacy which 1 there is a conceptual and psychometric difference between privacy fit and workprivacyprivacywork interference the latter refers to workfamilyfamilywork interference builds on altmans privacy regulation framework that is related to personenvironment fit theory as such work privacy is regarded as a control process of input and output of information and social stimuli in the work environment workers attempt to regulate stimuli coming from their colleagues and output they make to their colleagues workers strive to achieve the best possible fit between their actual and desired levels of input and output four distinct dimensions of work privacy are considered distractions interruptions task privacy and conversation privacy for further detail on the conceptual underpinning of work privacy please refer to weber et al congruent with personenvironment fit principles it is possible to maximize workand healthrelated outcomes if environmental characteristics can be organised in a way that supports individual privacy needs prepandemic research indicates that work privacy fit in an office context drastically shapes the work experience as it is associated with various workrelated and occupational health outcomes such as work fatigue most pandemic studies on privacy fit or privacyrelated aspects have explored the impact on work efficiency and performance perceptions few studies have considered the relative effects of privacy fit on health and wellbeing those that do have concentrated on reduction of sleeping problems and musculoskeletal complaints when privacy was given studies that focused on occupational health have only observed aspects that were related to poor privacy fit these studies indicated negative associations with overall stress mood dimensions of burnout and multiple aspects of mental health however none of the studies distinctly assessed the relationship between all dimensions of privacy fit and all dimensions of work fatigue in this study we examined work privacy fit as a factor in the built environment and examined its relationship to work fatigue during lockdown teleworking we propose that h2 individuals reporting higher levels of work privacy fit will report lower levels of work fatigue during the covid19 lockdown after controlling for all other predictors home office characteristics as predictors of privacy fit pandemic research indicates drastic differences in home office environments supporting or hindering privacy across samples some experienced privacyrelated advantages such as less distractionsinterruptions that were related to increases in concentration and productivity others reported frontiers in psychology 05 frontiersinorg problems with privacy distraction or interruptions since pandemic teleworking considering the acknowledged impact of privacy fit on occupational health likely predictors of privacy fit ought to be explored based on prepandemic and pandemic evidence this study focuses on three key predictors of privacy fit sharedunshared workspace perceived noise levels and crowding pandemic research indicates that unshared workspaces at home were associated with fewer nonwork interruptions or distractions perceived workspace suitability or perceived performance loss similarly perceived social densitycrowding or number of people at home while teleworking was related to lack of privacy disturbances or perceived workspace suitability as evident from prepandemic research household size can make it difficult to regulate social interactions and achieve good privacy fit and the availability of an unshared room for work has been positioned as critical success factor for telework further perceived noise exposure was related to perceived homeoffice distractions workspace suitability and perceived performance loss to further understand the impact of the built environment during lockdown teleworking we examined how home office characteristics affected privacy fit we propose that h3 individuals reporting more noise more crowding and who work with others in the same room will report lower work privacy fit during the covid19 lockdown after controlling for all other predictors social environment factors childcare responsibilities privacy fit and work fatigue telework is promoted as a way to reduce workfamily conflict because it allows flexibility of time management and reduces the need to commute between different locations however this flexibility can also have negative impacts on boundaries between professional and domestic spheres for women family appears more likely to intrude into work time whereas for men telework may be seen as an opportunity to work for longer or in a more focused way where work already conflicts with family demands intensive teleworking from home has long been positioned to lead to interference between the two ultimately increasing work fatigue in the context of nursery and school closures as a result of covid19 lockdowns many parents had to combine fulltime work with childcare and education in their home environment emerging empirical evidence indicates this has resulted in reduction of work efficiency high selfreported loneliness anxiety depression psychological distress and overall reduced physical and mental wellbeing among parents especially among mothers and increased the risk for parental burnout 2 the presence of and number of children workhome conflict hometowork interference and home demand have also been associated with emotional fatigue job burnout nonwork specific exhaustion and reduced physical and mental health these are made worse in combination with low levels of familytowork facilitation low social support low job control and low partner support in terms of the social environment this study contributes to emerging evidence about pandemic telework by exploring the relationship between childcare and work fatigue during lockdown we propose that h4 childcare responsibilities will be positively related to work fatigue during the covid19 lockdown after controlling for all other predictors privacy fit as a mediator a considerable number of studies indicate incremental links between some or all of the following variables childcare responsibilities privacydistractions interruptions workfamilyfamilywork interferenceconflict fatiguewellbeing these links appeared particularly pronounced or are hypothesised to be when the home environment did not cater for spatial separation but forced individuals to share the work room with household members for example leroy et al showed relationships between nonwork responsibilities sharedunshared workspace at home number of nonwork interruptions and emotional exhaustion childcare responsibilities predicted more interruptions whereas dedicated workspace predicted fewer interruptions in turn interruptions predicted emotional exhaustion as such we suggest that a significant amount of variance in the relationship of childcare on work fatigue is explained by privacy fit to further understand the impact of the social and built environment during lockdown teleworking we therefore examined the potential for privacy fit to explain any relationship between childcare and work fatigue we propose that h5 privacy fit will mediate the relationship between childcare responsibilities and work fatigue during the covid19 lockdown after controlling for all other predictors 2 there is a conceptual and psychometric difference between parental burnout and job burnout we included gender age and country as control variables as research suggests they may influence experiences of pandemic teleworking for example women have reported to be experiencing more fragmented time whilst pandemic teleworking due to familyhome interference and as such genderrelated differences in privacy fit are likely gender differences have also been reported in mental health whilst teleworking and in prepandemic work fatigue research regarding age studies have indicated agerelated differences in pandemic working experiences country variation has been observed in teleworking preparedness with regards to equipment and home office environments and there were also country differences in terms of strictness of social distancing measures and other restrictions during covid19 lockdowns methods study design and procedure an online crosssectional survey using the platform limesurvey was conducted with an opportunistic sample of workers recruited mostly in three primary countries associated with the research group germany switzerland and the united kingdom participants were also recruited from other countries the survey was administered in english as a key measure was only available in english at the time given the particular limitations of conducting research during the pandemic this also helped to reduce the procedural complexity of data collection the survey launched on april 10th 2020 when lockdown or strict social distancing measures had been in place between 18 and 26 days across the primary countries data were collected until may 2nd 2020 participants were recruited via social media and email among the researchers extended networks of colleagues friends and family inclusion criteria were that during the previous 2 weeks of the covid19 lockdown participants were aged 18 years or older were working and had primarily worked from home a subset of the data has been analysed and reported in a previous study which examined the role of work privacy fit job demand job control and job change in predicting future teleworking intentions participants and ethics ethical review and approval were not required for the study on human participants in accordance with local legislation and institutional requirements participants were given the option to particate voluntarily and were required to provide written informed consent if they agreed to be in the study all survey data were anonymised to make it impossible to gather any identifying information data were shared only among the research team and all data were stored on a secure university server data collection procedures and data use were undertaken carefully so as to conform with the swiss federal data protection act as the covid19 lockdown was for some a stressful lifeevent a debrief page was provided to participants this was specific to each of the three primary countries and provided links to healthcare providers and other sources of available online support a total of 737 respondents participated of which 258 were excluded in the first data cleaning step due to extensive missing data or illogical responses suggesting nonvalid submission of responses this resulted in a sample of 479 respondents which included some missing data a total of 99 cases had missing data among individual items of the study variables little s missing completely at random test on all ordinally scaled study variables suggests it is unlikely for there to be systematically missing data 6216 p 065 and is congruent with listwise deletion as a second data cleaning step all cases with missing data on the study variables were deleted listwise resulting in a final sample of 380 respondents in the final data cleaning step all cases that indicated a not applicable response on job demand job control and job change items were excluded from the analysis the final data set comprises n 300 participation by primary country was almost evenly distributed 174 of responses stemmed from other countries the gender distribution among participants was uneven almost two times more females than males took part the majority of participants fell in the age groups 2130 3140 and 4150 approximately a third of the sample reported to have childcare responsibilities while pandemic teleworking however 320 reported that between one to four children under the age of 15 years 3 were present at home as such not all participants who had children present when teleworking had caretaking responsibility this discrepancy was only present in responses from males regarding teleworking arrangements before the pandemic 430 had teleworked from home before on average at a ratio of 333 per week during the pandemic participants worked on average 3557 h per week at home which was for 420 of participants about the same as before the pandemic the majority of participants stated that their working pattern has changed during pandemic teleworking 3 the age limit of 15 years was deemed appropriate as the age of legal responsibility and liability as well as maturity concerning various aspects ranges between 14 and 16 years in the primary countries hence it was assumed that children from the age of 15 years onwards would require less supervision than younger children regarding participants home office environment 183 had a dedicated home office 576 worked either on reallocated furniture or a dedicated desk in a room also used for other purposes overall the median number of people present at home when home working was 3 if others were also working from home 716 worked in separate rooms in relation to the participants 284 shared their room or their work area detailed participant demographics and home office information are provided in table 1 measures measures are described below descriptive statistics and correlations are provided in table 2 demographics data were collected on age gender country of residence during previous 2 weeks of lockdown number of children aged under 15 years and childcare responsibilities information about teleworking was also collected including teleworking start date prior teleworking arrangements and the percentage of time teleworking prelockdown hours per week worked whether they had worked more or less since the pandemic and if they had changed their work pattern during pandemic teleworking country and gender categories were dummy coded with other countries and male being the referent structural environment factors psychosocial teleworking conditions job demand job control and job change were assessed by the short version of the health and safety executive indicator tool the dimensions job demand and job control were each measured by four items job change was measured with three items items were measured on a 5point likert scale ranging from 1 to 5 the answer option na was added to account for those participants who were selfemployed na responses were discounted for the analysis internal consistency for all three dimensions was acceptable mean composite scores were calculated high scores reflect high levels of job demand job control and job change built environment factors home office characteristics and work privacy fit perceived noise and crowding were measured with one item each participants were asked to rate if the home office felt crowded and if it was noisy items were measured on a 5point likert scale ranging from 1 to 5 high scores reflect high levels of perceived noise and crowding the own work location in the houseflat over the past 2 weeks was assessed with five categories and other the first four categories were dummy coded with other being the referent other homeworkers primary work location in relation to the participant was assessed with three categories a fourth category was included to reflect participants who were not sharing their home with other homeworkers as with the previous dummy coding the first three categories were dummy coded with na no other teleworkers being the referent work privacy fit was measured using a simplified version of weber privacy at work inventory participants rated their satisfaction with the level of privacy they experience at work based on the importance of four separate dimensions of privacy assessment conversation privacy working without being overheard task privacy working without being overseen working without being interrupted and working without distractions explicitly the items for satisfaction were i was satisfied with the time i could work without being overheard i had the opportunity to work without others listening into my work or nonwork related conversations when i wanted to i was satisfied with the time i could work without being overseen i had the opportunity to work without others seeing me or my work when i wanted to i was satisfied with the time i could work without being interrupted i had the opportunity to work without engaging with anyone in my home when i wanted to i was satisfied with the time i could work without visual and acoustical distractions i had the opportunity to work in a quiet and visually calm environment in my home when i wanted to items were measured on a 5point likert scale ranging from 2 to 2 internal consistency for privacy satisfaction and privacy importance was adequate a composite score to reflect relative privacy fit was created by weighting privacy satisfaction ratings with privacy importance ratings using multiplication high scores reflect high levels of work privacy fit social environment factors childcare responsibilities childcare responsibilities were measured using a single item as part of the demographics section of the survey participants were asked whether they had to look after their children in addition to working from home they could answer yes or no these categories were dummy coded with no childcare being the referent work fatigue work fatigue was assessed using an 18item measure by frone and tidwell on a fivepoint likert scale ranging from never to every day this threedimensional work fatigue inventory takes into account three different resourcespecific types of fatigue at work emotional fatigue mental fatigue and physical fatigue an overall fatigue mean composite score across all dimensions was calculated the wording was amended to suit the study by using a reference frame of the last 2 weeks as opposed to the original reference frame of 12 months internal consistency was excellent high scores reflect high levels of work fatigue data analysis the statistical software package r version 422 was used to compute descriptive statistics and correlation matrices we used pearson correlations where both variables were continuous tetrachoric correlations between two dichotomous variables and pointbiserial correlations between a dichotomous and continuous variable the lavaan package and semtools package in r were used to test the path model and indirect effects using the mlm estimator as per hypotheses 15 the default confidence intervals from the lavaan package were used results the proposed model had a good fit with their robust estimators with chisquare not being significant an overview of the final model with details of direct relationships between variables is shown in figure 2 of the control variables only gender predicted work fatigue females were more likely to report greater levels of work fatigue h1 was partially supported as higher job demands predicted higher levels of work fatigue however neither job control nor job change predicted work fatigue as we had hypothesised congruent with h2 individuals levels of work privacy negatively predicted their levels of work fatigue during the covid19 lockdown those who reported poorer work privacy experienced greater work fatigue figure 2 and table 3 show partial support for h3 where noise and crowding both negatively predicted work privacy fit during covid19 lockdown noisier and more crowded homeworking spaces were associated with poorer work privacy fit contrary to our hypothesis however if and how workspace was shared during lockdown teleworking did not predict privacy fit no support was found for h4 as childcare responsibilities did not directly predict work fatigue however in line with h5 an indirect relationship was observed between childcare responsibilities and work fatigue with work privacy fit being a significant mediator those with childcare responsibilities experienced greater work fatigue as a result of experiencing poorer work privacy fit a posthoc power analysis showed that a sample size of n 300 yields a power of 73 to reject a wrong model with an amount of misspecification corresponding to rmsea 003 on alpha 005 this is below the recommended threshold of 80 suggesting a slightly underpowered model however given the concern around posthoc power testing the primary implication is recognizing the need for a larger study sample in future studies and the importance of power testing in the study design period discussion this crosssectional study examined predictors of work fatigue during homebased teleworking in the first covid19 lockdown by 103389fpsyg20231155118 frontiers in psychology 10 frontiersinorg examining the influence of various factors across different levels of a socialecological model of occupational health work fatigue was influenced by factors from the structuralpsychosocial built and social environmental levels and at the individual level on average our sample was only moderately work fatigued they experienced work fatigue around once a week in the 2 weeks prior to participation women were more fatigued than men which confirms previous pandemic and prepandemic evidence however these results should be interpreted with caution due to study limitations hindering the estimation of robust effects furthermore we recognise that despite the challenges associated with the sudden transition to teleworking those workers who were able to predominantly or exclusively telework during the early stages of the covid19 pandemic may well have experienced lower levels of job insecurity psychological distress physical health issues and fear of the sarscov2 virus than workers who continued working onsite throughout lockdowns and other restrictions with regards to work fatigue predictors we found two predictors in our dataset the first and strongest predictor job demands was at the structuralpsychosocial level other variables at this level were not significantly associated with work fatigue in our sample the second strongest predictorwork privacy fit was at the built environment level also at the built environment level the variables noise and crowding perceptions were significant predictors of privacy fit but sharedunshared workspace was not associated with work fatigue the social environment level predictor childcare did not predict work fatigue directly instead childcare responsibilities had an indirect effect on the likelihood of teleworkers experiencing work fatigue and this association was positively mediated by privacy fit to provide an indepth discussion of the associations observed each result is discussed by its socioecological level structural environment factors psychosocial teleworking conditions our results show that job demand levels were low and job control and job change were rather high in our sample we observed a positive association between job demands and work fatigue which is theoretically consistent and reflects findings from other pandemic studies indicating work fatiguerelated effects however overall pandemic studies have indicated that the experience of job demands and associated impacts varies drastically across samples some studies identified additional pandemicspecific job demands impacting teleworkers mental health in contrast other teleworkers mostly in workconducive built environment conditions experienced high demands alongside a sense of higher productivity and engagement this heterogenic picture is at least partially related to differences in sectors jobs and related teleworking readiness however the varying experiences are also likely related to differences in the home environment and social life domain for example if teleworkers experience low levels of socioenvironmental stress if they can regulate social contact at home and if they do not have children or care responsibilities they are more likely to have the ability to recover from the strain of high job demand in this scenario high levels of job demand can act as a motivational factor apart from permanent contextual factors varying levels and results of job demands across pandemic studies should also be interpreted in the context of when data were collected workload levels were dynamic during covid19 following a ushape time trend longitudinal data shows a dip in workload in march 2020 when pandemic lockdowns first occurred followed by a steady increase from april to may 2020 our results from april 2020 could fit this pattern it seems likely that once pandemicrelated changes decreased and practical problems at the start of pandemic teleworking were resolved people resumed their work and projects started again leading to rising workload in may the high level of job control also aligns with levels and time trends from other longitudinal studies for example syrek et al suggest control increased from february 2020 onwards it appears that workers experienced new levels of control and responsibility over their own work time when switching to pandemic telework however we failed to detect any effects of job resource variables on work fatigue this could be explained by small effect sizes and underpowered tests as job resources are acknowledged to be weaker predictors of work fatigue other pandemic studies could not detect known mitigation effects of job control on the relationship between workfamilyinterference and mental health workfamilyinterference was positioned as too extreme to be mitigable similarly the undetected effects of job control our test for a job changework fatigue association might have been underpowered this notion is supported by pandemic evidence indicating that job change takes a subordinate role in explaining wellbeingrelated phenomena such as work engagementvigour when compared to other psychosocial job aspects such as job control or relationships during the pandemic further our assessment might have had more validity if we had adapted items and made the link to covid19related job change management more apparent we employed the standard items of the assessment in fact other studies that made the link explicit indicated wellbeing effects of good communication regarding covid19related job changes overall this suggests the relationship between job demands and resources are complex during pandemic teleworking and warrants a systematic analysis of pandemic evidence by considering data collection timepoints built environment factors privacy fit and home office characteristics on average our sample had positive privacy fit scores with a slightly negatively skewed distribution which means that many were able to meet their work privacy needs at home those that had good privacy fit in terms of distractions interruptions task and conversation privacy had significantly lower work fatigue levels this lockdownspecific result is unsurprising given the body of evidence regarding the health effects of unsuccessful spatial regulation of social interaction therefore our study supports previous hints at privacy fitexhaustion associations that used elements of the privacy concept and complements emerging pandemic evidence of privacys role in mental and physical health issues furthermore this result adds to the substantive body of evidence on the link between stressfatigueexhaustion anthropomorphic noise and interruptions from prior to the pandemic noise from other people and interruptions represent two of four dimensions of the work privacy fit conceptualisation however work privacy fit as tested here also considers output controls specifically task and conversation privacy therefore the identified effect of work privacy fit on work fatigue broadens our understanding of social and environmental stressors and their impact on work fatigue as such our study adds to growing evidence that providing workers with the ability to regulate social interactions can influence occupational health with regards to work privacy fit predictors our results only identified noise and crowding perception to be significant whereas the type of workspace or the type of sharing in the workspace were not significant our study variables had each been identified in prior studies to relate to aspects of privacy such as disturbances pandemic research also indicates direct relationships not via privacy between these home office characteristics and healthwellbeing such as psychological distress this is not surprising since noise and crowding are acknowledged socioenvironmental stressors which can have various workrelevant consequences on cognition behaviour and affect and can pose a risk to health which is similar to the attributes of privacy however the lack of any observed effects regarding the objective predictors in our study might be explained by underpowered test statistics the fact that almost 72 of participants were able to work in a separate room and possibly too much shared variance between the objective characteristics of the environment and the perceptions of noise and crowding further from a theoretical perspective it ought to be mentioned that certain privacy conceptualisations treat crowding perceptions as an outcome of poor privacy whereas others treat it as a predictor indisputably there is a significant overlap between privacy and crowding which are both transactional socioenvironmental appraisals of the environmental condition thus both relationships could be true depending on the underlying conceptualisations of crowding and privacy used in conjunction with other pandemic evidence this study suggests that the possibility for withdrawal from crowded household situations can most likely help employees to protect their energy depletion recovery process and work focus qualitative accounts of other pandemic studies found that common rooms such as the kitchen and living room were permanently used by many as an alternative workspace which clearly does not provide adequate withdrawal possibilities indeed the availability of a private room for work and a workplace that is workconducive have been positioned as critical success factors for telework beyond obvious predictors of privacy such as a private room privacy appraisal can also be influenced by more nuanced aspects in the environment those can include personalization of spaces and other appropriation behaviours by appropriating a space workers change the meaning of a space according to their interests and claim the space spaceclaiming creates territoriesboundaries of social and environmental control which in turn is an acknowledged moderator for socioenvironmental and environmental stress this is exemplified by office studies showing moderation effects of personalization on perceived privacy and emotional fatigue overall privacy fit appraisal appears to be less related to the actual design of work environments and to depend more on psychological factors such as control social factor childcare and its link to privacy fit and work fatigue in our sample approximately 30 reported having childcare responsibilities while teleworking however caring for children had an indirect effect on work fatigue in our study whereas other pandemic studies identified direct effects however we found a positive indirect effect of childcare responsibilities on work fatigue through privacy fit ie having childcare responsibilities negatively impacted privacy fit in homeworking spaces which resulted in increased work fatigue given that privacy fit appraisal appears to be highly related to environmental control it is likely that teleworkers with childcare responsibilities not only experience more privacy violations but foremost feel less in control over their physical environment and social regulation possibilities further we found that work fatigue was particularly pronounced in women overall this corresponds with other pandemic evidence about people with children at home while homeworking those with a caretaking role experienced more fragmented time with more interruptions and in turn were more exhausted especially when familypartner support and familytowork facilitation was lacking in this regard qualitative pandemic evidence provided rich insights into pandemic workers lives they have portrayed workers who live with children as having no opportunity to withdraw due to spacesharing during working hours or switching work locations in the home for example during family dinner time when the dining table was used as workspace finding places that are quiet and free of clutter has been described as difficult for those with small children further echoing frontiers in psychology 13 frontiersinorg prior pandemic evidence in the present study women appeared particularly burdened during the pandemic with prepandemic acknowledged differences of homework intrusion and associated fatigue intensifying during pandemic conditions an illustrative example is provided by meyer et al study which indicated a curvilinear relationship between pandemic duration and nonwork specific exhaustion in women exhaustion intensified during the beginning of the pandemic when childcare was not available whereas exhaustion reduced when lockdown measures were eased partner support lessened the effect in contrast the exhaustion of men who worked from home andor did not take care of children was minimally affected by the pandemic limitations the present research is subject to several limitations the first pertains to representativeness which is undermined by using convenience sampling and possible participationselfselection bias as only those workers with the capacity to be part of the study or who were dissatisfied with pandemic telework might have participated as the lockdown posed new and intense challenges it is possible that study participation was not possible for those struggling the most hence our study might underestimate the negative impact of teleworking during lockdown further the sample is not representative for the entire teleworking population in the primary countries neither is the sample representative across any specific occupational groups or sectors the study registration was public therefore anyone interested was able to participate which likely brings a broad distribution and diversity of occupational sectors and roles however owing to the rapid onset of the pandemic and our attempt to start data collection quickly we recognise that we had overlooked to collect more occupational specific data such as type of sector occupation job role or tasks this information would be advantageous since across these factors workers may differ in their experiences of teleworking alongside their teleworking infrastructure and home office setup before and during the pandemic since countries worldwide introduced different containment measures during the crisis it is likely that occupations are differently affected by the coronavirus pandemic and the results should be interpreted against this background thus the impact of the forced transition to telework observed in our data may be more pronounced in certain occupations that are less accustomed to teleworking additionally this could be further pronounced in countries with lower levels of digitalisation or in countries with less developed teleworking initiatives than those primarily observed in this study the second limitation pertains to the crosssectional design of the study which examined variables at a single moment in time prevents causal inferences and is susceptible to common method bias however given the rapid onset of the pandemic and the fastmoving pace of lockdowns being implemented early in 2020 we had limitations in terms of time and resource to plan and conduct a study with more advanced study design as emerging pandemic research shows straus et al and syrek et al it proves valuable to observe the relationships between psychosocial social and occupational health variables longitudinally as the pandemic teleworking context is dynamic in which organisations and individuals adapt to the unprecedented changes to working life further although testing the mediation effect with a crosssectional sample is appropriate it still has significant limitations crosssectional mediation analyses carry the risk of misrepresentation of psychological processes and ambiguity of the direction of the effect longitudinal mediation models provide better representations of mediation processes in addition the low sample size has power implications particularly as some key dummy variables were low in frequency therefore the potential causal relationships identified in this study should be interpreted with caution and examined further using longitudinal designs and with larger sample sizes in addition relative importance analysis could be used in future studies to test for the relative importance of each predictor in relation to the presence or absence of other predictors the third limitation pertains to the socioecological framework it provides a useful lens through which to investigate the relationship between health outcomes and individual social environmental and work factors but it is possible that specific factors on each of these levels were unduly represented in our study for this reason further research that adopts a fuller reflection of all levels is warranted this could explore data that have not been present in research to date relating to eg sectors occupations company size selfemployment job tasks or job roles it is predicted that when these factors are acknowledged workers teleworking infrastructure may differ alongside workers experiences of teleworking additionally wider aspects of the social environment were not recorded in this study beyond a focus on family commitments study of the wider social environment could include support systems from coworkers managers and family furthermore on the individual level individuals traits and abilities such as introversionextroversion or sensory sensitivity could be linked to differences in work fatigue levels as research has shown that people who are introverted or sensory sensitive are more quickly aroused and disturbed by environmental and socioenvironmental stressors further studies could examine these factors in more detail and identify suitable traits for intervention targets a full investigation of the context levels was beyond the scope of this study lastly since a considerable amount of crosssectional pandemic research did not discuss the context of time in relation to data collection within the pandemic it was difficult to position our findings within the current pandemic literature as evident from longitudinal studies demands and resources were highly frontiers in psychology 14 frontiersinorg dynamic with nurseries and schools closing and reopening and some teleworkers and organisations appeared to have achieved better management of the multiple demands on various context levels as such we hope that future pandemic research can further contextualise the aspect of time when presenting their findings conclusion our study offers insight into the impact of the first lockdown of the covid19 pandemic on employees occupational health in line with existing knowledge the psychosocial factor job demand was the strongest predictor of work fatigue our study also underlines the emerging importance of privacy fit and its predictors in the home office environment as well as its influence on ones likelihood to experience work fatigue the results also indicate that women were more fatigued than men and that childcare responsibilities became problematic when optimal privacy fit was not provided further it shows the different capabilities of teleworkers for postpandemic teleworking due to differing home office conditions as such this study offers a multicontextual approach to the investigation of work fatigue and can inform strategies on how to best implement teleworking postpandemic this can help to ensure that any future more permanent changes to teleworking policies include the physical environment and are supportive of employees and organisations data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements the participants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

background during national lockdowns in response to the covid19 pandemic previously officebased workers who transitioned to homebased teleworking faced additional demands eg childcare inadequate homeworking spaces likely resulting in poor work privacy fit previous office research suggests poor work privacy fit is associated with lower wellbeing and higher work fatigue emerging evidence suggests a relationship between childcare duties during pandemic teleworking and work fatigue in addition to psychosocial working conditions job demand job control and job change management which are acknowledged predictors of work fatigue this poses a significant threat to occupational health during pandemic teleworking however the relative effects of aspects of the psychosocial environment job demands and resources the home office environment including privacy fit and the social environment childcare on work fatigue as well as their interactions are underexplored objective this study examined the relationships between the psychosocial environmental and social working conditions of teleworking during the first covid19 lockdown and work fatigue specifically the study examined teleworkers physical work environment eg if and how home office space is shared crowding and noise perceptions as predictors of privacy fit and the relationship between privacy fit childcare psychosocial working conditions job demand job control and job change management and work fatigue work privacy fit was hypothesized to mediate the relationship between childcare and work fatigue methods an online crosssectional survey was conducted with teleworkers n 300 during the first covid19 lockdown in april and may 2020 most participants were in germany switzerland and the united kingdom results path analysis was used to examine the hypothesized relationships privacy fit was lower for those reporting greater levels of noise in homeworking spaces and those feeling crowded at home work fatigue was lower amongst those with greater privacy fit and higher amongst those with high levels of job demand an indirect relationship was observed between childcare and work fatigue with privacy fit mediating this relationship

background with global economic integration international and intranational migration is common 1 economic reform in china and the transition to a market economy resulting in massive internal migration as workers were allowed to move from rural areas to the economically productive areas eastern and coastal regions in the pearl river delta including shenzhen were major destinations for migrants from impoverished western and central inland areas of china the nationwide internal migrant population reached 026 billion in 2010 2 according to the national seventh population census approximately 70 of resident population in shenzhen are mobile people 3 migrants are at the bottom of the social ladder and are discriminated against have a high prevalence of mental health problems and have experienced a high incidence of suicide 4 suicide accounts for approximately 800000 global deaths each year and is a serious global public health problem that needs to be addressed 5 the world health organization estimates that the suicide rate in 2016 was 106 per 100000 people with 80 of these suicides occurring in lowand middleincome countries 6 death by suicide additionally produces a profound emotional impact on bereaved loved ones 78 understanding the causes of suicide and best practices for assessing preventing and treating suicidal behavior has been identified as a key public health priority and global imperative 910 the interpersonal theory of suicide proposes that suicide occurs with two constructs namely the acquired capacity for lethal selfinjury and the desire to die neither of which alone is sufficient to cause an individual to die by suicide 1112 the most dangerous form of suicidal ideation is caused by the simultaneous presence of two interpersonal constructsthwarted belongingness and perceived burdensomeness tb describes the unmet need of being socially integrated and pb reflects the perception of being a burden for others 13 the interpersonal needs questionnaire was developed to assess the main constructs of the ipts for predicting suicidal desire 14 the factor structure of the inq has been validated by many researchers and among different populations 15 16 17 18 19 20 21 22 however results have been inconsistent with most studies validating a better model fit for the two dimensions of the inq 18 23 24 25 26 and some studies validating a better model fit for the three dimensions of the inq 27 currently most studies on suicide focus on students 28 29 30 31 and depressed patients 32 33 34 and few studies have been conducted on migrant industrial workers whose population reached 174 million in 2019 which was an important feature of chinas economic development 1 surveys have shown that 147 of migrant workers are at high risk of mental illness and may perceive unmet interpersonal needs which are considered proximate and causal factors for suicidal thoughts and behaviors 35 one study estimated that from 2015 to 2017 the annual suicide rate among migrant workers in zhongshan china was 446100000 slightly higher than the city average 36 the successive incidents of suicides and deaths of migrant workers have drawn particular attention to the psychological conditions of young migrant workers on the production line 4 in past studies there have been several versions of the inq including 10 12 15 and 25item questionnaires 1424263738 whereas hill et al recommended using the 15or 10item versions because these versions indicated the most consistent model fit in confirmatory factor analyses 39 in this study we primarily used the inq15 recommended by the van orden ka 14 the aim of this study was to validate the reliability and validity of the inq15 among industrial workers in shenzhen china thereby informing the application of the inq15 and indeed ipts theory to the chinese population to this end a series of exploratory factor analysis confirmatory factor analysis measurement methodology framework of the item response theory logistic regression analysis and receiver operating characteristic analyses were conducted while the structure of the inq has been confirmed on a solid theoretical basis by van orden et al 14 we believe that it is crucial to validate the translated version in the chinese population and that the results may vary following factor analysis we examined the psychometric properties of the tb and pb and their related constructs by comparing them and examining whether they accurately predicted suicidal ideation or whether one of the constructs had better predictive power method participants and procedures a crosssectional survey of industrial workers in shenzhen was conducted from october to december 2019 a stratified multistage sampling method was used for recruitment from 16 factories and 513215 industrial workers assuming a prevalence of pastyear suicidal ideation in migrant workers of 15 183334 using α of 005 and a relative error for sampling of 01 we calculated a required sample size of 1533 to allow for a nonresponse rate of 50 first 16 factories including 4 machinery processing factories 3 electronic device manufacturing factories 3 printing and dyeing factories 2 chemical material factories 1 smelting factory 1 garment factory 1 food and beverage manufacturing factory and 1 other factory were randomly selected fulltime employees aged ≥18 years in 3 to 4 workshops from each factory were then randomly invited to participate in a survey conducted at the longhua district center for disease control and prevention each participant signed a written informed consent and was informed of the potential benefits and risks of participating by trained fieldworkers before the survey since the questionnaire contained questions about their mental health the researcher provided respondents with assurance of anonymity during the survey the right to quit at any time and that there would be no consequences for refusing the survey each participant who spent approximately 30 min to complete a survey in a private room would be compensated with a usd 260 cash voucher a group of two public health researchers an epidemiologist a health psychologist a health communication expert and a factory worker designed the questionnaire twenty workers were invited to participate in a pilot study under the instruction of trained researchers some reading and comprehension problems were recorded in the process and the questionnaire was revised and finalized based on their feedback these 20 workers did not participate in the final survey instruments and measures the study collected sociodemographic information on workers age gender place of origin monthly income living alone or not and time staying in shenzhen and used the following selfreporting tools chinese version of the interpersonal needs questionnaire15 the 15item inq a selfreport scale published by van orden ka 14 and translated by cao 35 was used to measure thwarted belongingness and perceived burdensomeness previous research on the twodimensional inq15 scale has shown that the first six items measure perceived burdensomeness and the last nine items measure thwarted belongingness participants were asked to indicate how true each item had recently become for them a 7point likert scale was used ranging from not true for me at all to very true for me six items on the tb scale were reverse scored and total scores were coded with higher scores reflecting greater perceived burdensomeness or thwarted belonging the inq15 has been shown to predict suicidal ideation 13 the subscales have demonstrated good internal consistency with cronbachs alpha values ranging from 085 to 090 for pb and 081 to 087 for tb 3940 the suicidal ideation scale the suicidal ideation scale consists of three questions have you considered suicide in the past year have you planned suicide in the past year and have you committed or almost committed suicide in the past year in this study anyone who answered yes to any of these three questions was considered to be at risk of suicide a previous study has shown that singleitem assessments of suicidal ideation are significantly associated with total suicidal ideation scores from multiple assessments 41 ethics approval the study was conducted according to the guidelines of the declaration of helsinki and approved by the ethics committee of school of public health sun yatsen university data analysis all completed questionnaires were recorded by two people via epidata means and standard deviations are reported for normally distributed data a review of kurtosis and skewness indicated that inq15 scores were not normally distributed therefore nonparametric tests and medians are reported throughout the analysis exploratory factor analysis and confirmatory factor analysis were conducted using mplus 8 robust maximum likelihood estimators robust to nonnormal data 42 and oblique rotations allowing for correlation of the examined factors 42 were applied the irt allows one to maintain only those items that contribute unique variance in the measured construct making it possible to provide more precise psychometric understanding of each items contribution to an overall mean score 43 data screening and regression analyses were performed using spss version 25 to assess the accuracy of the inq15 total score and subscale scores in predicting suicidal ideation receiver operating characteristic analyses were conducted several fit indices were considered since each index of model fit has unique properties that give rise to strengths and weaknesses two absolute fit indices the chisquare and the standardized rootmeansquare residual two comparative fit indices the comparative fit index and the tuckerlewis index and a parsimoniouscorrected fit index for rootmeansquare error of approximation all fit statistics were associated with the mlr estimator of mplus and the reported chisquare was the yuanbentler chisquare 41 cfi and tli values 090 and rmsea and srmr values 008 were identified as acceptable model fit metrics in this study 4445 results of 2700 workers selected 2023 completed a selfadministered questionnaire the response rate was 75 since we focused on migrant workers local workers and those who did not report their homeland were excluded eventually 1805 migrant workers were included as shown in figure 1 the participant age range was from 18 to 61 the mean age was 3250 and 673 of them were male all participants were randomly split in two groups with equal numbers the first group including 874 workers was used for exploratory factor analysis the mean age was 3243 and 676 of them were male the confirmatory factor analysis was conducted on the second group including 931 workers with a mean age of 3256 who were 669 male descriptive statistics and intercorrelations of the inq items for all participants are presented in table 1 andfigure descriptive statistics and intercorrelations of the inq items for all participants are presented in table 1 and figure 2 the result of the shapirowilk test suggested that responses of the 15 inq items were not normally distributed therefore estimators of robust to nonnormality were used factor structure of the interpersonal need questionnaire the exploratory factor analysis as expected multiple items of the inq were skewed positively implying that the inq measured nonnormally distributed most items especially those of the same factor were significantly correlated supporting appropriate internal consistencies except for item 12 with item 13 item 34 with item 14 and item 15 and item 5 with item 13 the results of the exploratory factor analysis 14 as displayed in table 2 showed that the threefactor and fourfactor model demonstrated better model fits however the factor loading of a threefactor model had better indicators for each item than fourfactor model the pattern of loadings for this model in sample 1 indicated that the first six items and items 91112 clearly loaded onto a pb factor which means the three items written to measure thwarted belongingness crossloaded onto perceived burdensomeness items 7810 loaded onto thwarted belongingness a tb factor and the last three items strongly loaded on a third factor which we named social isolation an si factor the oblique rotated loadings for threefactor model are showed in table 3 factor structure of the interpersonal need questionnaire the exploratory factor analysis as expected multiple items of the inq were skewed positively implying that the inq measured nonnormally distributed most items especially those of the same factor were significantly correlated supporting appropriate internal consistencies except for item 12 with item 13 item 34 with item 14 and item 15 and item 5 with item 13 the results of the exploratory factor analysis 14 as displayed in table 2 showed that the threefactor and fourfactor model demonstrated better model fits however the factor loading of a threefactor model had better indicators for each item than fourfactor model the pattern of loadings for this model in sample 1 indicated that the first six items and items 91112 clearly loaded onto a pb factor which means the three items written to measure thwarted belongingness crossloaded onto perceived burdensomeness items 7810 loaded onto thwarted belongingness a tb factor and the last three items strongly loaded on a third factor which we named social isolation an si factor the oblique rotated loadings for threefactor model are showed in table 3 these days i have at least one satisfying interaction every day 0855 significant at 5 level the confirmatory factor analysis fit statistics for the cfa in sample 2 are presented in table 2 the fit statistics for original threefactor model in sample 2 did not meet the acceptable criteria proposed before therefore the model was refined according to the modification index the inclusion of residual correlations between the items 1 and 2 and between the items 11 and 12 improved the fit of the model clearly as shown in table 3 the values of both rmsea and srmr were below 008 in addition the cfi and tli values exceeded the cutoff score of 090 supporting a good model fit the χ 2 value was still significant and the χ 2 df value was still higher than acceptable level however the χ 2 value has been constantly criticized for its sensitivity to sample size 46 as the χ 2 value will always be significant resulting in the rejection of the model fit in large samples due to the controversy the χ 2 value was given less attention when it conflicted with other model fit indices estimated parameters for the refined model are presented in table 4 all items loaded onto the anticipated latent variable significantly with r 2 ranging from 013 to 081 along with the model fit indices parameter estimates supported the threefactor model of the inq15 there was a positive correlation between the si and the tb factor but negative correlations between the pb and tb or si factor irt modeling and m2 test the rmsea of the m2 test of the model was 0001 which was far below 008 while the pvalue was 074 indicating good model fit of the irt modeling predictive validity of the inq logistic regression analysis showed that the total scores of the inq predicted suicidal ideation with an or 1084 after controlling for sociodemographic characteristics for our data the selfreported rate of suicidal ideation was 34 and using the inq15 summed item scores to assess suicidal ideation produced an auc 0733 as shown in figure 3 contrary to other studies 1621 only the main effect of pb proved to be valid with an or 1094 and with an auc of 0786 in addition the comparison of the predictive ability between the inq total scores and pb scores was significant with p 005 the cutoffs were 53 for the inq score and 18 for the pb score discussion this study aimed to validate the chinese version of the interpersonal needs questionnaire15 among industrial workers and comprehensively test the association of interpersonal needs with suicidal ideation even though a growing number of studies have used the inq to examine the applicability of the interpersonal psychological theory of suicide as well as to examine its validity in different countries and various populations 17222426272938394748 the application of ipts and inq among chinese people is rare 4950 considering the collectivistic culture in china and the difference of inq across cultures 51 we reasoned it was necessary to validate the inq in a sample of industrial workers whose suicide events caused great social attention in the past years the result of exploratory factor analysis showed a threefactor model demonstrated better model fit and factor loading which is different from most existing studies 14192151 as the inq15 was developed as an english language instrument for measuring interpersonal needs cultural adaptation should be considered yeonsoo park et als results implied that the reading of an item and ultimately the experience of specific psychological states can vary depending on cultural influence 16 in a slovene translation and validation study the researchers chose to omit items loaded weakly on its hypothesized factor and reduced inq 15 to inq 12 47 however quintin a hunt et al extracted a third factor of perceived isolation pi formed from the tb factors instead of omitting them in a sample of clinically depressed and suicidal youth 27 meanwhile it is also worth noting that most industrial workers in shenzhen come from different cities and float around across the country most of their friends and social connections are in their hometown and people they work with are thus unfamiliar so it is possible that social isolation may exist if a specific population are removed from their living environment discussion this study aimed to validate the chinese version of the interpersonal needs questionnaire15 among industrial workers and comprehensively test the association of interpersonal needs with suicidal ideation even though a growing number of studies have used the inq to examine the applicability of the interpersonal psychological theory of suicide as well as to examine its validity in different countries and various populations 17222426272938394748 the application of ipts and inq among chinese people is rare 4950 considering the collectivistic culture in china and the difference of inq across cultures 51 we reasoned it was necessary to validate the inq in a sample of industrial workers whose suicide events caused great social attention in the past years the result of exploratory factor analysis showed a threefactor model demonstrated better model fit and factor loading which is different from most existing studies 14192151 as the inq15 was developed as an english language instrument for measuring interpersonal needs cultural adaptation should be considered yeonsoo park et als results implied that the reading of an item and ultimately the experience of specific psychological states can vary depending on cultural influence 16 in a slovene translation and validation study the researchers chose to omit items loaded weakly on its hypothesized factor and reduced inq 15 to inq 12 47 however quintin a hunt et al extracted a third factor of perceived isolation pi formed from the tb factors instead of omitting them in a sample of clinically depressed and suicidal youth 27 meanwhile it is also worth noting that most industrial workers in shenzhen come from different cities and float around across the country most of their friends and social connections are in their hometown and people they work with are thus unfamiliar so it is possible that social isolation may exist if a specific population are removed from their living environment the cfa confirmed that perceived burdensomeness thwarted belongingness and social isolation are distinct but related with thwarted belongingness and social isolation being closely related the initial model demonstrated poor fit however when allowing two pairs of items to covary the fit indices improved to excellent items 1 and 2 refer to the positive effects of an individuals death on others items 11 and 12 refer to the relationship between the self and outsiders because each pair shared a common theme we reasoned that allowing the pair of items to covary would be acceptable just like other research 1752 the irt modeling and m2 test approved the procedure in our study the tb was significantly negatively associated with pb and positively correlated with si and we interpreted such relationships to be due to the difficulty participants may have had dealing with reversecoded questions in line with the interpersonalpsychological theory of suicidal behavior 12 the results of the current study suggest that the inq strongly predicts desire for suicide as socioeconomic factors including relative income 5354 have been associated with suicidal behaviors we reran a regression analysis to identify a unique contribution of inq to suicidal ideation and the relation was still significant meanwhile the effect of pb and tb was significant before and after controlling for demographic characteristics these results are in accordance with the theory which assumes that all constructs are needed in order for suicidal ideation to develop 1114 and the findings of some previous studies also support it 1355 consistent with mitchell et al 56 and jeffrey b brookings et als findings the results of the roc analysis indicate that the inq15 may be useful and pb may be better in detecting suicidal ideation among individuals individuals whose inq scores exceeded 53 or pb scores exceeded 18 may be at high risk of suicidal ideation and in need of help in this study a hotline number was given to all workers in case they needed psychological counseling however the inq15 was not developed as a screening tool it was thus difficult to apply cutoff scores to measure suicidal ideation in reality limitations of this study are that it focuses on migrant workers in shenzhen only and that we did not repeat the survey to get the testretest reliability thus the findings cannot be generalized to average populations in china however we did use a larger sample in our study so the results may provide a worthy reference for the application of inq15 in largesample population surveys second since the culture effect has been demonstrated 1651 and the chinese version of inq15 was used in this study the culture effect and translation influence were not tested third the three questions measured shorttime suicidal ideation rather than lifetime suicidal ideation however the mean time the investigated workers were staying in shenzhen was 624 years so it was reasonable for the inq to predict shorttime suicidal ideation conclusions in conclusion the inq has good psychometric properties and can be used to assess how industrial workers living in the shenzhen perceive meeting interpersonal psychological needs to our knowledge it is the first study to validate the chinese version of inq15 in a sample consisting of migrant workers and the validation of the scale among migrants is the first step necessary to test the interpersonalpsychological theory of suicide on a specific population the translated inq confirmed three distinguishable and internally consistent factors corresponding to pb tb and si and predicted suicidal ideation properly future studies may seek to develop norms or cutoff scores at which elevated scores on the inqchinese would indicate an elevated risk for suicide and focus on interventions in this process to prevent suicide data availability statement data are available on request due to privacy and ethical restrictions the data presented in this study are available on request from the corresponding author the data are not publicly available due to protection of participants privacy

objective interpersonal theories of suicide suggest that the interpersonal needs questionnaire inq can be used to measure suicidal ideation but few studies have focused on migrant people a group with a high prevalence of suicidal ideation the aim of this study was to validate the psychometric properties of the inq15 and its prediction of suicidal ideation among migrant industrial workers in china method a stratified multistage sample of 2023 industrial workers was recruited from 16 factories in shenzhen china there were 1805 nonlocal workers which we defined as migrant workers with a mean age of 3250 ± 843 years old who were 673 male the structure of the chinese version of the inq15 and its correlation and predictive utility for suicidal ideation were examined through factor analysis the item response theory the m2 test logistic regression and receiver operating characteristic roc analysis results different from studies among various samples in which a twofactor solution is identified results within this sample indicated three factors perceived burdensomeness thwarted belongingness and social isolation the model fit statistics of threefactor inq were 0075 for rmsea 0945 for cfi 0932 for tli and 0067 for srmr the model standard estimated factor loadings ranged from 0366 to 0869 the summed scores of inq and perceived burdensomeness predicted suicidal ideation after controlling for sociodemographic characteristics such as age gender and income with auc of 0733 95 ci 07120754 and 0786 95 ci 07660804 in the meantime the comparison of the predictive ability between inq total scores and pb scores was significant with p 005 conclusion the inq has good psychometric properties and can be used to assess how migrant workers living in the shenzhen perceive meeting interpersonal psychological needs and shows good predictive ability of suicidal ideation perceived burdensomeness appears to play a role in suicide and may be a point of intervention yet the notable deviation from previous findings and the relative weakness of two of the other factors warrant further study

background in reginas north central neighbourhood issues of addiction continue to jeopardize the parenting roles of first nations mothers residents of this neighbourhood frequently encounter poverty injection drug use and domestic violenceall of which affect their caregiving ability in one support program offered to residents of the neighbourhood breastfeeding reestablished the caregiving role of mothers in the 1980s a young first nations population moved to regina canada looking for a new life away from their culture and its traditions 1 at this time however regina had a burgeoning drug market with a sextrade industry and gang affiliations to support it with little support for positive lifestyle choices many of the youth succumbed to a lifestyle of drug and alcohol use this lifestyle continues for many within the population today and has a profound affect on their parenting ability in 2010 a review of the provinces child welfare system identified that 80 of children in government care were of first nations descent a population that makes up only 10 of the provinces population 2 a national survey of human immunodeficiency virus cases further identified that the number of cases in north central regina were three times greater per capita than anywhere else in the country 92 were associated with idu and 69 were associated with first nations ancestry 3 healthiest babies possible program a prenatal postpartum support program in north central regina provides support to on average half of the neighbourhoods expectant mothers the program set up by first nations women in the community brought support to mothers with caregiving roles an increased focus on breastfeeding became a part of the program when the babyfriendly initiative a program promoted by the health region was introduced the bfi has been a part of the world health organization health action to support breastfeeding worldwide particularly in emergent situations in hbpp commitment to breastfeeding was further strengthened with the recognition of breastfeeding as a part of womens lifegiving role in first nations beliefs recognized to promote a caregiving relationship for the mother with her infant these beliefs also link mothers to the cosmic realm for ancestral support in this relationship with breastfeeding 4 hbpp participants experienced empowerment effects from breastfeeding which in turn significantly enhanced perceived ability to care for their infants in other activities as selfconfidence for caregiving increased drug and alcohol use stopped realizing the power of breastfeeding to increase an overall sense of caregivingempowerment hbpp staff and participants set out to measure this effect to further promote mothers breastfeeding opportunity not always supported by healthcare providers first nations breastfeeding practice caregiving was historically significant for women in first nations tribes and included the kill of small game planting of crops care of children and childrearing that included teaching children traditional values 4 5 6 the teepee has been used as a symbol of mothers in this role the poles are seen to be in the shape of a woman and the buffalo skin like a shawl wrapped around her the family is often shown inside the teepee further recognizing the mothers protective role for her family 5 infants were kept in the constant watch of their mothers who carried them in a moss bag secured to their backs keeping infants in this proximity encouraged the motherbaby relationship and promoted breast milk supplies fathers encouraged a high quality of breast milk by providing mothers with the best cuts of their kill other women in the tribe supported breastfeeding by assisting with the care of older children or breastfeeding an infant when the biological mother could not this was done when chief crazy horse a memorable first nations chief from the lakota tribe was orphaned as a young child in addition to this support older women known as kohkoms assisted mothers with their knowledge of herbal remedies such as the topical use of balsam to relieve engorged breasts 67 fig 1 written permission for the illustration the red tipi was provided by the artist holle hahn for use in this document november 11 2019 impact of western society on first nations breastfeeding many first nations people lost traditional cultural practices as a result of colonization and changes enforced by the indian act in 1876 48 when land designation went to males instead of females family roles were dismantled and the females leadership role for caregiving was undermined first nations food sources became food rations provided by colonizers creating dependency by first nations for their daily existence indian agents sent out by colonizers enforced the use of milk powder for infants thereby implying a mothers milk was substandard in a review of the canadian national database for breastfeeding a drop in indian and inuit populations breastfeeding was observed from 1960 to 1980 9 early in the 1960s breastfeeding rates were 694 significantly higher than the 38 reported for the general population at that time by 1980 breastfeeding rates had dropped to less than 60 in the indian and inuit population while the rates in the general population rose to 76 a lower percentage of women breastfeeding within these populations continues today 10 traditional caregiving practices and support for breastfeeding came under new scrutiny when government workers were brought onto reserves to monitor mothers caregiving in the 1960s not fully understanding how the first nations mothers caregiving had been devastated by colonization first nations women were portrayed by the workers as demanding filthy and prone to drunkenness 4 government workers relocated many children far away from their homes placing them in government foster care or residential schools in an action referred to as the big scoop 1 it was this action that brought young people to regina seeking a sense of identity that fit with western society and a life they believed to be better than what they would have remaining on their reserve ultimately this move created devastation for the youth and their lives empowering mothers caregiving in disadvantaged circumstances research underlines the value of accomplishments with caregiving to create a positive selfworth by mothers dealing with disadvantaged circumstances such as being adolescent having low income or education and marginalization in society 411 positive affiliations with families and peers for caregiving are important to support caregiving practices such as breastfeeding in one study relocation of mothers from rural communities in india to urban mumbai slums showed increased autonomy with caregiving despite continued partner abuse and isolation by their cultures class system 12 the change was linked to increased peer contacts and as well as observation of other mothers autonomy by social media this led to increased responsibility for families healthcare lifestyles and some income locklin 13 noted an enhanced sense of self in the caregiving role for a small group of mothers from hispanic descent with successful breastfeeding experiences the mothers who were multiparous had attempted breastfeeding in the past but discontinued prior to three weeks postpartum with this experience weekly support for breastfeeding was provided by peers who assisted the breastfeeding practise mothers became strong enthusiasts for breastfeeding empowered by their breastfeeding success evaluations of the empowerment effect were limited however to selfreporting at a fourmonth postpartum interview a study conducted by mossman heaman dennis morris 14 found adolescents who breastfed had increased selfworth believing themselves to be valuable family members and having more confidence in social groups enhanced by a sense of self following breastfeeding success evaluation of these indicators was at 28 days postpartum first nations mothers identified in the study were two times less likely to initiate breastfeeding as compared to other mothers possibly related to a decreased sense of self with caregiving epstein 15 a research psychologist and breastfeeding activist recognizes the value of a positive sense of self for mothers with breastfeeding she credits the breastfeeding relationship between a mother and her infant to her ability to reframe negative images of herself into positive ones caregiving accomplishments as with breastfeeding are recognized as significant to promote mothers caregiving roles particularly when disadvantaged methods while associations between positive selfimages and caregiving functioning have been made in other western research a strong association between breastfeeding and its capacity to promote caregiving in highrisk situations has not yet been evaluated the realization that breastfeeding empowered hbpp mothers to be stronger caregivers of their infants identified by infant feeding caregiving assessment and participation emotional support and follow up of infant health created interest by the researcher to measure this effect commitment to measuring confidence with breastfeeding following the promotion of breastfeeding in the program was shared by mothers in hbpp it was linked by some to their first real experience of unconditional love in a relationship the goal for the study was to empirically measure the correlation between breastfeeding and the mothers caregiving association while faced with challenges such as their own lack of rolemodelling with this care lack of resources and lifestyle risks both hbpp staff and participants recognized the value of such a measurement to support mothers breastfeeding opportunity often challenged by healthcare providers and government workers a longitudinal study design measuring caregiving indicators before and after breastfeeding as well as when mothers did not breastfeed was possible given mothers participation in hbpp until six months postpartum the intent of the study was to establish breastfeeding as a catalyst for caregiving and a lifestyle free from drug and alcohol use indicators of empowerment observed with breastfeeding included increased selfesteem more participation in infant care and cessation of drug and alcohol use kabeer 16 recognizes such achievements to indicate an ongoing empowerment process for caregiving when positive beliefs about caregiving ability are recognized by the mother as achievements continue these beliefs become deeprooted having a synergistic effect for confidence to assume additional activities with caregiving selection and description of population all hbpp participants were invited to participate in the study over a sixmonth period most begin participation at around 1620 weeks gestation expectant mothers more than 28 weeks gestation were excluded from participation due to the influence of elevated prolactin occurring by this time increased prolactin hormone levels and decreased activation of hypothalamicpituitaryadrenal axis occurring with breastfeeding decreases the mothers usual stress response potentiating her connection with the infant to enhance caregiving 1718 another variable promoting accurate measurement of empowerment indicators was the homogeneity of the group prenatal and postnatal support for breastfeeding was similar for study participants given their participation in hbpp as well participants came from the same neighbourhood and were dealing with similar disadvantages related to their first nations ancestry and the undermining of cultural beliefs and practices by western society concern regarding mothers drug or alcohol use during infant care was monitored as a part of their hbpp participation interaction for this also prepared mothers for cessation of drug and alcohol use continued support by hbpp workers in the postpartum period allowed mothers lifestyle choices to be monitored to safeguard infants from any possible change in lifestyle by mothers ethics and consent to participate hbpp participants were included in all discussion of the study including empowerment indicators study design assessment tools and distribution of study findings study participants signed consent forms to participate in the study however consent did not include personal identification of information they shared all study participants were over the age of 16 years canadian indigenous health research governance recommends that researchers and communities should work collaboratively for research in a communitybased process this interaction is recognized to increase acceptance of research findings by the population and the relevance of recommendations for the populations health 19 ocap principles further regulate research of first nations populations in canada ensuring that a population has full input regarding the study how it will be carried out and how the findings will be shared 1920 the study was fully approved by the saskatchewan health authority research ethics board ongoing updates regarding study decisions and progress were provided to this board procedure and instruments expectant mothers were informed about the study at their hbpp placement and again at a prenatal health assessment carried out by the programs registered nurse at around 25weeks gestation consent was reviewed with the expectant mothers at the 25 week assessment and their consent for participation in the study was received at this time the first interview for the study was completed following participant consent for participation mothers were invited to the second assessment at this time which would be carried out at two months postpartum a 20dollar honorarium was provided following the second assessment a celebration event was held at the conclusion of the study to acknowledge the contribution of the program participants to the study and to receive their feedback regarding study findings previously established assessment tools were used to collect information regarding empowerment indicators tools were pretested with four program participants to obtain their feedback regarding the tools ability to assess empowerment indicators their feedback recommended that opportunity be given for additional participant comments at the end of the interviews for feedback regarding participant experience with the empowerment indicators this reporting is suggested by other researchers as a means to enhance content validity with the use of closedended tools for data collection 21 assessment of participants demographic information including caregiving experiences was collected using hbpp tools in the first interview the tools were developed and tested by barrington researchers to evaluate program participants in canadian prenatal nutrition programs 22 an intake questionnaire developed by addiction services in the health region was used to assess study participants drug and alcohol use both employ closedended questions this assessment however was not a part of any program evaluation rosenbergs selfesteem scale measured selfesteem 23 respondents assessed ten selfesteem statements on a fourpoint scale ranging from strongly agree to strongly disagree with a higher score indicating higher selfesteem the rses has a coefficient of 73 for reproducibility 72 for individuals scalability and an internal consistency coefficient of 84 to 87 fawcetts inventory of functional status after childbirth assesses caregiving behaviors characteristic of optimum caregiving function 2425 the ifsac was used to collect data about caregiving activity by a study participant before and after giving birth the tool contains five subscales measuring a mothers caregiving functioning family care selfcare household activities social and community activities and educationoccupation respondents rate a total of 36 items using a fourpoint scale higher scores indicate better caregiving ability content validity measured by the researcher for this tool was established as 96 data was entered into an epiinfo data base and analyzed using version 16 of the statistical package for social sciences indicator measurements using instrument scores were reported the ttest and chi square analysis were used to evaluate subgroup differences correlation analysis examined the extent of the relationships between possible factors influencing a mothers decision to breastfeed results study participation was maintained in conjunction with mothers participation in hbpp of the 53 mothers who agreed to participate in the study within a sixmonth span of invitation 51 or 96 completed both assessments the two mothers who did not finish the last interview had moved to another location and could not be contacted for the final interview however only the data of those completing both assessments was used for evaluation in the study group 40 mothers chose to initiate breastfeeding but only 32 continued to breastfeed until the twomonth interview eleven chose not to breastfeed for infant feeding two mothers identified as hiv positive and were not supported to breastfeed due to the risk of transmitting hiv to their infants through the breastmilk indices of caregiving empowerment indices of caregiving empowerment were measured and compared to the mothers chosen method of infant feeding a change in selfesteem from pregnancy to postpartum was significantly correlated to a mothers infant feeding practice the mean scores for mothers who continued to breastfeed at two months postpartum increased significantly from 287 prenatally to 357 postpartum for the mothers who did not breastfeed there was a decrease in the mean selfesteem score from 305 prepartum to 218 postpartum the findings for mothers who did not breastfeed have limited value given the small sample size however other research of larger study groups established a decrease in confidence with caregiving when mothers did not breastfeed in larger study groups these mothers were often identified to be adolescent having limited resources or marginalized in some way 13 14 15 26 significant change in caregiving function was also correlated to infant feeding choices the average caregiving function scores of mothers who did not breastfeed decreased from 266 prepartum to 226 postpartum however for mothers who continued to breastfeed at two months postpartum the mean caregiving function score increased to 316 postpartum from 260 prepartum lastly the most significant change observed with breastfeeding was related to drug and alcohol use for mothers who breastfed there was a decrease from 59 to 9 for drug and alcohol use a dramatic difference compared to nonbreastfeeding mothers where there was no change in scores for drug and alcohol use during the second interview several participants identified breastfeeding as becoming a new addiction and admitted returning to breastfeeding after weaning afraid of losing the sobriety they had gained with breastfeeding correlations to breastfeeding decisions selected determinants of health discussed in the toronto charter for a healthy canada 27 were measured to identify their relationship to breastfeeding outcomes specific determinants consisted of social support networks support of family and friends and formal education the staffs experience with hbpp clients led to measurements of age previous breastfeeding practice and the presence of a partner as possible determinants affecting a mothers breastfeeding choice support from family and friends in addition to program support was found to be important for promoting breastfeeding this was consistent with research findings which explored the value of this support to promote breastfeeding in disadvantaged situations 13 14 15 21 for mothers who initiated breastfeeding 27 out of 40 attended hbpp programming every one to two weeks mothers were 88 more likely to breastfeed when support from family and friends was average or above average among the eleven that did not breastfeed nine rated family and friend support as average or less only four attended programming more often than once a month somewhat surprisingly having a partner reduced the practice of breastfeeding of the mothers who continued to breastfeed at two months postpartum only 19 of the 32 participants were with their partners as compared to 16 of the 19 mothers who were no longer breastfeeding overall the mothers who were breastfeeding reported less contact with their partners due to partner drug and alcohol use these women recognized that such a relationship could jeopardize their ability to continue parenting breastfeeding initiation was most likely to occur when mothers were able to maintain primary caregiving responsibility of the infants nine study participants lost their infants to government foster care following delivery all were multiparous and lost their infants because of past drug and alcohol use none had ever breastfed through the assistance of hbpp staff four maintained the use of their own milk for infant feeding by providing expressed breast milk to the foster parent two of these four mothers were reunited with their infants prior to the twomonth postpartum interview demographic information and postnatal experience provided insight for program support fig 2 means comparisons for selfesteem before and after infantfeeding outcomes fig 3 means comparisons for care giving function before and after infantfeeding outcomes younger mothers aged 1826 years were more likely to initiate breastfeeding than those who were more than 26 years old making them an especially important group to target for infant feeding information prenatally primiparous mothers were more likely than multiparous mothers to initiate breastfeeding however six of the eight mothers who discontinued breastfeeding were primiparious this result suggests breastfeeding support in the postpartum continues to be important for this group of mothers the majority of mothers who chose not to breastfeed were in the oldest age category 26 years or older with most never having breastfed before they were also less likely to attend hbpp programming further examination of this situation is needed to understand how this group of mothers can be engaged to initiate breastfeeding discussion the study underlines the importance of promoting caregiving practices such as breastfeeding that empower mothers caregiving association this is true even when issues of drugs and alcohol are faced not supporting them with this choice can permanently jeopardize caregiving associations as was seen in north central regina using the punitive approach of placing children in government care to promote caregiving association has only led to ongoing issues of substance use violence and loss of caregiving roles in the population this research has found that reestablishing cultural identity with caregiving through breastfeeding has proven to be a more effective way to promote mothers caregiving association while diligence was asserted to promote the strongest evaluation possible with this population and their infant feeding conclusions are limited to the mothers of this group however attention to the need for cultural perspectives in health promotion is identified in other reseach 27 this type of promotion has led to members of the population experiencing an increased sense of self due to the realization that the strength of their beliefs can promote health and function 28 29 30 research guided by a communitybased research approach is recognized to increase the populations perspective regarding health practices and to better inform healthcare workers for their support of these practices 31 for hbpp participants who chose to breastfeed it was observed that their commitment to breastfeeding rights increased this is consistent with kabeers 16 recognition of an empowerment process with caregiving when achievements occur other research has linked the prohibition of showing emotions particularly in the first nations culture to increased grief reactions which is suggested to be a part of the healing process 32 several study participants challenged hospital school and mall managers when their breastfeeding was not supported in these locations in one situation a meeting with the provincial government was set up following an insult experienced by one mother reprimanded for breastfeeding in the mall this resulted in a breastfeedingfriendly statement coming from the ministry these interactions further enhanced attachment to breastfeeding and recognition of its value for the infant and their own caregiving association it is wondered if the pursuit by some participants later on of careers including nursing addiction support work and paramedics could be linked to a positive breastfeeding experience longterm benefits observed with breastfeeding for maternal health are relevant for this population given their fig 4 percentage comparisons for drug and alcohol use before and after and infantfeeding outcomes health risks for diabetes and cancers in a prospective danish cohort study an inverse association was observed for breastfeeding duration and weight retention up to 18 months correlating with anthropometric measures seven years after delivery 33 for mothers who already have symptoms of gestational diabetes mellitus breastfeeding has a protective effect against the development of type2 diabetes 33 in a large systematic review including more than 9000 abstracts and 29 systematic reviews and covering 400 individual studies the effect of breastfeeding for longterm health of mothers and infants was investigated 34 a history of breastfeeding was associated with reduced risks for type2 diabetes breast and ovarian cancer early cessation or not breastfeeding at all was associated with a higher risk of postpartum depression attention has also come to the omission of breastmilk for use with infant feeding in the consideration of gross domestic product in norway it is estimated that the market value of breastmilk lost to formula and baby food sales totals 70 billion 35 it is also estimated that health care costs incurred for premature deaths in united states associated with low breastfeeding is 4382468 billion 36 similarly morbidity costs for diseases directly related to low breastfeeding are 73377 indirect costs of disease are estimated to be another 1261 million 36 likewise in the united kingdom the costs for healthcare during 20092010 to treat illnesses associated with suboptimal breastfeeding was 957 million pounds for mothers and 89 million pounds for children 37 infant benefits directly from breastfeeding are linked to protection from infections and biological signals for promoting cellular growth and differentiation 38 for example living in crowded housing puts children at risk for respiratory infections in disadvantaged housing situations breastfeeding reduces the severity of respiratory problems particularly in the first 27 weeks of life recognizing this benefit the american college of obstetrics and gynecology recommends breastfeeding infants exclusively until six months followed by continued breastfeeding with complementary foods for one year or longer 38 conclusion the loss of traditional roles and functions as a result of colonization has contributed to issues of violence abuse and dysfunction within many first nations families children raised outside of their biological homes have been deprived of cultural knowledge relevant for roles and functions as well as the sense of self with these support to reestablish this identity through experiences such as caregiving is needed for confidence with these functions given the importance of breastfeeding for both the mother and babys physical and emotional health american college of obstetrics and gynecology asks for a multidisciplinary approach involving practitioners family members and child care providers to support breastfeeding in disadvantaged situations breastfeeding is recognized as a lowcost intervention which prevents cardiovascular disease obesity and diabetes in highrisk women along with respiratory illness for the infant 39 initiatives like the bfi have an important role to play in assisting healthcare providers with reflection and reconsideration of their stance on relevant health issues this could lead to more openminded recommendations and approaches toward disadvantaged population members receiving their care the contribution of breastfeeding toward empowering a positive selfperception for mothers in the first nations population cannot be undervalued breastfeeding is a powerful mechanism to enhance caregiving identity for all mothers additional research on the empowerment effect of breastfeeding in other populations is still needed to further support breastfeeding empowerment the collection of breastfeeding experiences by traditional knowledge keepers is underway in the regina population to further support identity with breastfeeding increased opportunities for mothers to breastfeed along with collection of cultural knowledge for breastfeeding beliefs offers a return to pride in caregiving identity and a sense of self once experienced by this population with caregiving abbreviations bfi babyfriendly initiative hbpp healthiest babies possible program hiv human immunodeficiency virus idu injection drug use ifsac fawcetts inventory of functional status after childbirth ocap ownership control access and possession principles rses rosenbergs selfesteem scale funding sources canada prenatal nutrition program public health agency of canada these funds were used as seed money to initiate the project money was used to fund research time and conference attendance by the primary author as well the money was used for honorariums and tobacco exchanges for community support and meeting regarding the proposed research project funds were also used for a ceremony held to recognize the project at the start of the research hospitals of regina foundation this money provided funds to purchase honorariums and gifts for participants it also covered costs for a celebration that was held at the completion of the study consent for publication not applicable competing interests not applicable

background an innercity neighbourhood of regina saskatchewan continues to have recurring issues of drug and alcohol use affecting parents caregiving opportunity in relation to this many children mostly of first nations descent are raised in outofhome care away from their families with the promotion of breastfeeding in a neighbourhood prenatalpostnatal support program breastfeeding rates have doubled and mothers participation in their childrens care has increased recognition and promotion of cultural beliefs about breastfeeding is integral to raise community awareness of the practice to bring additional support for breastfeeding the empowerment effects observed were measured methods using a longitudinal study design indicators of empowerment were assessed prenatally and again at two months postpartum indicators included selfesteem caregiving activities and drug and alcohol use outcomes of assessments were correlated to infant feeding practices and findings compared results findings supported a statistically significant improvement for empowerment scores when mothers breastfed mean scores for selfesteem increased from 287 to 357 r 90 p 001 for caregiving scores increased from 260 to 316 r 91 p 001 and for drug and alcohol use scores decreased from 59 to 9 p 001 the study brings attention to the value of breastfeeding for caregiving in situations of addiction and limited resources practitioner reflexivity in regards to their support for breastfeeding is critical and includes openness to alternate breastfeeding situations and beliefs the study found that a positive outlook on breastfeeding is the first step for a practitionerclient relationship that fosters confidence for marginalized populations

infotainment and the current spanish audiovisual context infotainment is the tendency to address news information in the form of entertainment or show business starting from the premise that being interested in entertainment involves a cultural process that is not limited to the media but is observed in different aspects of contemporary society it is understood that the very idea of culture becomes confusing and multifaceted making space for much of human activity as it is approached from a multitude of points of view and disciplines garcía avilés reasons that content and narrative forms are selected taking as the principal criterion the impact they can have on the audience rather than their ability to provide relevant information in the most rigorous way possible hence for example youtube transforming into a catchall ranging from videos known as tutorials where formal and informal educational knowledge is shown to other audiovisual proposals of an analytical or opinionated nature in which very active creators such as youtubers have become opinion leaders and massive phenomena it is worth asking whether this is due to the fact that they are more accessible than other traditional media figures as it is possible to have a new conversation with them that is subjective and free insofar as conversations begin and end are resumed or abandoned without protocol which implies a new consumption that is dependent on the circulation of everyday and expert knowledge how it is appropriated or not and of course to whom it implies a border and thereby exclusion or integration twitch also represents another major competitor to traditional television with some studies showing that spanish consumers believe that twitch has the potential to equal television as a favorite audiovisual entertainment medium and even surpass it to become the first choice for entertainment in the long term although live streamers in principle do not seem to differ so much from those of television except that time limits disappear and that content creators are aware that most people who follow their broadcasts have them as background while doing other things in a socalled radio mode that is something that allows the same channel to be used as television or radio depending on the attention paid by the user in terms of new trends or audiovisual formulas for some authors it does not seem so necessary to name or classify programs spaces or sections instead prioritizing the final feeling that remains after viewing them or in other words to assess whether a viewer has been informed andor had fun watching them and which of the two feelings predominates understanding that the hybrid phenomenon is also related to a change in the audiences reception of the messages broadcast by television media likewise interesting fresh and original content is necessary since the public generally synchronous seeks surprise from a clear concept that corresponds to a pioneering idea and another point in favor that is gaining more and more followers is the option of participation either through twitter in the case of traditional television or chat donations and subscriptions in the case of youtube and even more so twitch since it offers a direct opportunity to interact talk and create a community around the figures of content creators despite the fact that the very development of the platform suggests concomitance with the old formula of success of television communication the live audience sharing the same content synchronously regarding television one should not forget the changes produced since its first stage in spain when the channels offered were expanded in 1990 which ended tves monopoly and marked the passage from captive to shared audiences or when digital terrestrial television was implemented in 2010 establishing the duopoly of mediaset españa and atresmedia which together retain 584 of the audience in the case of atresmedia hybrid proposals ended up being established when it came to planning the programs with an infotainment more linked to humor and politainment predominating so as to continuously resort to political information since atresmedias strategy consists of dumping all the programs with political content on its second channel la sexta which is the case of el intermedio broadcast since its establishment similarly other formulas such as espejo público in its morning magazine format alternates news topics with formulas that appeal to the audience additional more recent examples can be seen such as todo es mentira which is another prominent case of an infohumor program that analyzes fake news broadcast by television or other media relying on resources such as social networks to interact with potential audiences and even to incite debate furthermore there are also media figures who in addition to hosting their own programs hybrids between journalism and show businessparticipate as collaborators in entertainment programs such as cristina pardo cohost of más vale tarde and thursday night talk show host of el hormiguero not to mention the fact that these programs increasingly resort to occasional contributions from specialized analysts who are mainly found on youtube such as juan ramón rallo or rocío vidal la gata de schrödinger transmedia consumption and the new challenges facing infotainment professionals because television has been the main cultural mode we have to know ourselves and the fact that the internet and social networks are increasingly present such presence in turn must be increasingly perceived on television especially in infotainment which constantly pursues the approval of the public causing hybrid trends to become inseparable from the concept of social television this stems from the practice of questionasking which generates an extension of the main content on other platforms and establishes some crossmedia productive routines with the purpose of generating a permanent dialog with the audience on second screens to achieve a greater engagement with the broadcasted content and their protagonists when engagement is delved into in a deeper way the audience is no longer understood as a passive entity which is placed at the end of the content distribution process and whose only value is to be reflected in the industrys information systems hence traditional television networks increasingly emphasize transmediation strategies that retain younger audiences and allow them the option of consuming their content for free through other channels thus some argue that audiences are migrating to new ondemand television services independent of live broadcasting and others consider that we are witnessing the decline of the medium owing to the new possibilities of delayed consumption although they recognize that it is still early to guarantee a change in trend because there are still no data available on the convergence of audiences in the media regarding political information twitter has been positioned as the main network for communicative exchange thus far for its ease of use for allowing realtime commentary regarding what is viewed and encouraging interaction with other users with the program itself and its protagonists however users have become increasingly accustomed to the use of social networks to comment on what is happening in their daily lives and to share their television experience 85 of active twitter users talk about television in prime time finding in digital platforms a new more dynamic television with charismatic figures such as ibai llanos who is currently the owner of the spanishspeaking channel with the largest audience on twitch and the fourth worldwide and which has generated enough media impact for journalist jordi évole to interview him on his program lo de évole on march 7 2021 however although a change of control is discernible in terms of ceding some prominence from the professionals to the viewers this does not mean that the latter take advantage of all the technological opportunities to personalize television viewing owing to the fact that in most cases they consume fiction and entertainment so some viewers intersperse their internet conversation with comments about their daily routines and personal circumstances and use twitter to recommend entertainment to other users thus the audiovisual trend has evolved from a primitive television imitating cinema or old journalism to a more reciprocal and inspiring one as streaming social networks and digital media in general provide spaces that traditional media have systematically denied to ordinary people to this is added the idea of simultaneity in terms of the habit of being able to enjoy several forms of content at the same time thanks to the availability of different devices which is known as multiscreen consumption the action of reading commenting on and sharing information about television content on second screens from secondary consumption devices thus there are thousands of examples of audiovisual consumption that are not being recorded and are being lost which tesoalonso and piñuelraigada qualify by noting that while the screen that used to occupy the central stage of the home called the desktop is increasingly larger and has a more panoramic and spectacular format others are becoming increasingly lighter and more transportable media as well as content options are multiplying so it is not surprising that competition is increasing between spaces and professionals in the same way objectives and methodology this research proposes to deepen the understanding of what is currently viewed and consumed on hybrid audiovisual products in spain in terms of information and distraction understanding that infotainment can be broadcast both through the traditional means of the television set as well as through digital channels the idea was thus to approach programs sections or spaces that dealt with news issues with resources associated with entertainment and comedy the object of study however was not to analyze these types of program since there are already numerous works dedicated to content analysis but rather the professionals involved in them since many of them belong to one of the branches of infotainment whether journalism or entertainment and might be forced to adapt to the needs of other spaces in which they participate or to the needs of the receiving public the main hypothesis holds that the figures most valued by viewers are those who are most adaptable to the topics covered and the context in which they are addressed regardless of whether such communicators belong to journalism or comedy which in reality would imply being suitable for both in the eyes of viewers as a complementary hypothesis from the audiences point of view audiences seem to appreciate the professionals who are a bit more unpredictable as long as they do not attempt to go against the rigor of their original profession ie a journalist making jokes with certain unacceptable lines or a comedian not overreaching in their comments on the news of the day in this sense taking into account personalities such as ibai llanos brimming with energy and spontaneous impudence and who continually repeats that he is not entitled to give his opinion on news issues despite conducting interviews with people involved in them another research question is whether audiences hold figures such as llanos in higher regard than established journalists on the spanish audiovisual scene the third hypothesis is related to the perspective of professionals suggesting that they feel some unease toward personalities such as ibai llanos or jordi wild and see their interview spaces on twitch or youtube as an increasingly invasive emerging competition to corroborate or disprove these reflections a qualitative methodology composed of indepth interviews and focus groups was applied the interviews were conducted with communicators andor audiovisual professionals for the selection of profiles that compose the sample some previous studies took into account the circumstances in which the communicative products to be analyzed are constructed paying attention not only to those who appear on screen but also to the agents of production pérezpereiro 2007 p 70 while other authors take as a reference parameter the success of a space as associated with its longer broadcasting time thus establishing its creators in the collective imagination for this study the interviewees were selected according to their functions roles and specific characteristics with at least two people belonging to similar occupations to identify similarities or differences in the performance of their role therefore it was deemed convenient to consider the profession of the presenterhost of programs preferably involving a certain polemic relevance so for example vicente vallés and antonio castelo the former a journalist and presenter of noticias2 the evening news program of antena3 and the latter a comedian and collaborator of todo es mentira an infohumor space represented two totally different ways of approaching information the same contrast was intended to be made in terms of the female figure thus cristina pardo cohost of más vale tarde and collaborator of el hormiguero and rocío vidal influencer and content creator for her youtube channel la gata de schrödinger and who has participated in various journalistic talk shows such as la sexta noche were interviewed the role of the program director was also considered so josé antonio lavado deputy director of todo es mentira and jorge gallardo camacho deputy director of the morning magazine espejo público were interviewed although both with the purpose of dealing with newsworthy issues in a manner closer to infotainment than to classic moderate information the six interviews were conducted by telephone or online and lasted an estimated 20 minutes consisting of 68 questions regarding their professional dynamics their impressions of other media figures or their impact on spanish audiences to address the contrast of opinions within the audience three focus groups were conducted with potential consumers of television infotainment and internet audiovisual products that were the object of the research they were recruited through social networks such as twitter or whatsapp or by resorting to the snowball method through social networks to identify participants who were interested and involved in the field of study with the purpose of bringing to light generational factors that could influence group dynamics one of the groups consisted exclusively of eight young people aged 2034 years the second of eight participants aged 4168 years and the last of nine people aged 2164 years that is there were a total of 25 informants between the ages of 20 and 68 years of whom 13 were women and 12 were men the two groups differentiated by age were carried out first then the six interviews with professionals and finally the group composed of participants from both generations of consumers with whom the results obtained in the first groups and in the meetings with journalists comedians and content producers were compared the scripts of the dynamics revolved around the following themes the interest of whether to address newsworthy issues with entertainment formu the audiovisual sector has evolved from a primitive television imitating cinema or old journalism to a more reciprocal and inspiring one las whether there are professionals andor figures who are more legitimate than others to work in infotainment and whether the channel on which these media personalities appear is important in terms of their credibility and establishment results when reflecting on audiovisual consumption the question that arose from the outset both in the interviews with professionals and especially in the audience focus groups was that of the principal way in which they viewed content that is whether they used traditional media or online resources in this sense perceptions about the boundaries between one medium or another were blurred and in all cases preferences depended on the content offered the clarity and convenience of how it was presented and whether one communicator or another was able to retain and secure their audience regardless of which branch they originally belonged to journalism entertainment or humor i have journalists who i like the way they tell me things and i think the new generations are looking for personalization then as they feel they are connected to streamers and youtubers well in the end that is what they attract and that is not informative but pure entertainment despite the explanations given by the participants in the discussion groups and their conviction that they know how to distinguish one channel from another or one audiovisual proposal from another the professionals interviewed argued that for them preferences depended first on what was provided to the userspectator both in terms of platform and content and then subsequently a viewing criterion was generated according to the nature of the space or the type of communicator offering it many people many young people especially are not only informed through traditional media but they are in their free time or when they have time and they open youtube for example and say oops this person has talked about this topic so lets see what they think and from there draw their own conclusions and also have a good time so i think that balance between entertainment and information generates an engagement that makes people want to continue watching your videos because apart from the classic information it is also a video that can be entertaining for them i really like my work in todo es mentira because i think it is the purest function of the comedian that there is it is also a bit similar to what i do in a vivir que son dos días because all the time i am playing against reality to go against it is the natural function of the comedian and it is summarized in the question i ask all the politicians when they come on the program as guests have you ever been forced to tell the truth it is engaging in current affairs from a criticalphilosophical point of view both susana griso as well as espejo público as a whole is an opinion leader because she is a person who is not limited to being a talking head because of the identity that presenting a program like that gives her then precisely in that part of tainment of infotainment that is where a presenter is allowed to be human to have personal assessments and to empathize a little more with the viewer this question as to whether audiovisual professionals can continually move from information to analysis opinion and commentary or to humorous nuances gave rise to continuous debate among those consulted the professionals interviewed seemed to approach this issue with greater permissibility than the audience focus groups as they considered that the same barriers between programs and even between media and channels are disappearing and that presenting or collaborating in an informative program had nothing to do with participating in an entertainment space via traditional television or internet platforms when someone goes in front of the tv what youre looking for is for them to be the best communicator they can be they may or may not be a journalist they may or may not agree a journalist is something else or may be the same it may happen that there are different communicators who are journalists and perform this double function but they communicate the journalistic product that is produced by a newsroom with people who specialize in that product preferences depended on the content offered the clarity and convenience of how it was presented and whether one communicator or another was able to retain and secure their audience i have always believed in the possibility of sharing current affairs in a lighthearted way without losing credibility i believe in rigor but not in rigor mortis and el hormiguero is not la isla de las tentaciones where it would perhaps be more complex to defend a purely journalistic approach you dont have to have so many complexes making a program that is not entertainment purely informative does not imply that you cant also go to an entertainment program at a certain time and deal with the topics you may be a specialist in in a more lighthearted way this is not something that we have invented in spain the programs of british french or american television there are many entertainment programs that also deal with informative matters lets say in quotation marks serious in a more casual way the participants of the audience focus groups did not entirely agree with this view of the professionals and respected one or the other more or less depending on whether they did not overstep their predominant functions in other words they could understand an occasional appearance on entertainment and variety shows or in interviews and talk shows on youtube or twitch but this second part had to be very complementary and anecdotal so as not to consider that the professional was straying too far from their competencies they could give them credit as long as the comicpolitical role of the media character was well defined and well delineated as far as the format in which they appeared allowed this i dont watch youtubers and whats more i dont even like that kind of hybrid program because there are many programs of that type on tv what do i know david broncano has been on movistar since the beginning and his programs are still being broadcasted and such i dont find them interesting because man sometimes ive seen a little bit and they dont entertain me nor do i think that what they inform me about is very interesting i think that for example the character of risto mejide is useful above all to generate controversy and use controversy to get a lot of information right because when he is polarizing he forces people to place themselves in one extreme or another and that is something that i really like about the character he plays that it can be considered favorable if you want to learn something new considering whether audiovisual communicators are overreaching is precisely what led to the concern about the politicization of the spaces an issue that in principle most participants disliked furthermore they only considered it to be legitimate when the professional communicates in advance what they think and takes a personal position but never in a masked or subversive way while presenting or analyzing news content i believe that the greatest achievement they have obtained here in our country is atresmedia atresmedia has managed to make a coin with two sides one is antena3 the other is la sexta and each of the channels gives the bait to those political followers they have with antena3 giving a more rightwing version and la sexta in theory being the leftwing one its just that that is the issue do we know how to distinguish opinion from news maybe not but when i realize when i say this is an opinion it makes me very angry when i realize that it makes me very angry and i clench my fists because its as if youve slipped me your opinion and ive realized it ive seen it regarding the position of the professionals interviewed they stated that they deeply respected their consumers viewers and followers insofar as their intention was to offer them a consistent audiovisual product tailored to the format the channel or broadcasting impact since they understood that each space marked its rhythms and languages which did not necessarily have to be shared by everyone who watched them so their discourse could be modulated according to the lesser or greater diversity of audiences in this program we play a lot we laugh a lot and we create a lot of humor but we take it tremendously seriously and every time we make a decision each and every one it is based on deeply respecting that the viewer is a person at least as intelligent as we are i appeal to the critical intelligence of my viewers when i use a sarcastic tone or when i make a joke about something its like spoken sublanguage and its like when youre talking to your friend isnt it the tv tone is totally different the codes used in social networks the memes the ability to edit your own videos for example to make a joke at a given moment television does not allow you to do that because you are in a foreign medium as more and more content creators analysts and even journalists are positioning themselves on social networks or creating their own youtube or twitch channels regardless of whether they are involved in traditional media it is often this fame that gives them the opportunity to once again be claimed by television to participate in different spaces meanwhile some youtubers and streamers have news talk shows or carry out interviews without necessarily being journalists the professionals and audience focus groups discussed whether content creators were invading the sphere of press or television professionals to the point of becoming confused or overlapping with journalists with the participants consulted recognizing that this issue creates a generational division of positions and of understanding in their environments there are a lot of wellknown youtubertype journalists carles tamayo is a journalist but this guy that i see more often because of my children jordi wild for many younger people are journalists in other words my son identifies these youtubers as journalists maybe for my mother it is vicente vallés or the people who appear on tv but for my son it is jordi wild or tamayo i have witnessed real pitched battles at home between my mother and my son because for my mother carlos herrera is god then my mother explained to him what a journalist is and my son said no tamayo has been involved in i dont know what and hes been caught with i dont know who and my mother said he is the greatest thing in journalism and the two of them discussed who is a journalist and who is not as a specific research question professionals and participants were asked whether streamers such as ibai llanos were direct competition for television professionals the former said they did not see them as their rivals as they believed deeply in the freedom for anyone to offer content and proposals through any channel while the latter felt that professionals in any case had to deal with it because times change they said and those who do not adapt end up being cast aside in favor of more attractive alternatives what ibai does is take advantage of the opportunity he has to interview people who are in the news who would also be of interest to journalists you can be a great communicator without having to answer or comply with all the requirements demanded of a journalist i have a lot of respect for the work of any content generator and of course the streamers have a very notable success with the public and i think that is very praiseworthy i think they do a specific job for a certain type of viewer or listener and they enjoy unquestionable success if many people follow them it must be because they are interesting and maybe thats what conventional tv should have done i dont know theyve been introduced on the side and are making a niche for themselves i think its good i think the point is more for people to consume and understand that jordi wild for example is a youtuber who does entertainment interviews with his opinion and so on which is not the nodo a spanish newsreel from the past thus in the various conversations in the audience focus groups audiovisual proposals emerged that were much more attractive to them than traditional television which is why they said that some programs have been using social networks or platforms as a method of engagement for some time such as todo es mentira or la resistencia if i put something on to watch on tv on some channel its i dont know something like el intermedio or jordi évoles interviews which i like a lot or ana pastors interviews but its not the norm its rather unusual and i dont know if im eating alone or i have some free time and i start its more like im going for a fixed shot maybe well on youtube im interested in such and such i like this podcast that i know they comment on more current affairs and i go and listen to it i started watching la resistencia on youtube and for the last year ive been with movistar and on there i watch the whole program every day not when it is broadcast but when i have breakfast or when i take advantage of meals es the professionals interviewed considered that the same barriers between programs and even between media and channels are disappearing pecially when i eat that is when i watch it and more than the interview itself to see him david broncano to see the comedians in general in the specific case of younger audiences when they consider watching audiovisual content whether it was television or not they agreed that they were more likely to look for specific videos on youtube in the case of women and on twitch in the case of men even though the participants in question were not regular consumers of these platforms no one disputed that some of the wellknown personalities appearing on these audiovisual channels have a following that exceeds the expectations and predictions of many television networks i consume youtube for example such as microprograms a channel that talks about certain topics uploaded in a fifteenminute format always about a topic i like weekly which is a less rigid format that maybe tv could not afford and twitch is a little bit the same first it is a medium where listening is active plus they bring something an ibai an amazing thing where people write it goes so fast that you will not even read yourself nor will you read anything nor will they read what you write you know perfectly well but its a kind of active listening youre kind of actively out there doing things are influencers killing tv stars no its just a new approach to the origin of the star system before the star system was monopolized by the cinema only movie stars were recognized by the whole world then television began and to this was added the star system of radio stars so little by little the origin of what stars are was diversified and what has happened is simply that a new starcreating agent has appeared audiovisual in this case and they have escaped from the powers of the big media so are they competitors no i believe that in the end it is a situation of coexistence it can even be said that the selection of who is a star has been democratized although under the same criteria as television in fact another interesting question that arose regarding this supposed alternative star system or media figures who can jump from television to platforms and the internet indiscriminately was that the viewers consulted did not distinguish between interviews and talks on youtube or twitch channels and those done via podcasts insofar as the latter are consumed in the same audiovisual way or because they are simply presented as such my wife usually watches these programs half entertainment that help her to clear her head to disconnect a little from work and i usually use the tablet or my phone mostly also the internet and youtube and podcasts also podcasts are very convenient because you can listen to them anywhere you dont have to be watching a screen many times i may see that a certain interview of a certain person is a trending topic but im too lazy to look for it turn on the tv and search for the channel ill wait for the video and when the video is available ill watch it because im sure someone will post it even if its just a summary on my cell phone but bits of television short videos from la resistencia or an interview with jordi évole the audience focus groups consulted thus did not differentiate channel or platform as much as they claimed because the format and type of exposure seemed similar to them the only feature they highlighted to justify their impression of consuming a different product either to categorize it as more conventional television or more typical of youtube and twitch regardless of whether it was offered by a journalist or another type of communicator was the time the feeling that the interview or the talk show is long and has the possibility for the guest to elaborate something that did not happen nor did they think it could happen on television likewise the participants equated this to freedom of demand ie freedom of choice the ability to choose when where and to whom since on television no matter how many options there are there would never be as many as on the internet in their opinion audiences felt that professionals in any case had to deal with streamers because times change and those who do not adapt end up being cast aside some of the wellknown personalities appearing on these audiovisual channels have a following that exceeds the expectations and predictions of many television networks discussion and conclusions after analyzing the results obtained in the interviews with the professionals and in the audience focus groups it was confirmed that the use of social networks by programs as an online tool was becoming obsolete for viewers in the opinion of both young and mature participants because for them channels such as youtube and twitch better met their interaction needs if they used the networks they did so mostly to obtain additional content or learn more about the collaborators and not so much with the intention of interacting with them in line with similar studies that show that paid humor formats prefer to offer small doses from transmedia narratives through instagram as an engagement strategy that allows for reaching the general public on the contrary some of the professionals of programs consulted such as espejo público and todo es mentira did state that they continue to use social networks especially twitter to involve their audiences in the program or to promote debates although none of the participants in the focus groups acknowledged having used this system although they had used or knew people who had used youtube or twitch thus when it comes to interpreting which figures are the most valued by the viewers consulted those belonging to the youtube twitch or podcast sphere enjoyed a higher regard than those linked to traditional media reflections in line with previous works that declare ibai llanos as the unbeatable leader of spanishspeaking audiovisual content this was the case even for older audiences because many of them acknowledged following media figures who came from television or the traditional press only because they had moved to online broadcasting with greater freedom to express themselves and present their content in their own way confirming that the pain threshold of comedy that is of the concessions or license allowed to the figures and the spaces depend on the type of format scheduling in this case nonexistentand the degree of broadcasting in this sense the main hypothesis viz that viewers value those figures who are more adaptable to the topics dealt with and the context in which they are addressed regardless of whether these communicators belong to journalism or comedy is confirmed because what concerned them above all else was that they worked consistently and that the content offered was interesting with more merit if they were glued for several hours to a screen something they would not do with television because its rhythms and restrictions were more rigid as a complementary hypothesis regarding the viewers perspective the audience focus groups appreciated the professionals who are unpredictable as long as they did not violate the rigor of their original profession ie a journalist could make jokes within certain limits or a comedian could stay within the limits of their supposed analysis of news information in this way personalities such as ibai llanos or jordi wild were respected because in the opinion of the participants they always reflected on topics from their position as mere generators of entertainment and for this reason they received greater esteem from the focus groups insofar as the latter recognized that some established journalists of the spanish television scene did go beyond their competencies often in a subversive and unclear manner however the third hypothesis which held that television professionals would feel uneasy toward online content creators and would see them as competitors and invaders was refuted since the interviewees did not feel threatened by figures such as ibai llanos and considered his interviews to be very different from the journalistic style of the one they practiced it was therefore seen that any professional can move through different hybrid programs and play roles assigned to any genre or media proposal as long as they have the capacity to perform such work thus constituting a sort of hypermedia star system that in imitation of the golden age of hollywood cinema in the early twentieth century puts forward presenters associated with specific personalities behaviors and even political ideologies in an attempt to transmit their essence to the programs and establish their success since they bet on a recurrent artistic casting that provokes onscreen chemistry with copresenters that converge in the figure of the presenter this also demonstrates that audiences are increasingly aware of the adaptation of traditional media to the internet to the extent that they have clearly identified news figures in entertainment programs and comedians in news programs many of whom are willing to make the leap to youtube and twitch however it is still too early to assess the consequences of these perceptions on the publics understanding issues on which professionals do not tend to dwell as twitch is becoming a parallel television unpredictable in its evolution in a society that still does not know exactly what a platform of such magnitude means studies such as this one are just a first step toward delving deeper into these emerging internet figures often very close to infotainment in both form and content but who lay the foundations for a new way of understanding audiovisual consumption and which will require more research as to the reception and audiences who are connected to the concept of transmedia consumption at all times any professional can move through different hybrid programs and play roles assigned to any genre or media proposal as long as they have the capacity to perform such work thus constituting a sort of hipermedia star system viewers value those figures who are more adaptable to the topics dealt with and the context in which they are addressed regardless of whether these communicators belong to journalism or comedy este artículo se puede leer en español en

spanish television is increasingly subject to transmedia consumption faced with traditional models in which journalists limited themselves to rigorously transmitting information to strengthen their audiences the networks commitment to infotainment as well as the competition with platforms or with figures from youtube and twitch forces professionals to reinvent themselves often by resorting to entertainment and show business resources tv programs such as el intermedio la sexta 2006 and el hormiguero antena3 2006 have been working for years to bring journalists and comedians together in the same space and others such as todo es mentira cuatro 2019 interact with audiences through social networks such as twitter and instagram the question is whether these efforts are sufficient or whether we are witnessing a transition period in which interviews conducted by content creators such as ibai llanos or jordi wild will end up being more highly valued than those of a journalist to answer these questions six professionals from the current audiovisual scene were interviewed

introduction flickering across ephemeral screens digital stories appear to relinquish their status as cultural heritage objects that sustain and empower via their longevity and stability especially for young adults digital storytelling instead prioritizes realtime connections and story creation contextual adaptability multimedia expression and accessibility with a smartphone and internet access even young creators with a bit of practice can instantly post a story create or remix a video or capture and narrate an event in real time thanks to gpslocation technologies and mobile cellular phones storytelling can happen nearly anywhere which brings storytelling into proximity with lived experience in newly intimate entangled ways how might we as educators draw on the dynamic multimodal affordances of digital storytelling as a way to engage high school students and enable them to recreate personally and culturally meaningful connections building a storybased sustenance for the twentyfirst century out of what might seem to be its ruins how might we draw on teens digital lives to expand their fluency with creative story practices in multiple genres enabling them to build sustaining connections with other local teen storytellers while counteracting their sense that nobodys listening to them how might the multimodality of digital storytelling speak to and catalyze more diverse creative expression writing cultural contexts and cognitive stylescounteracting a white euroamerican colonialist fetishization of abstract transcendent writing in early 2021 in the thick of covid19 pandemic lockdowns and restrictions as faculty members directing and affiliated with the center for engaged storycraft at the rochester institute of technology we recognized digital storytellingand the shift of storytelling to networked and real spaces where even new creators can create multimedia digital storiesas a profound opportunity to engage high school women through storytelling research since then has thoroughly documented the overwhelming impact the pandemic has had on youth and on teenage women in particular though it is early days for a definitive assessment of the complex forcesboth preand postpandemicthat are negatively affecting so many teen women in our own community of rochester new york it was apparent that the sudden transition to virtual learning platforms during the height of the pandemic resulted in the loss of social and emotional support outside of teens immediate family members we thus turned to multimodal storytelling as a way to facilitate engagement among high schoolers with their peers and to identify common ground from which they could share experiences however diverse responding to a call from the cornelia t bailey foundations new era women writers grant we developed and with their funding launched the first gathering stories a digital storytelling workshop experience for young women in july 2021 on the rit campus we focused on high school women with an interest in storytelling and invited them to apply to participate in the weeklong workshop our goal was to offer training in digital storytelling of diverse kinds and to facilitate a gathering of youth identifying as womenincluding transgender nonbinary and cisgender womenover the course of a week the workshop provided the physical and interpersonal space time and resources for participants to explore articulate and connect their voices and emotional experience to a community of local womenincluding peers and eldersso that they would feel recognized and valued as storytellers and each could learn how to prioritize their own experience and voice as a leading transformative driver in their educational personal and professional lives in this paper we discuss our approach to developing this digital storytelling workshop for young women describe positive outcomes highlight challenges we experienced in creating an equitable and collaborative storytelling environment and finally detail our plans for future iterations of the program theoretical framework much contemporary interest in storytelling and the approaches to storytelling that inform our workshop emerge out of late twentiethcentury narrative studies by french structuralist linguists literary scholars and philosophers such as roland barthes and jeanfrançois lyotard who turned attention to the narratives that inform everyday life in addition to the more artful crafted narratives we have long celebrated as literature folktales or myth barthess influential 1966 introduction to the structural analysis of narratives recast narrative and particularly narrative in its everyday practice to include narrative discourses we carry out with ourselves and the world around us formal or informal artful or bland narrative from this vantage point can unfold through an almost infinite diversity of forms narratives are able to be carried by articulated language spoken or written fixed or moving images gestures and the ordered mixture of all these substances narrative in other words is multimodal drawing on more than one semiotic and sensory channel as barthes initiates a new discipline of narratology that makes us all knowing storytellers he also expands the realm of narrative to include diverse media genres and creators and identifies narrative in every age in every place in every society famously stating that narrative is simply there like life itself in this vein our workshop aims to empower the individual storyteller within each high school participant the primary emphasis in the storytelling practice and final project is to empower each young woman to reflect on their personal experience experiment with narrative media and methods to express themselves and communicate something meaningful to an audience of peers the value is largely in the interpersonal process of writing about oneself experimenting with diverse narrative forms to compellingly craft and shape ones story and personally sharing it with a group of peer and elder storytellersnot to create a great work of literature though this is often a longerterm goal for many of these young storytellers as its title gathering stories suggests our workshop identifies and prioritizes storytelling and listening as a central means of connecting with others through shared experience a means of personally and collectively gathering together the pieces of our existence for shared enjoyment and reflective benefit barthess and other narratologists attention to the universality of narrative and their recognition of its centrality to human cognition unfolding like life itself in our minds led literary scholars such as peter brooks to explore how closely our sense of self is bound up with the stories we tell about our own lives and the world in which we live narrative capability shows up in infants some time in their third or fourth year when they start putting verbs together with nouns a conjunction that has led some to propose that memory itself is dependent on the capacity for narrative interest in narrative as a primary means through which we try to understand the world and construct its meanings quickly spread to psychology and then to other fields including medicine and economics a movement since described as a narrative turn in the social sciences instigated by jerome bruners study of child development through the lens of childrens informal storytelling among themselves and with adults in the narrative construction of reality joseph campbell similarly identifies an oftrepeated narrative structurethe heros journeyacross cultures and time noting its direct parallels to stages of personal development and maturation providing a wellknown example of research on narratives dynamic influence on personal development more recent interdisciplinary story work emerging from this narrative turn remains attentive to storytelling as a way people actively conceptualize their life experiences it recognizes the centrality of personal narratives to identity formation and therefore often mobilizes story as a key to behavior change both individual and societal for a recent model for implementing and assessing the influence of narrative in behavioral medicine as cognitive narratologists suggest storytelling is often enactiveie stories serve as intersubjective thinkingacting tools that connect tellers and listeners and in doing so provide models and potential trajectories of action connecting past present and future states inviting high school women to participate in the workshop and reflect on their own stories in the year preceding their transition from high school to college or professional life we are attuned to narrative as a principal way in which our species organizes its understanding of time and therefore as an especially useful way for these young women to explore and build narrative bridges between their own past present and future the threepart structure of a narratives dramatic arcits beginning middle and end as first identified by aristotle we underscore the emotional shape of a narratives rising and falling story arc as it moves through time and space like a smooth arc or a more dramatic winding rollercoaster encouraging these young women to envision the dramatic emotional shape of their story of their at once personal and narrative transformation our workshop participants are given complete freedom in their choice of a story to tell as long as it draws from their experiences and yet over ninety percent of the final stories regardless of their diverse media feature a pivotal moment of personal realization or maturation or prepare for it by reflecting on a childhood past a present and an asyetunknown nearfuture while this illustrates a familiarity with personal storytelling conventions the teen storytellers emotional investment in the particular stories they choose to tell also evidences their awareness of narratives power to meaningfully shape their experiences and as a result provide a reflexive means of revisioning themselves and their relationship to a broader community importantly there are continuing necessary debates about the extent to which narrative informs all peoples sense of self even if it seems neurotypical in addition the narrative turn and narrative constructivism that grew out of late twentiethcentury narratology and social sciences have been rightly critiqued for taking the universality of narrative so far that it eclipses nonnarrative modes of communication altogether or entraps us in a world that is exclusively narrative with no access to material reality outside the text peter brookss seduced by story the use and abuse of narrative describes his disabused sense of what has happened to narrative in the last century describing a harrowing narrative takeover of reality in the twentyfirst century as stories abound n arrative seems to have become accepted as the only form of knowledge and speech that regulates human affairs while brooks is correct in his assessment of how and why stories abound in such destructive ways today particularly in political and economic domains his call for a more nuanced and intelligent account of what narrative is and does is precisely the route already taken by twentyfirstcentury research in cognitive and in digital narratology which continue to explore the transformative power of narrative while providing important correctives to the narrative turn and its constructivist extremes by acknowledging the material environments media and events that reciprocally coinform and corealize narrative practices of selfunderstanding and of knowledgebuilding in given contexts or by distinct selves and storytellers in storytelling and the sciences of the mind cognitive narratologist david herman proposes two verbs as terms to capture the interweaving of narrative worlds and actual worlds storying the world describes the active reciprocal processes through which we use our narrative frameworks experience and assumptions as a kind of extendedmind to make sense of events in our material lifeworlds alternatively worlding the story involves processes through which we actively interpret narratives by asking empirical questions about characters and events in stories imagining who what or why things unfold as they do in both instances narrative understanding relies on an exchange between narrative storyworlds and lifeworlds rather than granting narrative full or unlimited rein over material actualities situating our young storytellers in the same physical workshop space daily over the course of a week and inviting local storytellers from the rochester new york area the workshop attempts to ground our storytelling practices in these specific contexts and to acknowledge the way geographical location physical space interpersonal dynamics writing tools and workshop leaders guidance all inform our storytelling practices as individuals and as a group researchers in spain recording human brain activity during verbal communication and storytelling sessions recently discovered that the productioncomprehension coupling they observed resembles the actionperception coupling observed within mirror neurons and thus a speakers activity is spatially and temporally coupled with the listeners activity through quantitative measuring of story comprehension they concluded that the greater the anticipatory speakerlistener coupling the greater the understandingof story sharing stories deeply and physiologically connects individuals something we cultivate over the course of our workshop through a series of smallgroup storysharing activities in addition guest storytellers model their brainstorming and the writing processes they use to draw on personal experience and identity and craft a meaningful shareable story these elder storytellers address the vulnerability and reflect on the questions that arise when transferring ones experience to a narrative shareable form storying the world is an active process with choices of many kinds to be made not a simple act of recording a preexisting story or narrative verbatim and notably it often requires our storytellers to break out of existing frames and conventions to express their very disdain for selfnarrative or the narrativization of life it is here that the workshops focus on digital storytelling and feminism and gender studies is particularly pertinent digital storytellingor storytelling that relies on the application of digital software and communication technologies such as the internet for its creation as well as its dissemination and readingas an emerging multimodal medium for storytelling requires creators and scholars to attend closely to the material affordances and constraints that are introduced in these new writing spaces to borrow j david bolters early term for digital writing environments in contrast to print conventions that over time seemed to be absolute transcendent necessities of storytelling digital storytelling has challenged and upended many of these conventions like turning pages by moving from left to right as opposed to scrolling down including only typed language in black font on a white page or having the text remain stable over time while digital writing environments digital cultures and cyberspace more generally were initially presumed to be liberatory and democratizing to their core digital storytelling scholars since janet h murrays hamlet on the holodeck the future of narrative in cyberspace and more recently the work of marielaure ryan and collaborators in her edited collection narrative across media the languages of storytelling take advantage of the newness of digital storytelling media as the basis for a comparative understanding of these storytelling technologies as their mediaspecific expressive capabilities and limits both enable and constrain writing as a result of their material and technological infrastructure and software for instance ryans typology of media affecting narrativity underscores the spatiotemporal dimensions of digital narratives and their inclusion of multiple sensory channels of communication at once as differentiating features of these narrative media as in web comics visual narratives or interactive narratives for example whereas storytelling in print formats and cultures privileges text and a single linear narrative movement through time the workshop story prompts final project and guest storytellers engage multimodality to unsettle and question the hierarchical privileging of symbolic language and its alignment with a single universal transcendent truth within euroamerican colonialism which has delegitimized and denigrated acoustic and visual modes of expression and the cultures that revere them the symbolic register of language and the written word are also gendered masculine and racialized as white within euroamerican colonialist contexts which initially led cyberfeminist and digital narrative scholars to believe that the introduction of nonlinear multimodal interactive digital writing environments might equalize the previously gendered roles of the author and the reader instead this heteronormative cisgendered opposition is increasingly displaced by more diverse subject positions and identities and all of these seem further differentiated and delimited not enabled or empowered by the software and social media platforms on which they rely for their selfwriting and storytelling for this reason our workshop draws on feminist theories of writing such as sara ahmeds outlined in orientations matter which understand writing as a resoundingly material and symbolic practice that historically and contemporaneously relies on putting writing technologies and tools designed for others benefit and uses to your own uses in the best traditions of womens writing from virginia woolfs 1929 essay a room of ones own to barbara smiths a press of our own kitchen table women of color press ahmed and other feminists attention to the spatiotemporal material dimensions and sociocultural dynamics of writing if extended to digital storytelling practices is likewise effective in reinforcing the immersive and participatory potential of digital storytelling whether that is through coauthoring a story online providing feedback on others stories presenting an online story to a live andor remote audience or connecting with other people and with geographical sites in real time in ways that impact our perception of space time and community stories are highly contextual and complex actively engaging their audiences on cognitive emotional affective interpersonal symbolic and cultural levels by providing these young women storytellers with ample opportunity to choose and combine text images video sound interactive elements or kineticsin one storyand thus draw on multiple sensory channels at once we open up diverse ways for them to express themselves and engage their audiences at all of these levels in transformative ways in the next section we describe the structure of the workshop and the materials used to foster storytelling collaborative storytelling approach digital storytelling workshop for young women the gathering stories workshop employed multiple dimensions of story work to equip and empower young women as storytellers and as cocreators of their life stories both individually and collectively the workshop introduced the young participants to guest storytellers from the rochester community and historic examples allowing them to understand and themselves practice story work as a transformative tool for women to reflect on and effectively transform their own lives and communities through selfexpression knowledge and community building the workshop gathered young women from across the rochester area and provided them with an educational stipend of 250 upon successful completion of the workshop this stipend enabled participation by those hardesthit by the consequences of rochester city schools remote learning during the height of the pandemic and subsidized those who might typically be working through the summer the workshop also gathered together diverse and differently valued kinds of multimodal digital writing as equally valuable storytelling methods focusing on storytellers development of their own voice through the digital storytelling medium of their choice workshop structure our program is organized as an annual oneweek fiveday program running from 9 am until 3 pm daily for a group of 1018 femaleidentified high school students in the first iteration of the program in 2021 our 18 participants worked individually in story circles and in the full group each day was predicated on a theme and broken into several segments to maintain a lively pace we enjoyed a shared lunch every day as well where stories were shared in more casual surroundings each of the first two days offered a mix of faculty instruction and facilitation of writing and sharing guest storytellers longer intensive writing sessions icebreakers and exploratory play day 3 focused on each participant taking their chosen story and expanding its aesthetic possibilities through the incorporation of media elements during day 4 and the first half of day 5 participants revisioned and revised their projects and by the afternoon of the final day they had completed an edited shareable story we also ended each day with the participants documenting their experience in a digital reflective journal that the facilitators had access to which provided workshop leaders with insight into each individuals progresseven their processes of transformation on the last afternoon we hosted a story showcase inviting family and friends to join us for the culminating presentations and story performances workshop methods in order to build connections and foster collaboration between young storytellers we coauthored ground rules with participants that ranged from asking openended and nonjudgmental questions to being respectful when others express their ideas and to paying attention to nonverbal cues we prioritized interpersonal feedback and exchange one of the overarching goals of the workshop was to encourage the group to engage in a practice of radical listening to ensure that reciprocity care and listening without judgment remained central to our workshop space and interpersonal interactions each days activities were also linked to elements of the storycenter model and its seven steps to creating a digital story think it feel it show it see it hear it mix it share it the gathering stories workshop goals included documenting experience addressing vulnerabilities and empowering positive responses centering authentic knowledge production cultivating interpersonal connections fostering compassion for self and empathy for others and facilitating speaking listening and writing skills along with our allfemale workshop leaders and student assistants with diverse identities we hosted guest speakers including an awardwinning memoirist a journalist and a ghanaian literary scholar one important goal of the workshop was to practice documenting experiencesboth visual and writtenand model respect for diverse storytelling methods and kinds of storytellers this approach allowed participants to leverage their strengths and attempt a new skill as one young storytellers journal entry on day 5 reflects i really enjoyed seeing everyones storiesprojects i feel as if its really inspired me and its making me strive to be better because everyones story was so unique and very well done i think ive really learned a lot that will help me with my writing for my upcoming college applications and even for other personal creative projects sad to go but so very excited for the future this is just one example of the thoughtful journal entries our young storytellers wrote at the close of each day highlighting what worked well and where they struggled it was refreshing to see the gradual change in their writing and the deepening of the stories they worked on during the week as well as to see written confirmation of the rapport that we witnessed in our daily interactions building connections with other local teen storytellers too often teens keep their most affecting narratives to themselves offering less authentic stories in the public arenaor remaining silent many gathering stories participants initially present as quieter and more introverted and report that they have not found a community of writers and storytellers until our program finding a comfortable safe inperson social connection remains elusive to many youths thus the workshop design and implementation focus on teen participants developing their own stories bringing together students from urban suburban and rural regions from a crosssection of different socioeconomic demographics as well as a diversity of ethnicities and levels of education and writing experience gathering stories provided a separate space a few paces away from familiar high school social scenes and pressures allowing these high school women to develop affinities as storytellers without these usual concerns emphasizing teens experiences creates opportunities and presents challenges in order to create an opportunity for sharing personal experiences we began the workshop by honoring each participants initial engagement level and leaving plenty of space for reorienting and revisioning as each day the week and their storytelling practice and reflection progressed we asked them to create seed stories to build upon during the workshop and into the future and we emphasized that although personal writing and selfexpression can often be cathartic and the most successful stories are of course born out of narrative conflict there are no expectations that their stories will be those of traumatic life experiences freeing them to explore a range of narratives including those that might present as more quotidian humorous or lowstakes results storytelling successes at the end of the first workshop in 2021 18 participants completed and shared their final projects which ranged from a blog exploring crosscultural experiences of food to an experimental documentary film to a comic following the trajectory of a personal passion to a textimage project demonstrating how love can overcome familial challenges in daily reflective journal entries and in feedback from participants after the workshops end the majority of the young women expressed excitement and appreciation for the wide range of writing activities and storytelling approaches introduced over the week while differing in their preferences they indicated significant personal satisfaction in completing their story and sharing it at the end of the week as well as some recognition that this was the beginning of a work in progress that they would continue to develop as one participant posted on her final project web site this workshop brought out confidence in my writing that i wasnt aware that i had in me a parent of another participant later confided that her daughter hadnt thought her voice mattered but the workshop changed that and strengthened her resolve to apply for a competitive college program to which she has now been admitted in a journal entry for day 3 of the workshop titled living on a prayer one young storyteller wrote this week went by insanely fast as per usual today was pretty dope there were also a few talks that i enjoyed the exercises were also quite creative overall i think that ive learned a lot which is great now to pray that my project and site turn out well video recording time woohoo one young storyteller who had been homeschooled through high school titled her project diary of an insecure filmmaker using drawn text and family photos to chronicle her development as a visual storyteller two years later she is enrolled in a university film program and determined to become a director two participants were attending a title 1 school in rochester with 964 economically disadvantaged students and 925 minority students one of them wrote an illustrated comic about a young wolf who is scorned by the pack for being weird this young woman acknowledged in her final journal entry the storytelling workshop may have been a bit nerve racking due to my terrible anxiety but i still loved the experience there were many things that i did that were out of my comfort zone but i still found the courage to do it because i wanted to learn from this experience i also did something that ive been meaning to do myself and because of this workshop express my art through comic form and i loved it both of the young storytellers from this title 1 school returned for a spooky halloween storytelling event we held for young women for the next two years although one of them has yet to graduate from high school several young storytellers also expressed their desire to participate in the workshop again next summer in the next section of this essay we reflect on the lessons learned from our first offering of the workshop and discuss the ethical implications of teaching multimodal storytelling to young adults lessons learned the age demographic of the workshops participants means they are digital natives but there also exists a very real digital divide exacerbated by the recent pandemic not all of our participants have access to a computer at home or internet access making it difficult for some to spend additional time building on the work completed during the workshop or to experiment with the tools introduced during our daytime sessions while the grant funding allowed us to offer a program that was both free of charge and provided an educational stipend to participants some interested students were not able to commit for a full week as they needed to work summer jobs this is a realworld situation we are working to address hosting the workshop on a university campus provided access to various digital platforms to create multimodal stories expanding writing projects in a way that encourages creative experimentation the campus however is not centrally located which resulted in transportation challenges for some of our participants who sometimes were delayed in getting to campus and missed out on some of the activities the socioeconomic diversity of our participants also highlighted differences in writing skills and variances in parental support or caring duties at home students who required extra writing help also struggled to complete the homework before the next days activities which slowed the progress on their main projects prioritizing experiential dimensions of learning and capturing personal experiences through storytelling meant the participants were encouraged to use their smart devices to collect information thus keeping all participants engaged in the radical listening process sometimes became an issue when cell phones instead introduced distractions discussion stories are a primary means for individuals and cultures to produce meaning identify patterns and transmit these across generations and cultures from this vantage point it is no surprise that today we are seeing broad turns toward storytelling which might be understood as an attempt to ground or stabilize our cultures in the midst of radical change yet it is precisely these aptitudes and inclinations to identify and consolidate recognizable repeatable and memorable patterns or metanarratives that can serve simultaneously as a limit and liability to stories in their capacity to calcify oversimplify and mislead the turn to narrative threads like ronald reagan and later donald trumps make america great again for example is reactive and retrogressive in the desire to return to a wholly idealized unreal american past though obviously comforting to many americans nonetheless addressing this conundrum the philosopher paul armstrong usefully situates stories at the crux of our cognitive need to identify patterns while also remaining open to new information and change he suggests that the complex dynamics of exchanging stories are in fact a twoway backandforth interaction between the story and reader that might effectively keep our cognitive processes from congealing into rigid habitual patterns by holding open their capacity to be reshaped and reformed the legacy of octavia butlers fictional the parable of the sower and the parable trilogy in particular provide an instructive fictional precedent in this regard as armstrong theorizes stories involve us in the play of configuration and refiguration which can loosen the habitual ideological hold of any particular set of narrative patterns on our individual and social minds our teen participants are very aware of events at least at the local and national levels and their reaction is often to internalize their emotional responses particularly those that might cause discomfort a storytelling practice mitigates these tendencies by situating healthy selfexpression within a universal milieu that illuminates commonalities and fosters core connections amid differences while our teen participants are socially aware they do not necessarily have a strong grasp on the affordances of digital platforms and the implications of sharing personal stories publicly so demonstrating the power of these tools and practices is a fundamental goal of the workshop we fully recognize the importance of creating longerterm consistency and engagement by fostering the community we have built over subsequent months yet there is the ongoing challenge of how to support the gathering stories summer participants especially those from underserved communities after the program ends we offered a few workshops and gatherings throughout the year after the workshop but it was admittedly a challenge of scheduling and funding and some participants aged out of high school and understandably moved on in their lives thus one of our lingering questions is how to expand access to multimodal storytelling tools and provide and grow a space for the creation of stories after the program ends in future iterations of this workshop and related wraparound storytelling events we are considering partnerships with the city of rochesters libraries and recreation centers so that we can hold halfday storytelling events throughout the school year and make these lowrisk and highaccess for more young storytellers of all genders these easyaccess gatherings focusing on flash fiction horror stories or slamperformance poetry would complement our more intensive summer workshop and we hope open doors to more young people we recently launched a web page on the center for engaged storycrafts website to feature our young storytellers and their digital stories annually and archive the workshops although we are fully cognizant that some of our young storytellers prefer not to have their stories publicly accessible and therefore we will ensure consent and keep some stories password protected with chatgpt and other largelanguage ai models actively pilfering the web the question of how and whether to publish these young storytellers work online at all is an increasingly loaded ethical question in the short term we intend to educate our young storytellers about chatgpt and other largelanguage models whose predictive learning methods may impact future writing and our understanding of individual creative work and how it should circulate we will encourage informed choices and explore how generative ai might contribute in the way of brainstorming audience research or writing feedback if used with its abilities and blind spots in full view conclusions in closing we acknowledge that the ability to take time out to focus on storytelling is a privilege not available to everyone creating a collaborative space for storytelling in itself is not sufficient as intersectionality is about structural power not just multicultural gatherings or identity the challenges and tensions of gathering young women families and educators who remain extremely stratified along racial economic linguistic and cultural lines and have wholly different experiences of american opportunity are a constant concern whose remedy extends well beyond the workshop space of gathering to broader transformations in the community and in networks of storytelling power racial understanding healing etc as educators we recognize that more work is needed to truly corealize collaborative spaces where universities can work with communities to address larger structural issues in informed ways and foster multimodal storytelling to this end we nonetheless remain committed

digital storytelling prioritizes realtime connections story creation contextual adaptability multimedia expression and accessibility this article discusses the unrecognized affordances and value of digital storytelling practices for teens living in precarious neo colonial lifeworlds we review the workshop methods developed as designers and leaders of gathering stories a digital storytelling workshop for young women in july 2021 to enliven and illuminate high school students voices while also addressing social emotional and affective experiences and needs during the pandemic the article details how we corealized spaces where teens lived experience of gathering and the draw of story were the driving forces for their diverse storytelling practices identifying positive outcomes for the first iteration of the workshop we also identify challenges that will inform future iterations of the workshop such as structural dimensions of intersectionality and the challenges predicative ai such as chatgpt poses to such efforts to prioritize experiential dimensions of learning through storytelling

literature review over a decade ago the regional strategy on teachers in latin america and the caribbean organized by the united nations educational scientific and cultural organization emphasized the need for a profound renovation of the pedagogical and academic traditions of initial teacher training in the region this is key to ensure inclusive equitable and quality education and to promote lifelong learning opportunities for all by 2030 at international level especially in latin america teacher training has focused on a competencybased model this professional training model arose in europe in 1999 and its extrapolation to other socially and culturally diverse contexts represents a new neocolonial strategy that redresses the epistemic convergence of peripheral societies with the european cultural center in 2004 the competencybased training educational model became institutionalized in higher education in latin america through alfa tuning latin america an international cooperation project with the aim of standardizing teacher training plans in the region with the european teacher education model in a context of globalization however the competencybased training model does not necessarily adapt to the major social and cultural diversity present in latin american territories since most pedagogy programs do not consider the contexts of social inequality and poverty in which indigenous people live and are brought up consequently the westernized curricular design reveals its decontextualization of educational needs and purposes of indigenous territory interculturality is excluded from teaching competencies since it is not an indicator evaluated by the national commissions for the accreditation of higher education in most latin american countries generally initial teacher training in intercultural perspective is relegated to the goodwill and intentions declared in the mission of universities despite the centrality of interethnic relations in the social and academic debate in the region consequently intercultural teacher training is not mandatory for most universities in the region therefore it is an invisible aspect in the content of pedagogy programs this has resulted in the lack of preparation of teachers to meet the educational development needs of minority groups such as indigenous peoples however a more updated perspective on teacher training reveals that this should be configured based on the reality in which organizations and individuals engage this comes into tension with the paradigm of a globalized world under the western cultural hegemony systematized under the competencybased training model likewise this decontextualized training increases structural racism towards historical minorities continuing with the coloniality of knowing and doing in the formation of trainee teachers this increases the gaps between indigenous and nonindigenous since for the latter higher education becomes a negative space that does not fit their family and community environment the article has been written in the chilean region of araucanía the ancestral territory of the mapuche culture the larger indigenous ethnic group in the country as teacher trainers and researchers of the preservice teacher education in a context of social and cultural diversity the authors seek pedagogical alternatives that allow the incorporation of an intercultural educational approach in pedagogy programs to advance in an epistemological pluralism that progressively favors decolonization of higher education and thus fosters the formation of new citizens from an intercultural perspective it is assumed that in contexts of social and cultural diversity competencybased training in educational science programs is based on a monocultural teaching method of a western eurocentric fashion which results in the denial and lack of validity given to indigenous peoples knowledge and ways of learning in higher education training programs this assumption is taken into consideration for the analysis of the data extracted from the selected literature the purpose is to comprise new knowledge that claims for an urgent rethinking of initial teacher training based on the development of intercultural competencies to offer teaching and learning alternatives to account for local diversity with a strong rooted sense of social cultural and territorial relevance consequently through pte western education systematizes a set of knowledge procedures attitudes and values that attempt to homogenize an increasingly more diverse society from this analysis in terms of the development of educational sciences programs in a context of social and cultural diversity we pose our research questions is an educational sciences curriculum based on a competencybased training model compatible with an intercultural education approach what is a relevant pte alternative to implement in contexts of highly populated indigenous communities what competencies can be incorporated into initial teacher training as a transition to an intercultural educational model although several studies have highlighted the limitations of the competencybased training model in relation to an intercultural perspective of educational sciences programs there are few alternative proposals to this training model in response to the research question above the objective of this article is to conduct a descriptiveinterpretative analysis of the systematized and emerging theoretical assumptions in academic literature which show hints of a training model based on professional performance as an alternative for teacher training in a context of social and cultural diversity its intention is to contribute to the reflection in the current debate associated with pte from an intercultural perspective theoretical framework the reflections and analysis carried out in this article are based on the intercultural educational approach an academic alternative to the colonizing process of western eurocentric pedagogy in this sense the underlying coloniality of western pedagogical traditions standardizes the formation of people under the precepts of scientific epistemology thereby denying other ways of knowing and understanding the world such as indigenous lore and their ways of education as a result a monocultural process of pte has been imposed in a context of social and cultural diversity aligned with the cultural exclusion and social marginalization of minority groups in the case of the indigenous population they have developed their own educational rationality conversely an intercultural educational approach contains an analytical and critical aspect that questions cultural domination and social injustice imposed by western culture in indigenous contexts by means of the competencybased training model in this sense some studies have argued the urgency of decolonizing teacher training in contexts of large indigenous populations the current article is an attempt to promote the intercultural educational approach in chile a model of education that values and respects cultural ethnic and linguistic differences of all students also it progressively incorporates other views into the training of the new generations such as indigenous educational contents and views to understand the world likewise it promotes incorporating indigenous educational methods such as learning by doing observing listening and inquiring about family members and the community to transmit knowledge from an intercultural educational approach it seeks to offer a relevant training process from a sociocultural point of view for children and young people based on the educational needs and purposes of their respective territories this argues in favor of including the history culture and languages of indigenous peoples in the educational curriculum as well as the promotion of equal opportunities for students of different cultural backgrounds progressively reversing the educational gap between indigenous and nonindigenous students in higher education however advances in educational policies in chile have remained disconnected from initial teacher training so inequality and discrimination towards indigenous peoples such as the mapuche continue to be installed in the curricula of pedagogy programs in higher education and the teachers rationale in recent years there has been a greater emphasis on implementing the intercultural educational approach in chilean schools especially in rural areas and indigenous communities at the same time a latent challenge in the countrys educational policy is to guarantee that in regions with high indigenous demography such as the araucanía region teachers should be trained in pedagogical skills to understand and value other rationalities other than the western one such as the mapuche culture that has struggled to survive and develop however indigenous rationalities such as the mapuchean one continue to be excluded from higher education in chile especially from the pte process the lack of an intercultural educational approach in the educational policy of chile is a consequence of the imposition of the training model in pedagogy programs that denies the epistemic value of the social cultural and linguistic diversity typical of a globalized world pte is understood as the first stage of professional development in which teachers in training acquire a set of teaching disciplinary methodological knowledge skills values and cultural models associated with the requirements of the social context in general and the school institutions which precede the professional performance stage however westernized professionalization of educational sciences programs has turned pte into a positivist and utilitarian process through which learning scientific and methodological material related to education must precede the development of practical skills for teaching in this positivist hegemonic and monocultural pedagogical framework competencybased training is presented as the ideal model for the professional training of teachers regardless of the cultural identity of the actors involved the current model implies professional training in ignorance of the characteristics of sociocultural diversity of the children and young people that trainees might educate in the future this current situation hinders training of future teachers in pedagogical and intercultural skills the term competency arose in the educational realm in the mid20th century when the production and academic frameworks began to question whether the use of intelligence tests ranking of scores from positivist evaluations and the level of schooling reached would successfully guarantee insertion of people into the job market the competencybased training approach is based on the dynamics of job training which diminishes the prominence of higher education in holistically training professionals for the structural change of society in consequence competencybased training in a context of social and cultural diversity has been conceived of as an essentially practical scientific hegemonic and professional education based on work and action in which diversity is negated or unseen it is questionable whether the competencybased training model for educational sciences programs promotes a professional preparation that is relevant to the context or whether it alternatively inhibits teacher autonomy methodology the study has a qualitative paradigm since the research focuses on understanding and explaining the process of formation of pedagogical competencies in the context of social and cultural diversity through the interpretation of the data obtained in an indepth review of the stateoftheart literature thus the research consists of a systematic literature review which is a rigorous method of collecting and analyzing previous studies on a specific topic to identify trends patterns or common conclusions in existing research this survey of scholarly sources provides an overview of the research problem the findings were organized and coded through a qualitative content analysis since it is a data analysis technique used to understand the meaning and context of the data to conduct the study a varied significant and sufficient literature was selected that allowed the construction of a decolonizing theoretical framework regarding the pte process in the context of social and cultural diversity the selection of the literature and codification of the information was carried out in five steps selection of varied literature the selection of studies from different authors methodologies and theoretical approaches allows for a more complete and objective perspective on the topic in question the criteria for selecting varied literature are a to include studies from different authors and countries b to select studies with different theoretical and methodological approaches peerreviewed c to include studies published in different internationally recognized databases d to include studies with contradictory results in order to be able to analyze the differences and similarities between them as a first step a literature search was conducted in spanish english and french with the following keywords intercultural competencies initial monocultural training curriculum design initial teacher training the literature consulted is of local national and international scope this ensures that the selected articles address the topic of interest from different cultural perspectives and from different scientific positions in this step 328 texts were selected selection of relevant literature the selection of relevant and significant studies allows obtaining more accurate and reliable results it is important to obtain results based on the available scientific evidence criteria for selecting significant literature include a to select uptodate studies on the topic b to include studies that present novel results in the field c to select studies that use rigorous methodologies and clear methods of data analysis d to prioritize studies published in the last 5 to 10 years as a second step most of the selected literature is indexed in the scopus database a globally recognized data archive that applies rigorous procedures for the approval and publication of scientific studies scientific papers published in other databases peerreviewed or conducted by recognized authors on the object of study were included in the selection the search is conducted after 1973 as this year marks the first academic publications on the competencybased training model however in the search strategies priority was given to the selection of recently published literature in this step the number of selected articles was reduced to 173 texts selection of sufficient literature the selection of sufficient literature minimizes a bias in the selection of studies and increases the validity and reliability of the review which in turn increases the reliability of the results obtained as inclusion criteria we established theoretical saturation of the emerging categories as a fourth step after the literature was selected and examined summaries of the most relevant articles and texts were written down the summaries were evaluated by two reviewers working independently using include exclude or maybe as evaluation options choice conflicts were resolved in reviewer team meetings by inviting an expert as a third party to ensure that there were no threats to validity in this step the literature selection was reduced to 97 academic scientific texts in the fifth step the literature review was organized around the description of three areas of pte teaching research and practice until the theoretical saturation of the content was reached as a result of this last step 55 academic scientific texts were selected for the systematic review they are referenced at the end of this article coding of information coding is the process of identifying significant themes or patterns in the data collected during qualitative research it is a process of analysis that involves examining the content of the data and grouping it into thematic or conceptual categories that reflect the main ideas or themes that emerge from the data the coding of the information is carried out as follows data processing conceptualization and interpretation of the data and discussion of the findings data processing the first step in the coding of the information was to identify the key concepts that emerge from the data and that allow us to have a first approach to understanding the object of study the coding of the information was carried out with the help of the atlasti9 software this software allows that once the selected documents have been entered the data can be segmented into units of meaning in accordance with the objective of the study this software reveals data in the form of networks of key concepts first a list of key words phrases and concepts related to the objective and research questions was made the significant phrases were organized according to their meanings into groups of common content called codes for reasons of space the list of codes is not included in the article they are implicit in the discussion section the codes were regrouped according to patterns and relationships between them into subcategories subcategories possessing the same meaning were grouped into new units of meanings of a higher order of abstraction called categories the emerging categories were interpreted as the professional performance guidelines applicable to initial teacher education in an indigenous context conceptualization and interpretation of the data during the development of the system of codes subcategories and categories the researcher goes in a constant backandforth reading and coding of the data in that sense as a second step of coding links among sets of data were established to group them into thematic networks this search for common denominators involves thinking procedures inductiondeduction and analysissynthesis the study of the competencybased training model starts deductively ie it is carried out from the general to the specific this occurs because general statements based on existing theory are applied to the specific circumstances of initial teacher education in an indigenous context parallel to deduction inductive inferences were made in that sense the analysis of the information moves from the specific to the general this type of argument has as its starting point the accumulation of many specific events or similar crosscultural pte experiences to identify based on the repetition and likelihood of the collected data thematic patterns and emergent categories inductive and deductive inferences from the data indicate that the professional contents of pedagogy programs are of little relevance to intercultural teacher education in the context of social and cultural diversity therefore comparing the competency training model systematized in the literature with the facts of initial teacher training in the context of social and cultural diversity revealed the urgency of deepening the logic and content of a model of initial teacher training based on intercultural professional performance at the same time the analysissynthesis of the extracted data was carried out the analysissynthesis consists of the organization classification summary and interpretation of the selected information the gathered information was broken down into three areas of pte teaching research and practice to go deeper into each area of professional training as a result irrelevant concepts for the study were eliminated and the data sample or simplified into smaller units of importance then through synthesis the integration of information takes place without juxtaposing the analyzed data to make the units of signification extracted from the text as meaning the analysissynthesis has been fundamental to capture in depth the richness and diversity of meanings systematized in the documentary sources consulted that indicate the importance of including intercultural professional performance in pte discussion of the findings finally as a third step the theoretical triangulation of the three areas of pte teaching research and practice the triangulation allows mapping the emerging qualitative relationships which characterizes the modes of intercultural professional performance in that sense the theoretical triangulation allowed the discovery of ten subcategories which were grouped by the theoretical affinity in three categories of a higher level of abstraction development of intercultural critical thinking autonomous search for intercultural knowledge and intercultural communication as a result a conceptual framework was developed to synthesize the relationships among codes categories and subcategories identified in the qualitative systematic review this conceptual framework helps explain the results and provides a solid basis for understanding the object of the study critique of the monocultural educational sciences curriculum in an indigenous context most of the definitions of the term professional competency agree on relating this to the accumulation of professional contents conceptual procedural and attitudinal which the competent individuals can activate to optimally resolve situations and problems that are specific to their work profile pte professional content is part of the pedagogical cultural background transmitted to teachers in training from diverse sources which is appropriated throughout the course of the degree program the conceptual contents are associated with the system of knowledge that must be mastered by the subjects training to be teachers the procedural contents are associated with the system of skills habits actions procedures problemsolving methods that the agents in training structures around the value placements they make on their social and cultural environment such as values interests convictions feelings and attitudes out of which decisions are made teachers are competent when they are capable of mobilizing and integrating all these cognitive resources capacities and practical skills to efficiently face determined situations in their professional performance the professional content in the curricular framework responds to these questions what to teach what to learn the answers to the previous questions urgently demand a rethinking of the professional content of teacher training programs considering the diversity of outlooks points of view and different identities in existence in the context of training a summary of the main competencies implemented in pte is as follows a cognitive competencies associated with pedagogical and disciplinary knowledge of the subject taught generally this type of competencies is biased by scientific knowledge so that indigenous knowledge is generally excluded from the professional content of pte this results in cognitive competencies that do not fit the ways of teaching and learning styles historically developed by indigenous peoples b metacognitive competencies associated with the development of reflective critical and selfcritical thinking about pedagogical work generally in western culture the development of teachers metacognitive competencies is based on the understanding of western reason and logic that ignores the indigenous vision of a holistic and integrated world in that sense metacognitive competencies are directed to the development of an individualistic conception of professional performance without taking the community and cultural dynamics which affects learning process of indigenous students c social competencies related to communication participation and knowledge of the educational environment these competencies are developed by teachers in training from the western perspective of power hierarchies this causes student teachers to conceive their teaching work as a linear and hegemonic act of communication without valuing the pedagogical importance of other forms of pedagogical communication such as dialogic or symbolic typical of indigenous cultures in this way the forms of education developed by indigenous families which are based on close and horizontal relationships among people are made invisible in initial teacher training d competencies to plan and organize the teaching and learning process these competencies are centered on a linear and homogeneous conception of teaching which does not take specific learning styles of indigenous individuals into account therefore teachers in training develop competencies such as the design of standardized lesson plans selection of teaching materials and evaluation types this standardization does not integrate the specific needs and realities of indigenous contexts into teaching it also hinders inclusion and equitable education for all students consequently the competencybased model has no intention of promoting the contributions of the indigenous worldview to understanding the world and the education of people as part of pte thus the model of training by competency by not projecting an inclusive vision towards the whole of society constitutes a mechanism of social control through which the dominant culture has historically determined an ideological orientation of education to legitimize itself in power on the other hand from an intercultural and critical standpoint ferrada and flecha maintain that curricular design is a social construct contextualized to the teaching and learning requirements defined by the people who make up an educational community through multiple sociohistorical interactions of power and dialogue these ideas distance the pte process from the standardization imposed by the competencybased training model and place it in a process of interpretation of experiences which in a context of social and cultural diversity are necessarily different from westernized ones from this perspective we must urgently reinterpret the pte process in a context of social and cultural diversity in terms of the connections and tensions that occur between people in the exchange of meanings from culturally distinct positions from this perspective unesco and the organisation for economic cooperation and development maintain that ptebased on intercultural developmentis essential to ensure that future professionals be capable of developing professional performance methods that are consistent with diversity in teaching and learning processes in a region which those demographic characteristics another limitation of the competencybased training model in context of large indigenous populations is the fragmented position of pedagogical and disciplinary knowledge in the training itinerary through the areas of professional education teaching research and practice this is an educational conception that equates to the westernized cultural vision in terms of understanding the world which is transmitted to new generations through education and especially through teacher training consequently the central focus of the teaching area of curricular design is the acquisition of theoretical disciplinary and normative knowledge of the teaching profession the priority in the competencybased training model is scientific knowledge therefore learning the conceptual contents of the disciplines their methodologies and procedures becomes a hegemonic approach where the professional content excludes the ecology of types of knowledge that could be present in the training context furthermore the historical teacherstudent relationship in intercultural contexts has been sustained by a hegemonic hierarchy of the teacher towards the subjects in training through the transmission of scientific knowledge as the only civilized option for understanding the world however for zabalza preservice professional education is a process that encompasses more than learning disciplinary content to integrate a much broader set of capacities dispositions and attitudes the according to larochelleaudet et al demands that educational sciences programs train teachers to learn to act in a particular context for this reason the urgency of training teacherswho might work in contexts with large indigenous populations in professional performance calls for the development of intercultural critical thinking this is why some scholars such as freire have supported the feasibility of adapting the teaching and learning process to the social historical and cultural characteristics present in the school context favoring the emancipation of children and young people having a strong sense of sociocultural belonging at the same time this process of adaptation might give them tools to develop in a globalized world in the competencybased training model the research area is associated with the ability to discover and interact this is significant in the acquisition of new knowledge on education and its practices within the framework of educational interactions however the barriers imposed in academics to intercultural dialogue have meant that historically in the curricular framework of educational sciences programs research competencies from an intercultural perspective have been overlooked for this reason the pte process in indigenous educational contexts should encourage teachers to autonomously search for intercultural knowledge a way of professional performance that provides teachers with tools to handle intercultural problems that emerge in contexts of sociocultural diversity in the competencybased training model the area of preprofessional practice involves the interaction of the subject in training with the object of the profession this is the most professionalizing curricular area in curricular design according to shulman this is about the knowledge obtained from the practice itself in this sense the teacher appropriates learning to do in education that is based on two components the first has a theoretical nature associated with the disciplinary and professional domain which in essence is knowledge and the second component comes from the practice itself the operative spontaneous and dynamic element knowledge in action however according to quilaqueo et al the competencybased training model does not prepare pedagogy students in preprofessional practice to communicate and interact with indigenous students their families and the community in their native languages the preceding demands that pedagogy students be trained in indigenous customs and languages and professional performance to allow them to establish appropriate intercultural communication in the indigenous educational context the issue raised so far confirms that curricular design in educational sciences responds to the question posed by sleeter what is the perspective from which we want to teach students to see the world and to see themselves in the world the answer within a framework of a culturally and socially diverse society places preservice teacher education at the crossroads of the conflict between the hegemony of occidental teaching and the interpretation of life experiences in context figure 1 relationships between the competencybased training modelprofessional performance training model note authors own elaboration with the help of the atlasti9 software context labor market competencybased training training in intercultural professional performance contradicts is a property of this dilemma challenges institutes of higher education to rethink the daytoday modes of learning to know and learning to do enclosed in the competencybased model of teacher training programs to move towards other forms of intercultural knowledge relevant to the diversities of the training context historically however institutes of higher education have been known to make cultural differences invisible in professional training processes in this sense the logic and content of a training model for teachers based on intercultural professional performance will be delved into in the following section training in intercultural professional performance from a constructivist critical and intercultural standpoint pte curricular designs in a context of social and cultural diversity must integrate relational content to conceptual attitudinal and procedural content in the curricular design relational content includes the system of interactions of people with the natural and social world where these are associated with learning to live together learning to understand and learning to connect when it takes on a professional character this content expresses the awareness knowledge understanding and sensitivity that the graduate demonstrates towards other cultures that are epistemically different from western culture however this type of content is usually absent or minimal in most educational sciences programs according to fougere teacher training in intercultural professional performance is composed of five main components 1 intercultural point of view and approach which implies being able to be oneself based on ones own frames of reference this implies the development of an attitude of epistemic openness to address and discover other ways of understanding the world from ones own frame of reference in articulation with other culturally different frames of reference 2 knowledge which implies knowing the different social groups in interaction their products and their practices awareness of their interactions between society and individuals this includes knowledge about intercultural theories and different cultures context mutual understanding which implies putting interpretations into dialogue based on the subjective and intersubjective meanings and standards of the sociocultural frameworks in interaction a way of systematizing knowledge about ones own culture in epistemic articulation with other frames of reference that interpret natural spiritual and social phenomena differently 4 the ability to discover and interact to acquire new knowledge about a culture and its practices making it possible to negotiate different points of view and aptitudes within the framework of realtime communication and interaction it is essential for teachers to develop skills that allow them to put into practice diverse learning strategies from other cultures promoting analysis and selfanalysis to respond appropriately in a context of social and cultural diversity 5 the capacity for critical vision which refers to the ability to critically evaluate points of view practices and products in ones own frame of reference with other frames of reference in interaction burgess found that teachers who have been trained in intercultural professional performance feel more confident and willing to engage in educational relationships with indigenous peoples from this perspective pte becomes a multilateral learning process in which future teachers learn to coexist with other teachers and students with epistemic frameworks other than the western framework learn from them and assimilate new individual and collective responsibilities in the face of diversity consequently professional performance methods acquire an intercultural character when they enable teachers to establish appropriate and effective relationships with knowledge worldviews and people with different cultures in short training and development of intercultural professional performance methods in teachers enable education in the context of social and cultural diversity to respond to two big challenges for sustainable development the first is associated with ensuring access to equitable quality education and lifelong learning for all the second refers to an awareness of the importance of social and cultural diversity without hierarchy where individual experiences are valued and promoted from the previous analysis this study raises the intercultural professional performance methods that are most frequently discussed in scientific productivity in relation to pte results and discussion fiftyfive texts were selected for the study fortytwo scientific articles were included representing 7636 of the selected literature of which 6905 were published in the scopus database the rest of the articles were indexed in other peerreviewed databases in addition seven books published by authors widely cited in the research topic and one doctoral thesis report were included this means that the consulted material has been validated by experts in addition five reports or articles published on the websites of relevant international organizations were selected to support the social significance of the study of the 55 titles included in the review 40 texts have been published in the last 10 years thus 3091 of the total number of systematized references are between six and nine years old and 4182 are less than five years old this has made it possible to identify the current state of research in the field epistemic gaps in theory and emerging trends it was found that qualitative methodological approaches prevail in the research community in relation to the formation of teaching competencies in the context of social and cultural diversity therefore results consulted are influenced by the subjective perspective of the authors nevertheless three studies with a quantitative approach and three with a mixed methodological approach were included which provides a point of comparison although the search was carried out in international databases 14 studies of local and national scope were included which shows the contextualized perspective of the problem in a globalized world the main findings of the study are discussed below after applying the theoretical triangulation to the content of the three areas of pte namely teaching research and practice information is graphically represented it was known that in the context of social and cultural diversity the content of the areas of professional training interacts in the curricular design in a logic of unity and reciprocal opposition among them figure 2 map of qualitative relationships between professional training areas note authors elaboration consequently the dynamics of the initial teacher training process in indigenous context provokes methodological epistemological and ontological interactions of a transdisciplinary and holistic nature in which it is important to delve deeper the theoretical triangulation of the content of the three areas of pte revealed three categories which are latent in literature development of intercultural critical thinking autonomous search of intercultural knowledge and intercultural communication which are interpreted as useful professional performance for the initial training of teachers in the context of social and cultural diversity category 1 development of intercultural critical thinking this first category emerges from the epistemological and transdisciplinary relationships between the areas of professional training for teaching and research undergraduate teaching is the training area associated with learning to know and learning to be because this is where an individual learns to feel the profession and build a professional identity in the training model in intercultural professional performance studentcentered learning is prioritized in undergraduate teaching under this concept subjects in training are responsible for their learning and the development of their professional skills however historically in the field of western monocultural teaching academics have sustained their formative influences within the framework of disciplinary teaching which has limited students construction of educational meanings associated with other logics of understanding the world such as indigenous worldviews teacher training in intercultural professional performance implies transmitting a diversified set of knowledge to future teachers both in terms of skills and intercultural strategies to conceive of teaching and learning situations with social cultural and territorial relevance table 1 development of intercultural critical thinking definition of the category subcategories the development of intercultural critical thinking is a social practice through which individuals develop epistemic curiosity to understand the position of another person in juxtaposition to their own by giving meaning to situations in daily life it is a way to develop intercultural curiosity by trying to analytically examine the relations of oppression and inequality that have historically been legitimized through education and pte this category is associated with learning to connect epistemological pluralism selftraining in the knowledge of the profession autonomy capacities questioning power relations undergraduate teaching linked to the research of teaching experiential and methodological knowledge of epistemological plurality favors the development of intercultural professional performance therefore the undergraduate teachingresearch relationship is the fundamental epistemological combination for teachers in training to develop the professional performance method of intercultural critical thinking intercultural thinking is associated with teaching epistemological pluralism harvey and russell propose the formalization of an intercultural curriculum raised in neutral terms that trains teachers in the creative selection of educational content based on the articulation between indigenous knowledge and the understanding of scientific knowledge this is an aspect that still represents a challenge to higher education in latin america extrapolating from freire the development of intercultural critical thinking is a means of lifelong reflective learning which requires the development of professional autonomy and selftraining capacities consequently chilisa argues that intercultural critical thinking is based on the understanding and recognition of ones own culture and the culture of the others through research into educational reality to understand the effects of these intercultural relations this can be achieved through dialogue and reflection with subjects who have been placed in a subaltern status to then build common knowledge professional action based on critical ways of thinking questions hegemony and social inequality rooted in contemporary society which has historically conditioned the construction of meanings in the educational system teachers are expected to become empowered as agents of educational change to promote the shared wellbeing of the most dispossessed such as indigenous peoples category 2 autonomous search for intercultural knowledge this category emerges within the framework of methodological and transdisciplinary relationships between the areas of research training and preprofessional practice in the training model in intercultural professional performance the research area contributes to the appropriation and development of autonomous and innovative professional performance which allow teachers in training to learn to solve professional problems that arise in the classroom applying acquired knowledge to new situations it is possible for the subject in training to critically reflect on and research their own professional practice therefore curricular relationships between the areas of research training and preprofessional practice are relevant for future teachers to learn to build a tailored educational intervention that considers the sociocultural relevance of the other it is within the framework of intervention in intercultural educational practice through research that intercultural professional performance is formed in teachers autonomous search for intercultural knowledge table 2 autonomous search for intercultural knowledge definition of the category subcategories the autonomous search for intercultural knowledge seeks to provide teachers in training with the set of knowledge skills and values needed to search for information on new methodologies and teaching resources for independent construction through reflection in and on educational action of new knowledge in context that provides answers to problems that emerge in the intercultural classroom this mode of intercultural action is associated with learning to understand training based on professional problems learning in context coconstruction of educational knowledge the autonomous search for intercultural knowledge is associated with learning to understand which requires teachers in training to learn to get involved in the social diversities of all their students indigenous or otherwise to interpret the origin of intercultural tensions that may arise in an educational arena thus pte based on the autonomous search for intercultural knowledge helps teachers in training to continually develop the ability to learn to learn learn to educate and learn to research or put another way learn to make the act of instructing relevant and to educate in a context of social and cultural diversity for this it is necessary to focus on training based on professional problems the preprofessional practice of teachers in training can focus on the research of some professional problems such as a the need to characterize and diagnose students the group the family and the community environment in diversity b the search for intercultural procedures and alternatives that stimulate plural learning in indigenous and nonindigenous students c school evaluation from a bias of western pedagogical rationality d the coordination of predominantly western monocultural educational work with culturally diverse educational stakeholders and community leaders it is also important to identify the dynamics of rejection or isolation that can affect children and young people who come from vulnerable social contexts such as indigenous communities it is important to note that training based on resolving professional problems prepares teachers in training to teach indigenous and nonindigenous students to identify and resolve difficulties that affect relationships between people with different cultural origins in addition fickel et al reports that the autonomous search for intercultural knowledge demands learning in the context of professional content learning in context consists of the mobilization and integration of epistemic cognitive methodological and practical resources into professional work with a sense of social cultural linguistic and territorial belonging consequently it is important that the search for information carried out by teachers in training is developed through horizontal epistemic relationships with actors from the intercultural social environment in other words through the coconstruction of knowledge with fathers mothers elders and other preponderant indigenous stakeholders in the territories where training takes place kristoff found that the coconstruction of professional knowledge develops a respectful representation of indigenous knowledge in subjects in preservice education and contributes to reducing cultural gaps between people of different cultures ibáñezsalgado and drukeribáñez found that to the extent that teachers in training are able to autonomously delve into the coconstruction of intercultural knowledge they develop the ability to constantly reconstruct new meanings in relation to diversity and their profession hansen et al found that by coconstructing knowledge with the elders from an indigenous community educational sciences students developed transformative learning outcomes in a spirit of collective reciprocity this enabled them to consolidate skills to develop relationships of trust and mutual respect with other people as a result of this the autonomous search for intercultural knowledge is an intercultural professional performance method that helps future education professionals to develop greater sensitivity toward issues that affect indigenous cultures it is also a way to learn the role of cultural mediator that falls to teachers in intercultural school contexts category 3 intercultural communication this category emerges from the ontological process associated with the system of influences that teachers in training receive through undergraduate teaching which they interpret and then transmit to new generations through preprofessional practices in the intercultural professional performance training model the area of preprofessional practice is of vital importance so that future educators can appropriate professional performance methods and procedures that allow them to adequately handle problems and situations in a space of social and cultural diversity therefore training to be a teacher implies the development of learning to connect and learning to live together based on a symmetrical educational relationship between oneself and the other this is achieved through dialogue through intercultural communication intercultural communication implies using education to create a dialogue on the multilateral relations between the teacherstudentstudentstudent and between these and other social stakeholders based on the subjective and intersubjective meanings and standards of the sociocultural frameworks in interaction balakrishnan et al found that intercultural communication between subjects from different cultures facilitates cooperation between them by promoting mutual understanding in contexts of respect appreciation and acceptance of the other from a global and local perspective development of the intercultural communication professional performance method is associated with the contextualization of teaching an aspect that requires teachers in training to have the ability to acquire and assess knowledge educational traditions and worldviews of the indigenous world the preprofessional practice as a formative element of the intercultural communication professional performance method challenges educational sciences students to distance themselves from their own culture and be attentive to misunderstandings and erroneous interpretations that can emerge in the context of interaction with subjects belonging to different cultures such as indigenous students according to heyman the intercultural communication professional performance method implies a paradigm shift to advance the knowledge of the others culture to come to share the general values of humanity and the specific values of indigenous peoples in a shared sphere of action however for teachers to appropriate intercultural professional performance it is important to use teaching methods associated with educational traditions customs and worldviews relevant to the training context in undergraduate teaching activity table 3 intercultural communication definition of the category subcategories intercultural communication implies training future educators to interact through intercultural dialogue with subjects from different cultures based on negotiation and mediation processes of the heterogeneous cultural knowledge that enters the interaction this implies being able to put oneself in the place of the other as a legitimate other to build multireferential knowledge this is associated with learning to live together development of shared attitudes and behaviors systematization of intercultural dialogue contextualization of teaching teaching methods have an instructive function and an educational one consequently quilaqueo et al found that where the importance of intercultural methods for education is valued in pte significant modifications are produced in the perceptions of the actors in training regarding the meanings of indigenous educational knowledge for education in this sense the use of dialogical methods in pte is essential for the development of intercultural communication in teachers in training since language acts as a significant mediator between the context and the creation of meanings thus the construction of the intercultural communication professional performance method becomes a social space that counteracts the monocultural linearity of the educational sciences curriculum in the context of social and cultural diversity conclusions the study concludes that the competencybased teacher training model in the context of social and cultural diversity must move from a westernized monocultural conception that negates the logic of indigenous knowledge toward a comprehensive assessment of interculturality as a positive element that generates professional performance in teaching that is relevant to diversity courses of action include the urgency to redesign the educational sciences curriculum to promote a preservice training focused on the acquisition of knowledge skills and values that develop critical intercultural thinking in teachers in relation to the social and educational reality this would make pte a link between the social cultural and technological demands derived from globalized intercultural relations and the aspirations of equity equality and diversity of the most vulnerable people disclosure statement no potential conflict of interest was reported by the author

the purpose of this article is to conduct a descriptiveinterpretative analysis of the systematized and emerging theoretical assumptions in academic literature in initial teacher training which show hints of a model based on professional performance as an alternative in contexts of social and cultural diversity the article is based on an intercultural educational approach which has an indigenous perspective this raises the urgency of rethinking teacher training processes in relation to indigenous and intercultural contexts based on appraisal and respect for indigenous children and young peoples episteme who hold cultural ethnic and linguistic differences this article discusses the main limitations of the competencybased training model in educating teachers who take on inclusion and diversity of indigenous individuals as part of their professional performance this research is qualitative and is grounded on content analysis of literature selected from internationally renowned databases the literature review was organized around three areas of professional education teaching research and practice results taken from this search were interpreted from the perspective of the educational model of the universities of the araucanía region chile an intercultural context that is characterized by a high enrollment of students from indigenous and rural communities results show associations among conceptual attitudinal procedural and relational contents in professional training areas that might be subject of reconceptualization this is to enlarge the scope in the initial teacher training model by including intercultural professional performance in the context of social and cultural diversity these areas fall into three categories a development of intercultural critical thinking b autonomous search of intercultural knowledge and c intercultural communication which are interpreted as useful for professional performance and are highly recommended in literature for their inclusion in educational sciences curricula

the novel coronavirus disease 2019 threatened the health and wellbeing of all families with a disproportionate impact on families of children of color in response to covid19 health care systems restricted andor postponed inperson clinical appointments with many rapidly implementing telehealth including virtual remote and telemedicine services these health care systembased disruptions in diabetes care can present a challenge to youth with type 1 diabetes and especially for black and hispanic youth as they are more likely to miss appointments and have suboptimal glycemic levels compared with white youth the effectiveness of telehealthbased care for diabetes management during covid19 is promising given the availability of sharing electronic data from advanced diabetes technology devices indeed research conducted before the pandemic found that the use of telehealth in type 1 diabetes management resulted in improvements or no change in a1c levels over the course of 1 year and that patients were generally satisfied with telehealth although some reported technical issues unfortunately a successful telehealth encounter requires reliable internet access a device with audio and video capabilities and digital literacy which are common challenges for communities of color that are disproportionately affected by the digital divide from the available studies conducted during the covid19 pandemic it appears that attendance rates among patients with type 1 diabetes were similar for telehealth and inperson appointments demonstrating engagement with telehealth two pilot studies also found that people with type 1 diabetes who attended telehealth visits during the pandemic showed improvements in glycemia signaling potential effectiveness however survey data collected during the pandemic revealed a range of perspectives regarding acceptability feasibility and preference for telehealth suggesting that more research is needed to understand families lived experiences of telehealth during covid19 before the pandemic adults with type 1 diabetes expressed concern in qualitative interviews that over time telehealth would undermine their expertise in managing their diabetes by shifting control to their health care professionals they reported problems electronically transmitting clinical data and receiving meaningful feedback because of limited staff time and asynchronous support and they emphasized facetoface contact as being key to quality care this study on adults provided some insight into patients perceptions of telehealth for type 1 diabetes care but a pediatric perspective is still lacking pediatric populations have additional factors to consider when using telehealth more importantly there is a need to document the lived experiences of youth of color with type 1 diabetes a group at greater risk of suboptimal health outcomes and disproportionally affected by the digital divide such information may improve the quality of pediatric diabetes care delivered through telehealth as the pandemic persists prepandemic diabetes hcps felt that telehealth was generally acceptable and had clinical benefits however they also identified several concerns such as a lack of personal contact and families being unfamiliar with technology despite these findings it is imperative to obtain hcps perceptions to gain insight into unique facilitators of and barriers to delivering pediatric type 1 diabetes care through telehealth during covid19 to address these gaps in the literature the aim of the current study was to gather perspectives from youth of color their caregivers and hcps on telehealth for type 1 diabetes care during covid19 research design and methods this study was conducted as part of a larger qualitative project approved by the nemours institutional review board this larger project examined facilitators of and barriers to advanced diabetes technology use for type 1 diabetes among families of color initiated in june 2020 consistent with bestpractice guidelines for health disparities research the larger study included a stakeholder advisory board composed of two youth of color with type 1 diabetes and three caregivers who contributed to the research question recruitment procedures and interview guides and reviewed the final qualitative findings participant recruitment youth of color with type 1 diabetes between the ages of 12 and 19 years who had been diagnosed at least 12 months before recruitment did not identify as nonhispanic white and primarily spoke english or spanish were eligible to participate caregivers of eligible youth were also invited to participate regardless of their race and ethnicity eligible families were identified from electronic health records across two endocrinology clinics in a multistate pediatric health system located along the east coast of the united states purposive sampling was used to obtain diversity with regard to ethnicity primary language and diabetes technology use youth and caregivers were able to participate individually pediatric endocrinologists and advanced practice registered nurses who provided direct clinical care to youth with type 1 diabetes in these same two clinics were also eligible to participate eligible families and hcps were recruited via email with a message describing the purpose of the larger study research team members used text messages phone calls and email messages to follow up with potential participants who did not respond research team members scheduled a study visit with families and hcps who expressed interest in the study at the start of the visit families completed electronic informed consent and assent forms hosted in the redcap online platform to protect confidentiality hcps could waive providing their signature as documentation of consent data collection participants completed a demographics form followed by a semistructured phone interview conducted by trained interviewers youth and caregivers from spanishspeaking families were given the option to complete research procedures in spanish or english all caregivers completed interviews in spanish while all youth completed interviews in english all interviews were audiorecorded and transcribed using a thirdparty transcription service youth and caregivers were paid 30 for completing the study hcps received a raffle entry for one of four 30 gift cards measures demographics the demographic forms assessed race ethnicity age and sex additionally caregivers and youth reported on their education level and primary spoken language ehr data provided youths most recent a1c result duration of type 1 diabetes and insurance type hcps indicated their job titlerole years of providing type 1 diabetes clinical care and whether they provided services in languages other than english interview guides three semistructured interview guides were created interview guides were originally developed to assess families perceptions of facilitators of and barriers to diabetes technology use at the outset of the covid19 pandemic questions were added to ask youth and caregivers who had a telehealth visit to share their perspectives on telehealth whereas hcps were asked how the pandemic affected their clinical care youth and caregiver interview guides were developed in english and then translated and certified in spanish three bilingual stakeholders also reviewed the spanish interview guides qualitative analysis spanishlanguage interviews were translated into english for coding purposes all transcripts were reviewed for accuracy before coding qualitative analysis of all transcripts was conducted using dedoose 9017 three members of the research team iteratively developed the codebook by examining transcripts line by line and identifying key words and phrases all transcripts were coded by a twoperson coding team the coding team independently coded transcripts and met to review discuss and resolve coding inconsistencies and revise coding criteria another research team member experienced in qualitative research methods was consulted as needed to help resolve inconsistencies a phenomenological approach was used to extract relevant themes regarding perceptions of telehealth for type 1 diabetes care during covid19 the coding team met multiple times to develop and revise the emerging themes using a constant comparative approach comparing and contrasting exemplars within the data to formulate the final themes positionality statement reflexivity is the process through which researchers acknowledge and disclose how their own background and worldview influence their research the racial and ethnic backgrounds of the authors are somewhat diverse and include nonhispanic white nonhispanic blackafrican american and hispanic white all authors have graduatelevel education in psychology medicine or public health none of the authors have type 1 diabetes but they do have experience providing clinical care or conducting research with youth with type 1 diabetes and their families the authors with experience providing clinical care have used telehealth when working with youth with type 1 diabetes the authors recognize that their professional and personal background may affect their approach to answering the research questions posed in this article the information participants may have disclosed during interviews and their interpretation of the findings the research team worked to develop culturally sensitive research methods and had regular discussions to ensure that the study was guided by their cultural knowledge and expertise results thematic analysis three major themes capturing participant perspectives on telehealth for pediatric type 1 diabetes care during covid19 were distilled from the data they captured comments about 1 perceptions of telehealth 2 feasibility of telehealth and 3 quality of telehealth care details and illustrative quotes are provided below theme 1 perceptions of telehealth seven youth and 10 caregivers had positive perceptions of telehealth one caregiver liked the convenience of having telehealth appointments saying sometimes when we are there inperson we were there for 2 or 3 hours shes here in the house she does her lunch and she can continue to have the appointment one youth stated that attending telehealth appointments made him feel better when asked to elaborate he expressed how virtual appointments would probably just protect the health of everybody who would have been there in person a few caregivers and youth were initially unsure about telehealth describing video calls as strange different or creating feelings of anxiety however they tended to feel better about the experience afterward conversely one youth and six caregivers had negative perceptions about telehealth the one youth disliked the length of his appointment stating that it took longer than it would have taken in person one caregiver felt that telehealth was not suitable for her child because hes more of a type of patient that should be seennot somebody that should do a telehealth appointment another caregiver decided against attending telehealth appointments because she said i didnt feel comfortable with doing it on the computer we need to be able to talk to the hcp and not just be on the computer in sum despite some notable concerns most families found telehealth to be an acceptable way to receive type 1 diabetes care theme 2 feasibility of telehealth most families and hcps discussed potential feasibility issues with delivering type 1 diabetes care through telehealth two although one hcp noted that telehealth provided a more personal experience most hcps and caregivers raised concerns about the quality of telehealth diabetes care because of the lack of inperson interactions one caregiver shared that she canceled her childs telehealth appointment and wanted to reschedule for an inperson visit one hcp also expressed concerns about limited multidisciplinary care saying a lot of our kids need good strong psychology support i think theyre doing a great job with telemedicine but i dont think its the same when you talk to someone on the phone versus in person most caregivers and hcps also felt that the absence of physical examinations diminished the quality of diabetes care one caregiver described telehealth as a professional experience but said the difference with a video call is that the doctor cannot do his physical examination which is the one that i think is important especially for my childs condition one hcp shared how physical exams shaped her perception of the quality of inperson versus telehealth visits saying i think the care that i give when im doing a telemedicine visit is not as good as an inperson visit because of not being able to examine the child some hcps felt that the inability to retrieve type 1 diabetesspecific data made telehealth less effective as described by one hcp i didnt have access to their meters to physically go through they did not have a1cs necessarily for me to be able to gauge how things were going so that definitely made it tougher to have an effective visit however a few hcps believed that data from advanced diabetes technology devices improved the quality of diabetes care one hcp described how device downloads informed clinical care more than a1c saying we werent able to do a hemoglobin a1c so that piece of information was missing when we saw them but i dont think that it impacted the way in which we were able to provide care significantly because most of them downloaded data and sent it to us or sent logs in sum many hcps and families felt that care delivered via telehealth could be of lower quality however hcps noted how advanced diabetes technology could help them deliver higherquality care by telehealth discussion our findings suggest that most families of youth of color with type 1 diabetes in the context of covid19 had positive perceptions of telehealth although a few families reported minor concerns these findings are mainly congruent with prior research but extend the literature by identifying reasons why families of youth of color perceived telehealth positively importantly our findings also point to reasons why families of youth of color may be uncertain about telehealth these reasons for uncertainty are amenable to intervention and addressing such issues may help to minimize disruptions in care for example it may be helpful to assess families preferences for a mode of care delivery and level of comfort with telehealth technology before scheduling telehealth appointments to ensure that families receive care in their preferred way when possible and to identify families who would benefit from additional support to successfully complete telehealth visits interestingly our data also suggest that some caregivers and hcps in the sample felt that the absence of inperson contact and physical examinations diminished the quality of diabetes care which is also consistent with previous research many aspects of the exam cannot be completed via telehealth and the lack of inperson contact may hamper communication which is essential to patientprovider relationships treatment engagement and satisfaction with care therefore more research is needed to understand how physical examinations influence patientprovider relationships and to identify ways to promote patientprovider communication and relationships when care is delivered remotely relatedly results from this study highlight the need for equitypromoting interventions and initiatives although telehealth enabled continuity of care during the height of covid19 previous research and this study suggest that telehealth could exacerbate disparities in health care access and delivery for families of color technical challenges were common and digital literacy played a role especially for nonenglishspeaking families furthermore limited ability to share or access clinical data eroded participants perceptions of the quality of care delivered through telehealth advanced diabetes technology devices such as cgm systems and insulin pumps could facilitate the sharing of clinical data for telehealth appointments however there are persistent racial and ethnic disparities in the use of diabetes technology to ensure that telehealth reduces disruptions in care for all youth with type 1 diabetes clinics and health care systems need to identify and remedy factors and processes that contribute to disparities in care limitations the studys strengths include its use of rigorous qualitative methods a stakeholder advisory board inclusion of both family and hcp perspectives and a focus on families from historically underrepresented racialethnic groups however study findings should be interpreted with the following limitations in mind first the primary aim of the larger study was not to assess telehealth which limited the number and types of questions participants answered only youth of color with type 1 diabetes were recruited given the aims of the larger study thereby precluding the ability to compare themes across racialethnic groups future research should sample both white and nonwhite youth with type 1 diabetes to examine whether racialethnic differences in perceptions of telehealth visits exist additionally the study had a low recruitment rate as only 21 of contacted families were enrolled however this was sufficient to achieve saturation and purposive sampling allowed for greater representation in this sample characteristics of the coding team could affect how the data were coded and analyzed however the team was racially and ethnically diverse and worked closely with the advisory board to protect against any implicit biases the study was conducted early in the pandemic and used a crosssectional design which precludes the examination of changes in perspectives over feature article telehealth and type 1 diabetes care during covid19 time finally the sample was welleducated the study was limited to two endocrinology clinics within the same pediatric health system and the hcps sampled were limited in terms of racialethnic diversity all of which are factors that may limit generalizability conclusion and implications for clinical practice most families of youth of color with type 1 diabetes had positive perceptions of telehealth during covid19 although some families and hcps identified issues related to feasibility and quality of care understanding families preferred modes for care delivery may help hcps engage families of color in care health equity should also be proactively addressed to ensure equitable access to telehealth care it is recommended that health care systems 1 examine whether disparities in telehealth access exist within their patient population 2 develop ways to educate patients on how to navigate technology for telehealth visits and 3 review structural processes to make appropriate technical and logistical changes to facilitate successful telehealth encounters results of this study also highlight limited access to clinical data as a gap in telehealth use to mitigate this gap hcps should encourage more use of advanced diabetes technology among all youth provide more opportunities for families to complete laboratory testing before telehealth appointments and assist as needed and assess families individual needs to optimize the quality of their telehealth diabetes care

objective at the outset of the coronavirus disease 2019 covid19 pandemic health care systems rapidly imple mented telehealth services to maintain continuity of type 1 diabetes care youth of color are more likely to have suboptimal glycemic control and may benefit most from efforts to ensure continuity of care however research examining the perspectives of families of youth of color regarding telehealth for pediatric type 1 diabetes care is limited we gathered perspectives from youth of color their caregivers and health care providers hcps on telehealth for type 1 diabetes care during covid19 methods fifty participants 22 caregivers 19 youth and nine hcps completed semistructured interviews conducted in english n 44 or spanish n 6 transcripts containing mentions of telehealth n 33 were included for qualitative analysis to extract themes pertaining to perceptions of type 1 diabetes care and telehealth use during covid19 themes related to perceptions feasibility and quality of telehealth diabetes care were obtained most families had positive perceptions of telehealth families and hcps described logistical and technical challenges and noted the potential for disparities in telehealth access and use furthermore caregivers and hcps felt that the lack of inperson interaction and limited access to clinical data affected the quality of care conclusion families of youth of color with type 1 diabetes mostly had positive perceptions of telehealth but also iden tified issues with feasibility and quality of care our findings highlight a need for interventions promoting equal access to telehealth and quality care for all youth with type 1 diabetes to minimize disruptions in care

each life stage comes with challenges and obstacles and hence vulnerabilities and resilience may fluctuate across ones life span earlier analyses found that problem gambling risks generally decrease with advancing age with youth problem gambling rates being two to three times higher than that of the adult population particularly among males however increasing availability and exposure to gambling products and facilities accompanied by notable rapid uptake of gambling by older adults and marketing campaigns targeting older populations are challenging previous understanding of the relationship between problematic gambling and aging problem gambling has been defined as difficulties limiting money andor time spent on gambling which leads to adverse consequences for the gambler others or for the community this definition is chosen because it has been adopted as the national definition for problem the gerontologist cite journal as the gerontologist vol 54 no 6 103554 no 6 104854 no 6 doi101093gerontgnt107 gerontgnt107 advance access publication october 4 2013 gambling in australia and also because it encourages the viewing of gambling across a continuum from nonproblematic levels to the most severe forms it is well documented that problem gambling prevalence is significantly associated with gambling availability accessibility and participation particularly of electronic gaming machines these machines are the equivalent of the north american slot machines although the review of australias gaming industries by productivity commission note that the former differ to some extent from some of the latter in being rated as higher intensity machines in terms of speed of play and number of lines and credits that may be played in a single spin egms or poker machines are colloquially known in australia as pokies in victoria where the current study was undertaken these machines became legalized in 1992 and today are located in over 560 communitybased venues such as clubs and hotels and in the states casino making up a population ratio of 61 egms per 1000 adults in the state increase in gambling opportunity and older adults enthusiasm toward egms have therefore sparked concerns that these trends may culminate in latelife gambling problems in particular due to the unique life experiences in late adulthood and vulnerabilities lateonset problem gambling consequences may be more devastating than for younger adults the damage done may be irreversible and even life threatening as reflected in elevated suicide and suicidality rates among problem and pathological gamblers although gambling is a rather popular activity in later life latelife problem gambling is considerably hidden in victoria australia approximately 73 of adults have been shown to gamble in any one year with their games of choice being in decreasing order lottopowerballpools rafflessweepscompetitions egms horseharness greyhound racing and scratch tickets those aged between 50 and 64 years were more likely to participate in egms lottopowerballpools and competitions than the rest of the population whereas those aged 65 and older were likely to favor bingo more than other victorian adults although in north america from where the majority of the evidence on seniors and gambling originates the prevalence of problem gambling in older adults can span from approximately 2 to as high as 17 depending on the region and scale of survey whereas in australia statewide surveys tend to yield a lower rate of senior problem gambling prevalence specifically in victoria the 5064 years cohort had the second highest prevalence of problem gambling and for adults aged 65 and older problem gambling was more prevalent in women than in men it therefore appears that the trend of males being more at risk of problem gambling is reversed in older age at least for this cohort lateonset problem gambling has characteristics that are distinguishable from lifetime or earlier onset problem gambling for instance petry found that contrary to lifetime problem gambling latelife problem gambling was more associated with women and increased employment problems than social legal and substanceabuse problems the older women reportedly took up gambling at the average age of 42 and regular gambling did not commence until the average age of 55 years similarly grant kim odlaug buchanan and potenza found that the lateonset group was neither likely to declare bankruptcy and have credit card debt attributable to gambling nor likely to have a parent with a gambling problem but were significantly more likely to suffer from anxiety issues these differences suggest that generic risk factors and correlates commonly found in the general adult population may not necessarily apply to latelife problem gamblers which warrants further investigation the authors of the present study previously attempted to fill in this knowledge gap by conducting a thematic analysis and domain categorization of extant seniorspecific literature and crossmatching emerging patterns with the generic pathways model of problem gambling this model which provided the conceptual framework for the present study suggests that problem gamblers are a heterogenous population with three major pathways leading to problem status pathway 1the availability of gambling activities and psychological conditioning lead to a pattern of habitual gambling and chasing losses which results in problem gambling pathway 2builds on the trajectory of pathway1 but incorporates emotional vulnerability this cohort has a history of significant negative life events coupled with poor coping and problemsolving skills and accordingly gambles primarily to address negative affect pathway 3incorporates biological vulnerability and impulsivity traits such as adhd and antisocial behavior and represents the most severe form of problematic gambling our previous study generated three main clusters concerning individual vulnerability factors concerning social and environmental factors and concerning behavioral regulation these results represent one way of grouping the findings and may be limited by the inherent methodological limitations associated with some of the studies analyzed as well as the dominance of the north american context of the research reviewed consequently it is unclear to what extent these findings could be generalized to the australian context where the milieu of gambling is comparably more diverse and characterized by high rates of dispersed as distinct from centralized gambling opportunity in contrast to this prior analytic approach the current study utilized a groundup perspective for addressing seniorspecific problem gambling pathways specifically it directly engaged australian older gamblers and traced conditions that were subjectively perceived as causing vulnerability toward harmful gambling the purpose of the study was to develop a grounded theory through semistructured indepth interviews on how older adults who may not have previously experienced gambling issues come to develop gambling problems in later life design and methods analytic approach and participants as the aim of the study was to build a theory on pathways into latelife problem gambling the grounded theory approach was considered appropriate the conceptualization procedures therefore involved coding categorizing memoing constant comparison and theoretical sampling specifically applying a constructivist grounded theory methodology meant that emphasis was placed on the identification of pertinent constructs the associated properties and supporting codes concepts of similar characteristics were grouped together under a common classification or category and the accumulated interrelations were subsequently integrated to form the core of the emerging theory as not all categories were equally relevant the depth of inquiry into each category varied focus was therefore directed at reaching saturation with regard to core themes as much as possible for these serve as categories that would hold the most explanatory power thus categories that appeared to be less relevant for predicting and explaining the later life gambling behaviors were gradually eliminated to address the trustworthiness of the data interpretation a random sample of transcripts were reviewed by the two authors who had not collected the data and undertaken the first thematic analysis no areas of disagreement emerged the participants were respondents from newspaper advertisements project flyer distributions snowballing and a problem gambling counseling service newsletter the sample inclusion criteria were older adults who were aged 55 and older who were either regular gamblers or have ever experienced later life gambling issues and who were able to understand and consent to the research project exclusion criteria involved younger adults presence of health conditions that might hinder participation in an hourlong interview and the inability to provide a free and informed consent as a token of appreciation for their time participants were offered a 20 department store gift card at the end of each interview in order to identify pertinent risk factors and catalysts without having to intrude excessively into life histories attention was focused on key life events and turning points that coincided with gambling onset andor transition from regular gambling to problematic gambling as key themes surfaced the interviews progressively increased in structure and focus because both problem and nonproblem gamblers were recruited both risk and protective correlates were gathered nonetheless as this study focuses on the problem gambling pathways the current findings were primarily informed by participants with a problem gambling history although data from the rest of the sample helped suggest pathway interruptions and exits even though saturation occurred approximately after the twentieth participant was recruited the researcher continued to recruit up to 30 participants in order to check the scope of the emerging theory the additional one was due to a participant emailing her story over in the midst of recruitment results sample demographics thirtyone older adults aged 5685 participated in the study the average age was 67 although 30 of the participants were interviewed facetoface a supplementary story was emailed to the researcher by a participant who preferred to not meet personally but was nonetheless comfortable with sharing her gambling experiences of the 31 participants the majority was female with nine males 8 were married 16 were divorced or separated 5 were widowed and 2 never married six participants were employed full time or part time and 25 were retired in terms of income source 25 were receiving pensions and 6 were selffunded retirees or employed fifteen participants described their ethnicity as australian three each as yugoslavian greek or turkish two each as italian or english and one each as dutch finnish or british apart from three participants who were from three different country regions of victoria the rest were recruited from metropolitan regions sample gambling situations overall six participants described themselves as currently having gambling problems for which they were not seeking treatment eight reported having sought selfexclusion from gaming venues and perceived themselves as recovering or gaining more control over their gambling behaviors and four reported a history of binge gambling due to previous intermittent experiences of gambling issues conversely nine presented as regular nonproblem gamblers two considered themselves professional gamblers and one presented as a selfrecovered lateonset problem gambler whose gambling was regarded as currently under control key themes the fundamental social process involved in rendering the participants vulnerable to problem gambling was found to be the process of becoming isolated which could be both the causeprecipitating factor as well as the byproduct of gambling problems the concept of isolation consisted of properties such as having nobody there for you nobody for you to be there for nothing much else to look forward to and gambling venues as places for the isolated to unite and belong findings also suggested that as problem gambling risks escalated participants displayed a tendency to consider gaming machines as their companions which in turn increased their isolation and dependence on gambling venuesproducts to achieve a sense of belonging andor companionship moreover for a considerable proportion of the participants who experienced gambling problems gambling appeared to be used to replace work which reportedly was the antidote to all of lifes stresses during their employment years consequently the concept of isolation also included properties such as gaming machines as the isolateds companions work as previous distraction and gambling products enhanced the feeling of being isolated the construction of isolation is summarized in table 1 the number of times each code was reflected in the interviews is indicated in brackets after each code name indicating the relative density or salience of each code these densities or support for each component were used to guide the development of the grounded theory through examination of their occurrence and the interrelationship of the codes within each construct the first propertynobody there for youcould refer to both a representation of an idea as well as an actual or literal situation specifically the more tangible or concrete aspects of this property were found to encompass conditions such as loneliness scarce social contactdifficulties in meeting and forming new friendships lack of support and relationship conflicts the more hypothetical or abstract aspects entailed superficial existence having to live behind a mask and fear of dying alone in particular part of what made gambling venues a favorite place for lonely participants to spend time was reported because they could go there on their own do something on their own and still be able to enjoy themselves all names are pseudonyms its one place you can go where you can go in on your own and you dont have to be with someone thats a very big factor because i would not walk into a pub on my own and sit and have a drink but you can walk into a venue if youre lonely and and you dont have to drink you just have to play the above example portrays isolation as a lack specifically of human contact in contrast for another participant loneliness was more covert and complex in nature and isolation was a mix of various losses severe grief inability to truly be oneself among ones network and a sense of a bleak future we always say we we put in full time between us over 80 years into the workplace and we saved and we we bought this house and weve weve uh had some money for our retirement and our retirement was going to be full of wonderful things but his illness um has stopped that ill be 70 in a couple of years and um i see um ahead of me its only in a short span of time that i may be active enough uh in health terms for another participant loneliness meant living behind a mask its always been known that comedians are the loneliest people on earth and it is quite true closely related to the property of having nobody there for you was having nobody for you to be there for which covered aspects such as the need to be needed the need to control and a sense of redundancy some participants were rendered isolated when they were made to feel unneeded or unwanted for various reasons such as through lack of responsibilities lack of respect and recognition discrimination and technological advancements the impact of feelings of redundancy appeared to be greater for competitive individuals who simultaneously seemed to have a considerably harder time accepting negative gambling outcomes this consequently led to the development of obsessions about winning strategies and the subsequent acceleration down the isolated path more rapidly than their noncompetitive counterparts on the other hand a personality trait that was found to be commonly shared between the participants in the sample was being young at heart as a consequence of having this trait many of the participants reported that they did not really fit in with the mainstream older population and could not really derive much entertainment or satisfaction from existing services that cater to seniors in particular existing senior citizens social clubs and their associated activities were found to be dull and uninteresting accordingly this often prompted a need to seek out the company of other youngatheart older adults who were perceived as often found at gambling venues in fact joining seniors clubs even diminished some of the participants sense of wellbeing i dont like them seniors social clubs because um they all look very old and um you go there and you feel like youre ready to jump in the grave all these people you know theyre all very old and and they look old and um um they dress old and um and not um modern and not having good clothes to wear or anything and they look like beggars you know you think oh why did i come here i used to go to a cultural club down there its a disaster you only have to do jobs down there you have to make coffee for them and oh this coffees no good theres not much sugar uh its too strong its too weak you know theyre all complaints thats all so i dont go there anymore not happy going to those places thus existing seniorspecific social clubs may not be suitable for all types of seniors particularly those like some of the study participants who were disengaged from mainstream services it was not uncommon for participants in the sample to report meeting likeminded people andor people who were going through similar things in life at gambling venues consequently gambling venues became a setting that enabled vulnerable individuals to meet one another share with one another confide in one another and for those who did not really interact with others at least provided them with a sense of belonging older people that are lonely and are lost and they dont fit into something in this world so we go to the pokies and enjoy one anothers company theres not a lot of places to go with people and because these day and age people arent really friendly anymore very hard to to meet people and share with people nonetheless although a considerable proportion of the participants reported gambling due to loneliness or to meet people this ideal was often not realized with participants also reporting paradoxically wanting to be left alone to interact with the machines and the machines your partner chuckles the machine becomes your partner well you tend to talk to it um oh a lot of people do its not just me a lot of people do demonstrates stroking an imaginary egm um its my turn you know come on be good and be lucky for me tonight and yeah all that sort of thing when asked why despite feeling lonely he would rather have egms for companions instead of people another participants reply was at least you wont get an argument out of the machines there hence it appeared that for some social conflicts were considered more stressful than gamblingrelated losses conversely as participants frequently talked about using gambling to cope with one thing or another enquiries were made into previous coping strategies that were applied before egms were adopted for an overwhelming majority of those with current or previous gambling problems the concept of free time never really existed prior to their egm uptake andor work was their hobby nevertheless for some previous coping strategies involved nicotine andor alcohol consumption which in the current sample appeared to be male specific these findings suggest that overt coping mechanisms of the isolated may include substance useabuse whereas more covert coping mechanisms may involve workaholism however because most participants were brought up with rather strict work ethics workaholism was rather hard to diagnose and was beyond the scope of the current study findings also indicated that some individuals had higher sensitivity toward stimulation than the rest of the sample indeed it appeared that for these participants perceived egmrelated effects on their mind were immediate as opposed to a gradual development and the impressions of machine features were not just transient images but rather they repeatedly replayed in their minds and egmrelated sounds continued to ring in their ears long after their gambling sessions the colors noise vibrancy and features of the games on the screens stayed in my brain like imprints and seduced and lured me back and back again hundreds of times thats the planning behind the seductive images much study of human psychology must go into the design of the programs and then you haveyou go to bed and the machines still going off in your head and you cant sleep so you get up and go to work the next day and youve had no sleep and youve got no money and youre stressed and you and ive been doing that for the last ten years the quotations above demonstrate that the experiences that vulnerable gamblers go through while gambling may differ from those who are less vulnerable specifically in the way the former groups gambling experiences were often allconsuming which did not appear to be the case for the latter group the following three pathwaysgrief habit and dormant respectively represent trajectories that rendered the current sample isolated or vulnerable to latelife problem gambling the discussion of each pathway covers entry progression and maintenance or perpetuation of the trajectory based on analysis of the interviews exiting pathways is covered in the discussion section the key components of the pathways are summarized in tables 234 the grief pathway pathway entry substantial lossesgamblingrelated vulnerabilities associated with this pathway essentially involved losses of various forms and magnitude such as an illness striking a loved one or oneself an angerprovoking event stress and anxiety associated with conflicts presence of abusivemanipulativenegligent relationships andor what some participants had summed up as a hard life the gambling triggers were often situation specificas opposed to being related to a presumptive biological or genetic predispositionand these were reflected in participant history where something subjectively stressful reportedly preceded or occurred around the time of regular gambling initiation which prompted the need to seek out gambling andor gamblingrelated venuesincentives whereas prior to such turning points these individuals reportedly functioned well such presentation patterns suggest that the main catalysts for problem gambling progression in this pathway are potent negative emotionswhich in the current sample included chronic loneliness despair depression panic desperation and ragewhich may be activated by certain thoughts memories reminders of various forms or as a consequence of certain realizations finally sinking in pathway progression mismanagement or non management of lossesdue to the sheer force of negative emotions associated with this pathway participants experiencing this pathway primarily gambled to avoid feeling emotionally overwhelmed or to have a break from emotional exhaustion this pathway is therefore predominantly underpinned by the presence of unresolved issue which in the current sample appeared to be exacerbated by the lack of opportunities for grieving be it due to selfimposed standards social expectations or an overload of responsibilities because the triggers for this pathway primarily involved affect or mood states and rarely had anything to do with gambling per se gambling outcomes were often found to be of little if any significance to the respondents and winnings were frequently of minimal import or their value was short lived this was evident in the way the participants talked about the emptiness of gambling the meaninglessness of wins and how when asked what their gambling involvement meant for them the answers were often given as nothing really pathway perpetuation gamble to forget and or augment personal spaceparticipants on this pathway characteristically only gambled when feeling upset or needing time alone thus the need to gamble was usually dispelled when these participants were copingcontent with life or the reminders of their distress were absent accordingly motivation to continue or increase gambling was largely associated with the drive to disregard reality and ease emotional pain compared with the other pathways participants experiencing this pathway appeared to most likely to prefer the company of egms than actual human interactions consequently gamblingrelated wins appeared to neither significantly spur these participants on to gamble more nor did gamblingrelated losses appear to deter them from further gambling nonetheless for those who were considerably enlivened after gamblingrelated wins who attached sentimental meaning to gambling who came to rely on venuerelated services and incentives to feel better about themselves or who subscribed to the construct of nothing much else to look forward to complications often followed due to additional layers of emotional needs this means that a cycle of needs that begets more needs or the formation of secondary needs on top of unmet primary needs may occur and this can further complicate the trajectories of this pathway the habit pathway pathway entry subjectively minor unmet needsin contrast to the grief pathway participants experiencing this trajectory reportedly enjoyed a good life prior to experiencing gambling problems in the sense of lacking anything to complain about and any major unresolved distress anxiety or melancholy consequently this pathway was marked by relatively minor and rather straightforward needs for an out that were met by gambling thereby suggesting that their degree of being isolated appeared to be relatively mild these minor needs included missing the kind of responsibilities that one used to enjoy missing the times when one was needed running out of things to do to occupy ones time the desire to stir up routines andor the desire to merely try out something different and exciting conversely for others the initial triggers manifested as a need for a change of environment and gambling venues happened to be the closest location a need for a place to spend time outside of ones residence and gambling venues were found to be safe and consistently open a desire to postpone ones return to an empty house and gambling venues turned out to be the only locations that opened till late or in rarer cases a desire to prolong fun and happy feelings after a great day at work and gambling was perceived as enabling the momentum of positive feelings to continue pathway progression winningsluck encouraged further gamblingregardless of what the initial motives may have been the main catalysts for gambling progression or escalation in this pathway were found to be centered around big winsbeginners luck or lucky feelings which fostered subsequent need to chase bigger winslosses or to allow opportunities for lucky feelings to translate into actual wins consequently unlike participants from the previous pathway participants on this pathway were rather motivated to win at gambling and gambling outcomes mattered considerably thus this group appeared to be mainly after the stimulating effects of gambling and was more likely to stop gambling if early gambling experiences were negative pathway perpetuation gambling out of habitit was not uncommon for participants on this pathway to concur that although they started off gambling out of boredom or to be out of the house these eventually became an excuse to gamble further this is because they reportedly became so accustomed to frequenting gambling venues whenever they had the time and money that when other engagements or opportunities for engagements arose they still preferred to gamble instead thus the main perpetuating factor for this pathway appeared to be the formation of a gambling habit that overrode other activities and which was intensified and complicated by the desire to chase losses and bigger wins this means that with regard to the construct of isolation participants on this pathway mainly endorsed only a few and rather scattered components of each aspect of the construct nonetheless if complications were to occur such as depression secondary to gambling problems then more components of isolation are likely to be endorsed the dormant pathway pathway entry existence of comorbiditiesparticipants experiencing this pathway appeared to have preexisting predispositions toward compulsive behaviors for instance in the current sample there was a participant with tourettes syndrome whereas others described themselves as having an addictive personality an obsessivecompulsive outlook on life or possessing an addictive gene due to a family history of heavy gambling andor alcohol consumption nonetheless due to lack of prior opportunities to gamble or gamble regularly these vulnerabilities only manifested themselves in problematic gambling in later life although participants on the previous pathways were inclined to describe their gambling progression as insidious participants under the dormant pathway were more likely to express their gambling as an instant attraction or instant hook in fact a rather distinct gamblingrelated behavior associated with this pathway was that these participants often placed larger bets and did not appear to be satisfied with small bets thereby reflecting an arguably stronger tendency to take more risks for the enjoyment of taking risks and or a comparatively lower level of selfcontrol these participants also demonstrated a lack of coping skills or poor coping strategies in the past such as relying principally on nicotine andor alcohol to relax and unwind sleeping their days away to kill time or engaging in compulsive eating whenever bored overall it appears that participants on this pathway presented with relatively more indications of vulnerability in their psychosocial history than the rest of the sample pathway progression gambling behaviors propelled by comorbiditiesunlike the previous pathways the dormant pathway did not appear to require any specific triggers or external encouragements for gambling urges to be elicited although it could be aggravated by these factors this is because this pathway entailed the presence of comorbidities and in particular a history of other forms of addictive behavior such precarious foundations or somewhat dormant vulnerabilities once triggered appeared to create a momentum of its own so that gambling progression appeared to occur more rapidly than the previous two pathways consequently these participants were generally more likely than the rest of the sample to endorse gambling problems as feeling addicted as well as being the second group to most endorse the construct of gambling venues as places for the isolated to unite and belong thus in terms of isolation it would appear that these participants were isolated because other forms of outlets could not seem to help ease tension and offer satisfaction which may have contributed to their perception that gambling venues offered a sense of shared purpose or community pathway perpetuation avoidance of gambling related withdrawalsat the core of their gambling motivations participants on this pathway appeared to experience genuine gambling urges in the sense of having gambling itself as the main goal reward and less emphasis on the secondary benefits of gambling such as to regulate emotions or chase bigger winslosses as such physical withdrawal symptoms associated with gambling cessation or reduction such as shaking or trembling hands which were not reported under the other pathways were found under this pathway consequently gambling motivations associated with this pathway appeared to be characteristically associated with the need to satisfy gamblingrelated urges to calm the mind from incessant thoughts about gambling and to avoidease withdrawal symptoms discussion a number of pathwaysgrief habit and dormanthave been identified in this study all three of which rendered the current sample isolated or vulnerable to latelife problem gambling these pathways to some extent reinforce the heterogeneity proposed by blaszczynski and nower and the pathways in their model and reinforce some of the clusters identified and previously proposed by the present authors because findings are based on participants interpretation of their lives and their gamblingrelated experiences and the meaning that they attached to these the construction of isolation fundamentally represents the symbolic interaction between the participants and their environments nonetheless this does not negate the importance of macrosystemic factors that can considerably influence the trajectory of problem gambling development and progression because findings suggest that isolation and sense of redundancy can significantly propel vulnerable individuals to seek destructive ways of boosting selfesteem and regaining meaning purpose in life latelife problem gambling prevention entails the promotion of environments that are socially inclusive and a society that does not judge or devalue people because of inevitable factors such as age rather it should appreciate past contributions while provide ample opportunities for further contributions examples of interventions some of which were nominated by interviewees include the following policy makers can help by subsidizing or offering free courses to retirees so that older adultsespecially those who have spent most of their lives working and hence struggle to deal with the extra free time upon retirementcan develop new interests and hobbies and learn about alternative ways of meeting emotional and social needs in addition abundant opportunities for positive involvement for example through the creation of mentoring programs where older adults are linked with teenagersyounger adults thereby allowing retirees to continue to feel useful and valued by society while preventing isolation could be provided seniorfriendly neighborhoods could be promoted whereby adequate recreational options and social venues are provided within local settings so that older adults can feel safe to venture out and socialize and not have to rely solely on gambling venues as their only secure communal and easily accessible destinations policy makers should continue to listen to older adults and understand the changing contexts of aging so that policy initiatives are always relevant to seniors needs and resources channeled into aging sectors and programs are most efficiently applied as gambling was found to be used to replace work and its distracting effects this has significant implications for education around alternative leisure options and emotional outlets for instance activity scheduling interventions that help associate positive mood with nongambling social activities and mood monitoring in the context of daily activities can be helpful for both treatment and prevention strategies in addition as several participants were found to have an inclination toward dismissing losses andor minimizing the impact of losses so as to just get on with it as soon as possible part of retirement planning should therefore include raising awareness about the processes of grief reminding older adults that some forms of grief may take longer than others to heal and assuring older adults that just because they may take longer than someone else they know to grieve or get over a similar kind of loss it does not mean that they are weaker than that person indeed the emotional and social aspects of retirement may be the hardest part of retirement planning and may also represent aspects most easily overlooked by retiring individuals because income assets and finances tend to be at the forefront of retirement planning strategies accordingly empowering interventions that help equip older adults with copious ideas on how to compensate for losses are vital due to the predominantly emotional nature of the underlying causes for latelife problem gambling it may be more effective for intervention strategies to appeal more to sentiments than to rely chiefly on altering cognitions indeed the latelife problem gamblers in the current sample were generally aware that the odds of winning at gambling were against them but the majority appeared to be too overwhelmed by strong emotions to be able to harness any previous productive coping mechanisms and some appeared to be too lost in gamblingrelated fantasies to be able to regain insight on their situations thus the main issue was not ignorance of gambling odds but rather emotional struggles accordingly repetitive reinforcement of the probabilities of wins and losses at gambling are unlikely to be effective in fact there is growing evidence to suggest that older and younger adults process interpret and respond differently to risk messages and that emotions may assist with information integration in late life thus a homogenous way of educating the public about problem gamblingrelated risks may be ineffectual and this needs to be taken into consideration when designing interventions interventions to assist in terminating pathway trajectories the intricate emotional needs associated with the grief pathway suggest that effective interruptions to this pathway entail availability and accessibility of emotional support opportunities for alternative outlets and substituted forms of respite treatmentwise cognitive behavioral therapy may help to replace triggering thoughts alter unhelpful belief systems and minimize the inclination to link and develop somewhat unrelated hopes and dreams to gamblingrelated activities nevertheless if affected individuals were to become aware of their own triggering thoughts and underlying needs and come to resolve or let go of the losses experienced selfrecovery may be possible because the habit pathway was predominantly underpinned by relatively more straightforward vulnerability factors it would appear that unlearning somewhat conditioned responses to boredom and idle time is likely to be adequate while gambling habits could be replaced by alternative habits instead interestingly there were instances where the novelty of gambling actually wore off and the participants decided to progressively gamble less on their own due to an increasing sense of tedium with egms in fact a few participants reported that what used to appeal to them now annoyed them instead such as gambling venuerelated noises and lights this suggests that individuals in this problem gambling pathway may more readily experience natural recovery or have a higher chance of doing so than those who develop problem gambling via the other pathways due to an almost pure quality of gambling urges that underpinned the dormant pathway in the sense of gambling predominantly for the sake of gambling itself this group of participants appeared to likely benefit from strategies such as playing gamblingsimulation computer games instead of real egms in this way gambling urges could be fulfilled without real money being lost nevertheless where actual monetary rewards are deemed paramount where there is a need for gambling atmosphere the need to be out of the house or where emotional complications such as grief loneliness or depression are present this strategy is unlikely to be effective moreover due to existence of comorbidities these background conditions are likely to require addressing so as to not hinder gambling improvement andor accelerate pathway progression thus potential terminations of this pathway would depend on a variety of factors such as the nature of underlying gambling motivations and the types of comorbidities involved strengths and limitations because attribution of a problem gambling status was left to participant discretion a range of gambling experiences was encountered which enabled differences between nonproblematic recreational and problem gambling to be explored although issues such as denial and false claims may be common in the field of problem gambling the hows of meaning making are just as important as the whats of meanings produced the researchers therefore argue that any presence of inconsistencies between selfreported claims and presenting facts actually adds to the richness and complexity of the findings rather than compromise them moreover because both problem gamblers and regular but nonproblem gamblers were included in the study this allowed for factors identified as mediating moderating andor interrupting pathway progression to be extracted which adds to the uniqueness of the derived theory the proposed grounded theory on pathways to latelife problem gambling was developed in a manner that was able to fit the data gathered as such the theoretical propositions and pathways posited are likely to be most transferable to populations of similar presentations such as late gambling uptake and lateonset problem gambling among egm players of mostly anglosaxon background who reside in an area where gambling contexts are similar to australia nonetheless the proposed theory is flexible and should not be applied as a principle or fixed guideline instead the current propositions should help spark considerations for how societies and future social contexts may inadvertently create isolation and help promote ideas for how these can be prevented and minimized in this way vulnerable individuals can be protected from gamblingrelated adverse impacts before empirical evidence on further pathways can be established or become available the researchers therefore encourage creative application and transfer of the proposed knowledge in ways that can help capitalize on the usefulness of the current findings and enhance openness to how other extant knowledge in the field can be applied it should be noted that higher code densities are not synonymous with greater significance or influence care should therefore be taken to not assume that a construct with greater code density is a more important construct as salience does not mean impactful one should also be aware that neither the pathways that vulnerable individuals undergo may be as neat as presented in this study nor do individuals always remain in the same pathway or develop gambling problems from a single pathway indeed pathway crossovers are possible and the components of each pathway are fluid hence lack of substantial endorsements of constructs or its components does not necessarily mean less problem gambling risks are involved conclusion three main pathways to latelife problematic gambling have been identified all linked with a common theme of isolation a grief pathway associated with unresolved losses a habit pathway associated with habituation to gambling and a dormant pathway marked by preexisting behavioral excess or impulsivity it is important to note that overall unresolved losses andor mismanagement of lifes stresses were found to be the most significant predictors of latelife problematic gambling in order to explore this further rather than trying to find other categories and constructs that may be endorsed by a problem gambling sample future research might benefit more from obtaining the various combinations of potent relationships of constructs their subcomponents and their interrelated properties so that the most potentially damaging problem gambling pathways could first be interrupted because a grounded theory is developed from the data itself it can neither be destroyed by more evidence nor be deemed right or wrong rather more evidence would serve to modify it into an improved theory hence future studies of a similar topic will contribute to this foundation enriching it and extending the scope of its application and any subsequent divergence from the proposed theory and hypothesized pathways merely represent a more updated version of the current theory reflecting the dynamic nature of theoretical development

to develop a grounded theory on how older adults who may not have previously experienced gambling issues come to develop gambling problems in later life design and methods through semistructured indepth interviews with 31 adults aged 5685 routes that led the current sample of older adults to develop latelife gambling problems were identified and mapped into coherent pathways using a constructivist grounded theory methodology results three main pathways to latelife problematic gambling were identified all linked with a common theme of isolation a grief pathway associated with unresolved losses a habit pathway associated with habituation to gambling and a dormant pathway marked by preexisting behavioral excess or impulsivity overall unresolved losses andor mismanagement of lifes stresses were found to be the most significant predictors of latelife problematic gambling implications as latelife problem gambling appears to predominantly signify latelife emotional distress and an attempt to deal with this distress using gambling as an escape it is crucial for problem gambling prevention programs to raise awareness about the processes of loss and grief and provide ideas about constructive loss management in addition communitylevel recreational and social opportunities to combat isolation are identified

introduction understanding the bias in selfreported health and its determinants is of utmost importance because subjective data are often the only information at hand when researchers and policymakers ask healthrelated questions these data are readily available as their collection takes less time and is more costeffective than performancebased health measures however several studies show discrepancies between tested and selfreported health indicators 1 2 3 4 5 6 7 8 9 in a metaanalysis 1 find that correlation coefficients of tested and selfreported functional ability range from 072 to 060 thus subjective health measures are prone to bias assuming an underlying true but unobservable health status survey respondents will report a higher or lower level of health depending on their demographic characteristics overand underestimating health does not only harm the reliability of survey data but also individuals themselves the remainder of this paper is structured as follows the dataset is introduced in section 2 with a description of both the selfreported and performancebased variables utilised next the methods used are explained in section 3 sections 4 and 5 present our results which are discussed and compared with previous work in section 6 additional estimations along with robustness analyses are provided in s1 appendix data and variables the data analysed are provided by share a crosscountry panel study of noninstitutionalised individuals aged 50 and older who regularly live in one of the participating european countries 21 22 23 24 25 the survey was launched in 20042005 in 11 european countries with more countries joining in the followup waves resulting in 18 countries participating in 2015 in wave 6 share was reviewed and approved by the ethics committee of the university of mannheim and the ethics council of the max planck society 26 for our analysis we require pairs of tested and selfassessed health measures that can be matched directly share provides two such pairs namely for mobility and cognition since the performancebased test for mobility is conducted in wave 2 and wave 5 only we pool these waves to analyse selfreports of physical health 2728 wave 4 and wave 5 provide suitable data for the analysis of selfassessed cognitive health 29 in summary the analysis is based on pooled crosssectional data with 88087 observations from 17 different countries for mobility and 115785 observations from 17 different countries for cognition outcome variables we investigate the reporting behaviour in two health dimensions mobility and cognition by comparing the results of a performance test and its adequate selfreport the selfreports are requested prior to the respective performance test for mobility and cognition and thus the test results do not influence the subjective health measures we assume that the performance test and its selfreport cover the same health dimension therefore we are able to assess whether the two variables coincide after dichotomising them where necessary consequently three different combinations of objective and subjective health measures are possible for each survey participant in the study first respondents achieve concordance if they have the same outcome in both the performancetested and selfreported variable importantly we do not distinguish between positive agreements and negative agreement second respondents are considered to be overestimating their health if they report no impairment but are actually impaired according to the performance test third respondents are considered to be underestimating their health if they report impairments but show no impairment during the performance test mobility indicators performancebased mobility is measured by a chair stand test conducted in waves 2 and 5 while all individuals were asked to perform a chair stand test in wave 5 only individuals aged 75 years or younger were asked to do this test within wave 2 because greece ireland and poland only participated in wave 2 concordance of mobility measures can only be observed for the population aged 5075 in these three countries for the mobility performance task survey participants were asked to stand up from a chair without using their arms specifically the interviewer gave the instruction i would like you to fold your arms across your chest and sit so that your feet are on the floor then stand up keeping your arms folded across your chest like this following this introduction survey participants were asked whether they thought it would be safe to try standing up from a chair without using their arms everybody completing the performance test successfully is coded as unimpaired whereas individuals are considered impaired if they did not complete the test or if they thought it was unsafe to try in the first place moreover a small percentage of individuals used their arms to stand up from the chair this is also considered to be unimpaired we provide sensitivity analyses in which individuals who thought it was unsafe to perform are excluded from the analysis and a second set of sensitivity analyses in which individuals using their arms to stand up from the chair are considered as impaired the selfreported mobility measure is based on the survey question please tell me whether you have any difficulty doing each of the everyday activities exclude any difficulties that you expect to last less than three months among other everyday activities survey respondents could choose difficulties in getting up from a chair after sitting for long periods individuals are considered impaired if they reported having difficulties getting up from a chair cognition indicators cognition was addressed with a memory test in waves 4 to 6 because the selfreported memory item has more than 80 missing values in wave 6 this study only considers waves 4 and 5 selfreported memory is evaluated with the survey question how would you rate your memory at the present time which was answered on a likert scale with categories excellent very good good fair and poor every individual reporting fair or poor memory is considered impaired 30 the memory performance task reports the ability to immediately recall as many words as possible the interviewer reads aloud a list of 10 words and asks the survey participant to recall as many of the words as he or she can within 1 minute in any order in this study individuals are considered to be cognitively impaired if they recall only three words or less 3132 additionally in robustness analyses individuals are considered impaired if they recall only two or fewer words since the subjective memory question might refer to immediate and delayed memory we conduct an additional sensitivity analysis in which we operationalise objective cognition with delayed word recall determinants of concordance scientific studies on healthrelated questions as well as governmental health reports usually include separate analyses for one or more subpopulations the subpopulations that are most commonly compared are individuals from different countries different genders age groups and educational groups often these analyses are based on selfassessed health data which is crucial since these demographic characteristics are frequently identified in the literature as important factors of health misreporting 11131416173334 for example 14 showed that variations in selfassessed health between european countries would be much smaller if all countries had the same reporting behaviour these disparities are explained by cultural differences in reporting behaviour different perceptions of how restricting poor health is and compositional differences 11 it was also shown that older individuals often overestimate their health 35 possibly due to peer effects 36 some evidence suggests that women tend to underestimate their health 9 which could be related to them reporting limitations more frequently 37 38 39 however other studies find no effect of gender on reporting behaviour 15 finally evidence on educational attainment shows that highly educated older europeans are more likely to rate their health state negatively and that consequently health inequalities appear lower than they actually are 16 similar results were found for noneuropean countries 33 based on the observation that demographic characteristics are most commonly used for comparative health studies and that the same characteristics are associated with deviations in reporting behaviour this study focuses on the main demographic characteristics only in accordance with the international standard classification of education education levels are combined into three groups 40 the group of low education includes everyone with lower secondary education and less medium education refers to survey participants with upper secondary or postsecondary nontertiary education and tertiary education includes individuals with tertiary education age is operationalised as a categorical variable grouping 5year age groups only participants between the ages 50 and 94 are considered resulting in a total of nine age groups in addition to the main demographic characteristics other individual factors such as marital status parenthood or employment status might contribute to or mediate the effect of demographic characteristics on reporting behaviour for example employment status might impact health perception since persons working in analytical jobs experience their level of cognition regularly and persons conducting manual labour are likely aware of their mobility impairments the employment status of older europeans is highly correlated with their age since most individuals exit the labour force at a set retirement age thus parts of the effect of age on reporting behaviour might be due to differences in the employment status furthermore employment might also mediate the effect of education on health perception since highly educated individuals are more likely to work in jobs that require strong cognitive skills while results for such subordinate channels are not presented in the main document supplementary analyses including additional determinants are provided in s1 appendix methods we first investigate trends with descriptive statistics following this the relationship between demographic characteristics and the probability to overestimate or underestimate health is estimated finally a relative importance analysis highlights the magnitude of each explanatory variables contribution to the overall reporting bias the empirical strategy employed is based on a recent study by angel et al 41 who analysed the reporting bias in surveybased income data all of our analyses are first applied to indicators of mobility and then to indicators of cognition multinomial logistic regression a multinomial logit model is applied to estimate the effects of demographic characteristics on the probability to overestimate or underestimate health the characteristics of interest are gender age education and country of residence in addition we control for the survey wave to account for potential time effects the outcome variables used in the regression models are threecategory variables that indicate if an individual overestimates his or her health underestimates his or her health or achieves concordance between performancetested and selfreported indicators concordance is used as the reference category hence the log odds of the variables explaining overestimating and underestimating have to be interpreted relative to the outcome category of concordance more specifically the nonlinear baseline models are as follows ln pðy ¼ over à estimatingþ pðy ¼ concordanceþ � � ¼ b 10 þ b 11 country i þ b 12 age i þ b 13 educ i þ b 14 gender i þ b 15 wave i þ ε ið1þ ln pðy ¼ under à estimatingþ pðy ¼ concordanceþ � � ¼ b 20 þ b 21 country i þ b 22 age i þ b 23 educ i þ b 24 gender i þ b 25 wave i þ ε ið2þ country i is a dummy variable indicating the country of residence of each individual with the reference country being slovenia age i indicates the 5year age group of individual i with age group 6064 as the reference category the binary variable gender i is 1 if the survey participant is female educ i is a threecategory variable and medium education serves as the reference category wave i is a dummy variable indicating the respective survey wave when analysing mobility the reference category is wave 2 when analysing memory the reference category is wave 4 the standard errors are clustered at the individual level since respondents could participate in more than one wave first models 1 and 2 are estimated for the pooled sample including all countries then the models are estimated for each country separately to analyse how the effects vary by country in the countryspecific estimations the wave dummies are only included if the respective country participated in both waves relative importance analysis to analyse the contribution of individual characteristics to the overall bias in selfreported mobility and cognition relative importance analysis is conducted more specifically the fit statistics of the regression models are decomposed to evaluate how much of the variation in concordance overestimating and underestimating is explained by the regressors country i age i gender i educ i and wave i we utilise the userwritten programme domin for stata to calculate the relative contributions 4243 for this purpose different models with all possible combinations of the five explanatory variables except the constantonly model are estimated the fit statistic in our case a pseudo r 2 varies depending on the constellation of the regressors based on this variation the relative contribution of each explanatory variable can be computed importantly only explained variation can be decomposed hence only the contribution of variables actually included in the model can be quantified we calculate the relative importance of each explanatory variable in the pooled model as well as in the countryspecific models robustness analyses in addition to the main model specification described above we provide robustness analyses in s1 appendix to analyse if the results are sensitive to the definition of physical and cognitive impairment sample composition and model specifications first we control for additional variables to analyse the robustness of the estimated coefficients in particular we add employment status a dummy variable that indicates whether the survey participant has children and a dummy variable that indicates whether the individual is married or in a registered partnership to the models furthermore education is interacted with gender to determine if the effects of education vary with gender we also investigate whether learning effects influence the estimates that is when individuals had their mobility or memory tested in a previous wave they might be more likely to achieve concordance in a subsequent wave to control for a potential learning effect dummy variables are added to the model which indicate if an individual performed a test in any wave prior to the one investigated we also analyse whether the results are sensitive to the definition of mobility impairment in particular we investigate whether the results change when individuals that have to use their arms to stand up from a chair are considered impaired or when individuals that refuse standing up from a chair are dropped from the analysis we also investigate whether the results are robust to different thresholds defining memory impairment furthermore we use delayed word recall instead of immediate word recall to operationalise memory for a sensitivity analysis finally we investigate if the results are robust to different sample compositions first all frail individuals are excluded from the sample 4445 this allows us to account for the fact that frail individuals might be more likely to live in institutions in some countries than in other countries and consequently are not always included in our target population these differences in sample compositions could alter the results if poor health has an impact on reporting behaviour second we run the models on the exact same sample for both health dimensions for the main analysis wave 2 and wave 5 are utilised to estimate concordance of mobility measures and wave 4 and wave 5 are utilised to estimate concordance of cognition measures since we want to compare the results for concordance of mobility and cognition measures we also compute estimates based on wave 5 only which provides data for both health dimensions thus we ensure that differences between the two samples are not mistakenly interpreted as differences in reporting behaviour results on mobility descriptive results when asked about their mobility 192 of the survey participants report difficulties getting up from a chair after sitting for long periods however when tested only 172 are unable to stand up from a chair or considered it unsafe to try overall 804 of the survey participants show concordance between their reported and tested mobilities yet the outcome varies substantially by individual characteristics men are more likely to report their actual level of mobility than females mainly because women tend to more frequently underestimate their health interestingly 120 of all women rate their mobility lower than it actually is compared to 79 of all men concordance strongly declines with age in the 5054 age group 855 report their correct level of mobility but in the 9094 age group only 656 achieve concordance overestimating increases from 71 at ages 5054 to 247 at ages 9094 underestimating increases less steeply and not linearly from 74 to 97 there is also a clear education gradient in reporting behaviour highly educated individuals are more likely to achieve concordance than lesseducated individuals in addition the less educated more often overestimate their health whereas the highly educated more often underestimate their health finally concordance varies strongly between countries overall it is much higher in northern and western european countries than in southern european countries central and eastern european countries and ireland denmark has the highest average concordance of 877 and poland has the lowest with only 704 the variation in concordance may stem from differences in overestimating rather than underestimating as participants from southern and cee countries as well as ireland tend to strongly overestimate their mobility furthermore all southern countries are less likely to underestimate their ability to stand up from a chair regression analysis most findings from the descriptive analysis are confirmed by regression analyses for both the pooled sample with all countries as well as the countryspecific samples in regard to overestimating the gender effects are small and appear insignificant once we control for employment marriage or an interaction effect between education and gender as well as once participants that felt unsafe are excluded from the sample similar to the descriptive results the regression results indicate a clear education gradient in concordance lesseducated participants are 12 times more likely to overestimate their mobility and also 12 times more likely to underestimate their mobility compared to individuals in the medium education group on the contrary participants with a tertiary education have a lower tendency to both overestimate and underestimate mobility there is also an interaction between gender and education where lesseducated women in particular are prone to underestimating their ability to stand up from a chair similarly to age the education gradient in concordance appears less steep once employment is controlled for which supports the hypothesis that parts of the education effect are due to educational differences in employment fig 2 presents the rates of concordance overestimating and underestimating by country overall there is a tendency for higher concordance in western and northern european countries by contrast individuals in southern european countries cee countries and ireland are less likely to achieve concordance mainly because they tend to more often overestimate their mobility the tendency to underestimate mobility is more evenly distributed among countries yet there are still differences for example southern europeans underestimate their health less often finally the coefficient for the survey waves indicates that survey participants are less likely to overestimate their mobility in 2013 compared to 20062007 the coefficient decreases after controlling for potential learning effects but still remains significant this could be due to cohort effects but it is not possible to disentangle cohort effects from period effects using the present dataset a second explanation for the significant time effects could be that some countries changed their interview procedure between the two survey waves when estimating models 1 and 2 for the countryspecific samples the results from the pooled model are confirmed however standard errors are larger due to the smaller sample sizes leading to less significant results the output tables for the countryspecific estimations can be provided upon request furthermore the results are robust to different specifications of impaired mobility as well as to different sample compositions survey wave the estimates of time effects for these countries are not provided for the majority of the countries age is the single most important characteristic explaining the bias of selfreported health depending on the country either education or gender comes second the contribution of time effects is negligible in most countries except for france germany and italy as discussed earlier these time effects could be due to unobserved cohort effects or because these countries changed their interview process between wave 2 and wave 5 results on cognition descriptive results when asked about their memory 294 of all survey participants report cognitive impairment yet when tested only 161 recall three words or less overall 718 of the participants show concordance between their reported and tested memories but there is no clear difference between genders except for a slight tendency for men to overestimate and for women to underestimate their cognition concordance between mobility and cognition measures is highly related according to chisquared tests individuals that are prone to overestimate one dimension are also more likely overestimate the other the same holds for underestimating and concordance similar to mobility there is a strong decline in concordance with age while 806 of the 5054 age group report their correct level of memory only 639 of the 9094 age group achieve concordance misreporting is even more pronounced at ages 8084 in which 614 show divergence between tested and selfreported measures unlike mobility it is not clear from the numbers whether the decrease in concordance with age is due to an increase in overestimating or underestimating while the tendency to overestimate cognition increases steadily with age underestimating is highest at ages 7579 and decreases thereafter there is a pronounced education gradient in the concordance between tested and selfreported cognition where again western and northern countries have lower discrepancies switzerland has the highest rate of concordance and estonia has the lowest however the division is not as clear as for mobility mainly because sweden has a relatively low rate of concordance similar to that of slovenia and czechia regression analysis regression analyses also show concordance decreasing strongly with age individuals aged 8084 are three times as likely to overestimate their memory than the reference group of 60to 64yearolds the oldest individuals aged 9094 are 37 times as likely to overestimate their cognitive ability similar to mobility the probability to underestimate memory increases up to ages 7579 but slightly decreases again for the oldest individuals based on the country specific samples s2 fig provides the values of concordance by country and age contrary to mobility the strong age gradient in concordance does not change once employment is controlled for the effect of education on concordance is even stronger for cognition than it is for mobility lesseducated participants are 19 times more likely to overestimate their memory and 13 times more likely to underestimate their memory tertiary education is associated with a lower probability to both overestimate and underestimate cognition these results remain robust even after controlling for employment contrary to mobility women are less likely to overestimate their memory than men however females are slightly more likely to underestimate their cognition in the pooled model in the countryspecific estimations this finding holds for belgium estonia france italy portugal and spain however in austria denmark and the netherlands women are less likely to underestimate their memory the gender differences increase when memory impairment is based on delayed word recall which indicates that women and men either interpret the subjective memory question differently or relationship between immediate and delayed word recall differs between genders concordance between tested and selfreported cognition differs among the countries observed again southern european and cee countries have lower rates of concordance than western and northern european countries two exceptions are czech republic which achieves a relatively high rate of concordance and sweden which achieves a medium level of concordance as with mobility the tendency to overestimate cognitive ability is much greater in southern and cee countries interestingly participants of wave 5 are less likely to overestimate and instead more likely to underestimate this finding does not change when additionally controlling for a potential learning effect as with mobility this could indicate a cohort andor time effect or differences in the interview procedure over time both of which the available data cannot account for finally all results are robust to changes in the threshold of cognitive impairment to differences in the sample composition as well as to different model specifications relative importance analysis the bias in selfreported cognition is mainly due to differences in reporting behaviour by country which explain 449 per cent in the pooled model differences by age group contribute 297 per cent to the explained variation education is much more relevant in explaining the reporting bias in selfreported cognition than it is for measures of mobility variations in reporting behaviour by gender and survey wave are even less important for selfreported memory than they are for selfreported mobility this finding holds also when estimates are based on wave 5 only fig 5 shows country specific decompositions of the fit statistic age is still very relevant for explaining the reporting bias in cognition measures yet education is just as important in some countries on the contrary gender and wave are neglectable when it comes to explaining the reporting bias two exceptions are estonia and austria where the survey wave seems to contribute to the explained variance similar to the results on mobility these exceptions could either be due to cohort effects or because interviews were conducted differently in wave 4 and wave5 discussion in this study on older europeans we investigate the discrepancy between tested and selfreported health measures and explore which demographic characteristics are most important in explaining health misreporting in particular we focus on the demographic characteristics most frequently used for health comparisons namely country of residence gender age and educational attainment furthermore we investigate subordinate channels that might explain or mediate the effect of demographic characteristics on reporting behaviour particularly employment status parenthood and marital status conducting a relative importance analysis we find that differences in reporting style between countries and age groups explain most of the bias in selfreported health these findings suggest that comparisons of health between countries and age groups based on subjective data have to be treated particularly careful in addition for selfreported cognition specifically misreporting varies substantially between educational groups parts of the strong age and education effects on reporting style can be explained by differences in employment by age and education parenthood and being married however add little to the bias sensitivity analyses show that the results are robust to changes in the definition of physical and cognitive impairment sample composition and model specifications concordance as well as the tendency to overestimate and underestimate health vary strongly across europe results from the relative importance analyses show that 35 of the reporting bias in mobility and 45 of the bias in memory are due to differences in reporting behaviour between countries overall northern and western european countries have fewer discrepancies than cee or southern european countries southern europeans seem particularly prone to overestimating their health which is contrary to the results of 14 who finds that scandinavians overrate their health the most previous studies also identified country differences in reporting style for european countries 144647 lowand middleincome countries 4 as well as within countries and across subpopulations 5 it was shown that selfreports are influenced by culturespecific reporting behaviour compositional differences between countries and differences in the perception of how restricting poor health is 11 in addition the strong country effects could also be due to different health care policies for instance the proportion of elderly persons in residential care varies across europe thus frail persons might be sampled differently across countries if frailty affects response behaviour different shares of frail individuals in the country samples could explain differences in aggregated concordance we controlled for this possibility by excluding all frail individuals from the analysis yet the results remained robust speculatively the betweencountry discrepancies could also be due to differences in regional development for a subset of our country sample early results on the relationship between a regional developmental index 48 and discrepancies in mobility suggest that countries with better living conditions show more concordance than their counterparts however further research with data on the whole lifecycle is needed to investigate the potential development effect properly in addition to the cultural bias in selfreported data we find a strong decrease in concordance with age for both health dimensions this result is in accordance with earlier research on several physical performance measures 6 7 8 further previous research supports our finding that subjective health measures of older individuals are often upward biased 35 one explanation could be that octogenarians and nonagenarians tend to compare their health status with peers suffering from worse health which enables them to maintain a positive perception of their own health state 36 this so called downward comparison makes older persons feel more satisfied with their lives especially when they are frail themselves 49 resilience strategies like these help individuals to flexibly adapt to changes of their physical and cognitive health while maintaining a positive selfimage 50 overall the agerelated decline in concordance between performance based and perceived memory measures is robust to controlling for employment however concordance between mobility measures declines less steeply with age once the employment status is considered this indicates that a part of the strong age effect is due to variation in the share of employed persons across age groups the causal direction however remains unclear it could either be that employed individuals are more aware of their physical ability or that persons that are more aware of their own health status are more likely to be employed thus future studies could fruitfully explore the interrelations between health perception age and employment we also identify a clear education gradient in concordance for mobility and an even stronger effect for cognition lesseducated individuals tend to misreport their mobility and memory more frequently whereas the highly educated are less likely to misreport previous research does not provide conclusive results on this matter some studies report that higher education results in a more optimistic view on health 8 while others find the exact opposite 335152 or no significant education effect at all 5354 overall our results on education can be interpreted as additional evidence for the phenomenon that higher educated individuals have higher health awareness and literacy 5556 for example higher educated are more familiar with the risks of tobacco smoking 57 less likely to misjudge their weight 58 and as shown in this study also less likely to have a biased view on their physical and cognitive abilities since health literacy is an important determinant of health behaviour and consequently health itself 59 60 61 enhancing health literacy of low educated individuals could improve their health outcomes it may also be hypothesised that the gender gap in the education of older europeans contributes to differences in misreporting on average men at advanced age are higher educated than women within our investigated cohorts what supports this hypothesis is our finding that lesseducated women are particularly prone to underestimate their mobility in addition employment status at higher ages varies by gender and education with higher educated being more likely to work longer 62 our robustness analyses showed that the education gradient in concordance appears less pronounced for mobility once employment is accounted for but interestingly does not change for cognition the educational differences in cognition only changed when delayed word recall is used and education is less important to explain the differences we also find differences in reporting behaviour between men and women but they are less pronounced and explain very little of the overall reporting bias in particular women tend to underestimate their health more frequently in both health dimensions one explanation for these gender differences might be the tendency of women to report limitations more frequently 37 38 39 while men tend to underreport their health status 63 recent research also showed that reporting morbidity was more legitimate in femaledominated work environments indicating an association of gender norms with gender difference in reporting behaviour 39 this might also be related to women looking for medical advice more often than men 6465 interestingly our findings on overestimating health vary by health dimension with women being less likely to overestimate their memory than men but being more likely to overestimate their mobility moreover difference between genders increases when delayed word recall is instead of immediate word recall which indicates that women and men might interpret the subjective memory question differently our small and sometimes ambiguous gender effects are in line with the literature which does not provide conclusive results either while some studies comparing selfassessed and clinical data find clear evidence that women are more likely to overestimate their health 66 others identify women to be more likely to underestimate their health 6768 a recent study based on share data found no clear genderspecific pattern in reporting behaviour 15 in general our results not only give guidance on how to carefully interpret selfreported health measures but might also contribute to a reduction in adverse health outcomes due to mistaken selfassessments for instance overestimating lower body functioning might contribute to higher risks of fallinduced injuries 10 further overestimating cognitive abilities might result in illusory selfawareness of everyday functioning 69 in psychology the consequences of wrong selfawareness of cognitive abilities are discussed as the dunningkruger effect which states that unable individuals are especially prone to overestimate their abilities 7071 if the tendency to overestimate ones physical and cognitive capacity has an adverse impact on healthrelated behaviour of older europeans then awareness should be created in particular among the oldest old among men and among southern europeans a major contribution to the literature is that we are able to compare reporting behaviour of mobility and cognition simultaneously the results show that concordance of the two health dimensions is highly related individuals that are prone to misreport one dimension are also more likely to misreport the other this indicates that correlations between the two health dimensions are to a certain degree due to similarities in reporting behaviour however we also find differences in the reporting styles of subjective physical and cognitive health for instance concordance is slightly higher between mobility measures than between memory measures furthermore the composition of the bias in selfreports differs between the two health dimensions the cultural bias in subjective data ie differences across countries is more relevant for cognition than for mobility additionally reporting heterogeneities between education groups result in larger biases in selfreported memory than in selfreported mobility gender however explains relatively little of the bias in both health dimensions controlling for wave effects shows that participants in wave 5 are less likely to overestimate their mobility as well as their cognition even after controlling for potential learning effects these findings indicate that cohort or time effects influence the reporting style which is crucial since the analysis of mobility and memory are based on different waves to ensure that the differences in reporting style of physical and cognitive health do not stem from differences in the sample composition we conducted a robustness analysis for which we restricted our analysis to wave 5 which is the only wave that provides relevant data for mobility and memory tables h and i in s1 appendix show that the overall findings remain even after both health dimensions are analysed based on the same subsample the main limitations of this study are threefold first the population composition is likely to vary across countries we conducted robustness analyses for different sample shares of frail individuals but additional deviations in the sample composition could also influence the results second the questionnaire is conducted in the national language which could result in some bias when it comes to selfassessed health because the wording differs across languages third it appears that some of the effects are influenced by time or cohort effects however disentangling these effects is not feasible with the data at hands in conclusion selfreported measures of mobility and cognition have to be treated cautiously in particular when comparing health across countries and age groups in addition the education gradient in concordance needs to be considered when analysing memory finally men and women show different reporting behaviours yet the impact of gender on the overall bias between tested and selfreported health is less pronounced than that of other demographic characteristics the data underlying the results presented in the study are available from the survey of health ageing and retirement in europe in particular wave 2 wave 4 and wave 5 are utilised data curation sonja spitzer formal analysis sonja spitzer methodology sonja spitzer daniela weber validation daniela weber visualization sonja spitzer daniela weber writing original draft sonja spitzer writing review editing daniela weber

this paper explores which demographic characteristics substantially bias selfreported physical and cognitive health status of older europeans the analysis utilises microdata for 19 european countries from the survey of health ageing and retirement in europe to compare performancetested outcomes of mobility and memory with their selfreported equivalents relative importance analysis based on multinomial logistic regressions shows that the bias in selfreported health is mostly due to reporting heterogeneities between countries and age groups whereas gender contributes little to the discrepancy concordance of mobility and cognition measures is highly related however differences in reporting behaviour due to education and cultural background have a larger impact on selfassessed memory than on selfassessed mobility southern as well as central and eastern europeans are much more likely to misreport their physical and cognitive abilities than northern and western europeans overall our results suggest that comparisons of selfreported health between countries and age groups are prone to significant biases whereas comparisons between genders are credible for most european countries these findings are crucial given that selfassessed data are often the only information available to researchers and policymakers when asking healthrelated questions

introduction primary and secondary care services are under increasing pressure to meet the needs of over 15 million people in england who live with a longterm condition longterm conditions are chronic health conditions such as coronary heart disease or diabetes which are presently incurable and managed by medication and other therapies the notion of selfmanagement has become central to addressing the growing burden of longterm conditions moving the daytoday responsibility of managing health from the state to the individual families and social groups the needs of people living with longterm conditions are often associated with increased social isolation impacting on their physical and psychological wellbeing social functioning and their ability to selfmanage responding to psychosocial problems is often beyond the capacity of health professionals whose support for patients focuses on diagnosis and health advice because of these limitations health services struggle to effectively assist patients with psychosocial problems and the challenge of incorporating longterm condition management activities into their contemporary everyday lives although recognition of psychological and social dimensions of longterm condition management is well documented it has remained on the periphery of health interventions one possible means of addressing the gap between the demands of patients and the ability of traditional health services to deliver appropriate holistic support would be to engage with the voluntary and community sector where many healthrelated services such as exercise classes and support groups are provided furthermore socially disadvantaged groups suffer disproportionately from chronic conditions such as diabetes and heart disease but are often unable to make the most of available health provisions barriers people face are associated with access language cultural appropriateness transportation finance and health literacy to overcome these barriers it has been suggested that community settings may be a more appropriate setting for health support for instance community health workers and peer supporters have been used to improve chronic disease care and health outcomes however it is unfeasible for health professionals to keep up to date and to identify appropriate communitybased resources for patients within the time constraints of a consultation community and voluntary groups therefore often work in parallel without explicit links with primary care social interventions which facilitate access from health services to appropriate communitybased resources have potential for longer term health benefits for instance social prescribing is an approach which has gained momentum over recent years and is defined as enabling primary care services to refer patients with social emotional or practical needs to a range of local nonclinical services accessing a broad range of communitybased services is increasingly identified as having the potential to address the limited onesizefitsall approach to longterm condition management this review focuses on identifying key components and benefits of social interventions including social prescribing schemes which facilitate access from healthcare settings to a range of communitybased resources for patients and service users to improve their health and wellbeing methods this review identified the literature on social interventions which link participants from healthcare services to a range of communitybased resources to date the literature on interventions of this nature is scarce and not conducive to systematic reviews to examine the extent range and nature of research activity in this area scoping reviews are more suitable as they incorporate both published and grey literature to guide our review process we adopted arksey omalley methodological framework for conducting scoping studies the framework suggests five stages within the review process identifying the research question where the authors identify all aspects of the research area ie population intervention or outcomes that is most important to the review they then iteratively focus and redefine the research question as they became more familiar with the existing literature identifying relevant studies using a comprehensive strategy involving different sources to identify and thoroughly map existing primary studies and reviews relevant to the research question study selection whereby authors develop a mechanism to screen and eliminate studies from the search results that do not address the central research question charting the data which involves extracting and sorting information from individual studies according to key issues and themes collating summarising and reporting results to present an overview of all material reviewed the flexible and reflexive nature of the five stages enabled this review to achieve a broad range of results using studies with various designs and quality stage 1 identifying the research question for this review a social intervention was defined as an intervention whose primary aim is to improve health andor wellbeing by facilitating contact with other people groups and community organisation the review therefore focused on the linking mechanisms of social interventions which facilitate access to a range of communitybased resources research question and objective what are the types and benefits of linking mechanisms adopted by social interventions to support people in healthcare settings access wider communitybased resources in addressing the above question the review aimed to consider the following objectives 1 to identify key components of social interventions linking participants from healthcare settings to community groups and services 2 to identify facilitators and barriers to delivering an intervention of this nature 3 to identify key benefits provided to participants in relation to their health and wellbeing stage 2 identifying relevant studies the literature search was initially conducted between february and september 2011 because of problems with resources the review took longer than expected to complete and a second literature search was conducted between may and june 2013 to ensure that the papers included were up to date on both occasions the researchers used the following databases ovid medline embase sciencedirect cinahl and springerlink further studies were identified by searching reference lists of all articles and systematic reviews considered relevant and hand searching the following journals social science and medicine and chronic illness grey literature was identified using the internet search engine google a pilot scoping exercise of peer models of support and community interventions for selfmanagement identified 11887 papers through discussions with coauthors the review was refined to focus on community interventions where individuals are linked from healthcare settings to a range of community resources this was termed as either social intervention or social prescribing yielding an initial 959 papers specified search terms were used to search all databases during the initial search in 2011 while a slightly broader search strategy was adopted when updating the literature search in 2013 to ensure that any potentially relevant studies were not excluded stage 3 study selection titles and abstracts of 2695 identified studies were assessed for relevance and full text copies of 43 studies were obtained rm and rlm applied the inclusion and exclusion criteria to their reading of titles abstracts and full texts of papers eligibility criteria all studies in which participants were referred from a health and social care setting to an intervention that aimed to support them in accessing a range of communitybased resources were eligible electronic journals were searched from their commencement to the present date for literature published in any country written in english no restrictions were placed on study design or type of longterm health condition after removal of duplicates and studies found to be irrelevant a total of four peerreviewed articles and three reports were included stage 4 charting the data data were extracted and charted using microsoft excel spread sheet by rlm recorded information consisted of named authors year and country of publication target population inclusion and exclusion criteria description of intervention outcome measures and its principle findings the data extraction plan also included reported barriers and facilitators to delivering the intervention while further ideas and themes such as the role of the health professionals and intervention facilitators emerged in the course of our familiarity with the literature stage 5 collating summarising and reporting results the findings are presented in two ways first a tabulation of information regarding study population and intervention delivery and outcomes second key themes that emerged from the narrative accounts within the literature were used as subheadings results overview of results a total of 2738 papers were identified through initial search of journal databases and grey literature full texts of 43 papers were retrieved and screened and the findings from seven of these papers were included in the review three of the seven papers present findings from randomised controlled trials two populationfocused interventions and the other a referrals facilitator intervention within primary care three papers provide evaluations of interventions one which is a cohort study and the other two are reports of social prescribing schemes one other paper discusses findings from an action research project aimed to develop a business case to seek further funding for a local social prescribing service information extracted charted and reported from the papers relates to intervention population intervention delivery health outcomes social outcomes impact on health services facilitators and barriers and costeffectiveness target population the interventions target a variety of different populations and conditions including mental health social isolation in the elderly people and frequent service users in general practices brandling and house found that for patients who had three or more hospital referrals in the last 12 months the strongest indicators for suitability for social prescribing were poor social support mechanisms psychological difficulties and vague or unexplained symptoms another study reported that most patients referred to the social prescribing health trainers had a mental health issue followed by lifestyle issues and social isolation in the evaluation report of the social prescribing scheme called the community health advice team social isolation was also the most common reason for referral intervention delivery participants were recruited from general practices and social care services referrals to the linking scheme were made by a variety of health and social care professionals in one study social workershome help assistants visited and interviewed participants and organised the intervention while referrers in other interventions were usually general practitioners providing less input in regard to its delivery selfreferral was encouraged in combination with referral from a health professional in two interventions clarke et al recruited participants to their intervention using the findings from a survey of elderly patients from 12 general practices without the involvement of a health professional all of the interventions except one were facilitatorled identification of appropriate community resources and ways to engage in the local community took place through group discussions by participants in the ageing and loneliness project clarke et al used lay community workers situated in the community as opposed to a healthcare setting the remaining five interventions used facilitators whose role was specifically developed as part of the intervention graduate primary care mental health workers sphts the chat workers and amalthea project facilitators tools used to link intervention participants to community groups and organisations are only reported by one study the gpcmhws used directories telephone enquiries and other sources to identify appropriate services for patients grant et al describe the amalthea project as having been funded by the nhs to collect information about the voluntary sector which was used to refer patients to local and national voluntary organisations however details of how the information was collected organised and used to map patients needs to voluntary organisations were not provided similarly white et al and woodall and south describe the role of the facilitators as continually keeping up to date with all the activities and services in the local community but do not provide any description of the processes involved and the format in which the information was collected and utilised two papers report the proportion of participants referred to other organisations and services sphts signposted 51 of patients to other organisations including literacy courses at colleges volunteering and community allotments line dancing and citizen advice bureau the gpcmhws from the community link scheme are reported to have signposted 88 of their patients to community services in the amalthea project 97 of participants were reported to have received an initial assessment and 80 further contact and signposted to one or more community organisations however the exact numbers utilising community and voluntary groups were not reported in the rct conducted by clarke et al only 101 participants out of 260 randomised into the intervention arm received support but there were no details of the groups and services they were referred to only one paper reported the number of participants continuing to access organisations they were referred to by the intervention grayer et al reported that nearly twothirds of the 58 of participants who accessed at least one service were still attending a 3month followup overall it was unclear as to the extent to which participants in these interventions had found the communitybased resources they were referred to relevant to their needs grayer et al reported client satisfaction to be moderate among intervention participants at the 3 month followup with satisfaction being higher among participants who contacted services they were referred to than those who did not the service evaluations of the two social prescribing schemes alluded to qualitative findings of participant satisfaction which varied from very positive to quite mixed perceptions of the appropriateness of communitybased resources individual were referred to health outcomes two studies reported reduction in either depression psychological distress or probable mental health problems grant et al reported that improvements in depression measured by the hospital anxiety and depression scale were not significantly different between the intervention and the control groups however as anxiety and stress were the most common reasons for referral to the project the intervention focused primarily on addressing these issues rather than on depression they therefore reported a significantly greater reduction in symptoms of anxiety in the intervention group than in the control group grayer et al reported that fourfifths of patients were cases with 2 scores for mental or emotional distress on the general health questionnaire12 at baseline which was reduced to half postintervention three studies reported changes in the number of medications taken by patients patients reported a reduction in the number of medications they were taking particularly antidepressants as a result of seeing a spht because they felt more confident in dealing with social issues grayer et al also found a reduction of 158 in the proportion of patients taking psychotropic medication who were supported by the gpcmhws according to their medical records the intervention patients in the amalthea project however were found to have received more prescriptions for all drugs particularly mental health drugs while the primary focus of all studies addressed psychosocial problems three studies reported measuring physical health status for instance a majority of the patients in one study decided to focus on their mental health and wellbeing and very little is reported on changes to patients physical health status clarke et al reported no statistically significant difference in mortality and changes in physical status measured by the activities of daily living index at 2 years however a significantly greater proportion of intervention participants perceived their health status to have improved compared to control participants grant et al also reported a number of physical health outcomes in their trial using the coop wonca functional health assessment chart they reported greater improvement in pain feeling daily activities change in health and overall health in the intervention group than in the control group however statistical significance was not found for improvement in physical fitness on the assessment chart social outcomes reduction in social isolation and feelings of loneliness were reported by four studies andersson found a statistically significant improvement in the frequency of social contacts and number of leisure activities in the intervention group participants loneliness using the wenger loneliness scale and frequency of social contacts were also measured by clarke et al although neither measure of loneliness was statistically significant the median minimum and maximum social contact scores for the intervention group increased compared to the control group the dukeunc functional social support scale used by grant et al found no beneficial effect on intervention patients perceived social support grayer et al recorded 287 of their referrals to be socially isolated but did not monitor changes to social isolation postintervention furthermore white et al reported that some participants took up volunteering in the community as a result of participating in the intervention this was a socially significant outcome for a substantial proportion of their participants who were either unemployed or longterm sickdisabled similarly 74 of referrals to the community link service were unemployed and the intervention improved patients work and social adjustment scores from 2563 at baseline to 2194 at the 3 month followup increased social support companionship courage motivation and awareness of local services were also identified as key achievements of interventions in the qualitative findings of studies exploring participants experiences impact on contact with health services the impact of interventions on health service use was variable grayer et al reported a significant reduction in the recorded number of patient appointments with gps and other practice staff mean number of consultations with a psychosocial aspect and proportion of patients with prescriptions for psychotropic medicine at 3 months postintervention in the studies by white et al and woodall and south patients and practice staffs reported a reduction in primary care attendance particularly from high consulters and a decrease in social issues brought up in consultations grant et al however reported equal numbers of primary care contacts for control and intervention arms while grant et al reported fewer referrals of intervention patients to other services including mental health services grayer et al observed a significant increase in referrals to mental health services in the intervention group from 8 to almost 20 the authors suggested that this increase was suggestive of an improvement in the detection and treatment of mental health in primary care as a result of the intervention similarly the role of sphts was woven into an existing stepped care system allowing referral between the scheme and other services within the mental healthcare pathway clarke et al reported that contact with gps remained the same but highlighted a slight increase in patients use of district nurses home helps and home delivery of meals which they related to changes in the provision of health and social services and the wider socioeconomic environment beyond the control of their study facilitators to implementing social interventions in six of the seven studies it was a health or social care professional including gps social workers and practice nurses who screened patients for suitability before referring them to the intervention for further assessment the only study in which patients were recruited through direct contact by intervention staff reported a much higher percentage of participants refusing to take part in the intervention all papers discussed the role of the facilitator and the relationships they established with participants key characteristics of facilitators identified in the studies were skills in tailoring activities to the needs and preferences of participants and the ability to encourage attendance and flexibility in their approach engagement of participants was achieved by the relationship facilitators developed with them through being flexible trustworthy empathetic and accessible home visits to participants unable to attend appointments and accompanying participants to community organisations was an example of the flexibility demonstrated by sphts and chat workers in the social prescribing schemes the sphts were purported to be skilled in communicating with the public empowering people to come up with their own solutions to problems and providing personalised care developing relationships with both clinicians and voluntary and community groups was also considered an important responsibility for the facilitators to develop the profile of the intervention the single point of contact provided by facilitators based within the general practice was reported by healthcare staff as making the referral process easy and straightforward the physical placement of facilitators was important in ensuring effective engagement of healthcare staff as staff at the general practice hosting the chat social prescribing scheme felt reassured that confidential information did not leave the practice upon referral of patients to the scheme adequately staffed interventions based within healthcare settings enabled facilitators in both the amalthea project and chat social prescribing scheme to see patients within 7 days of referral barriers to implementing social interventions barriers to the implementation of social interventions included ambiguity of facilitator role when based in gp surgeries inappropriate referrals to the services clinicians apprehensions about referring to voluntary organisations and the sustainability of services playing a dual role sphts expressed conflicting pressure of integrating with the practice team and also continually engaging and keeping up to date with community groups and activities similarly some sphts did not feel fully accommodated by primary care services in terms of provision of reasonable physical space and clinical supervision also while one study reported reservations on the part of gps in referring their patients to the intervention another reported inappropriate referrals of patients with very severe mental health problems to the social prescribing scheme grayer et al reported that 21 of 255 referrals made to gpcmhw were inappropriate with half of these referrals requiring specialist service the referral process was briefly addressed by brandling and house who found two out of three practices unable to identify frequent attendees using their practice computer system to determine patients suitability for social prescribing although two of the studies provide encouraging evidence of efficiently responding to patients the gpcmhws saw patients after a mean waiting time of 2218 days postreferral the sphts had so many referrals there was an 8week waiting list at one practice while referrals were temporarily halted at another engagement and retention of participants proved a challenge in some of the studies clarke et al reported that over 50 of participants in the intervention arm either refused died or moved away before taking part similarly dropout rates of intervention participants were at 35 and 41 in the studies by grayer et al and andersson respectively however all patients in the intervention arm of the amalthea project attended baseline assessment and only 18 dropped out in the first month of receiving support clarke et al explained that participants who refused the intervention were among those who were physically most independent and perhaps perceived the intervention as irrelevant to their needs a smaller proportion of participants who either moved away or died were on the other hand highly dependent due to the severity of their illness and were already in contact with many services dropout rates in the two studies targeting the elderly population were relatively higher than those targeting a younger population with a mean age between 40 and 50 years the elderly population targeted by clarke et al and andersson were less inclined to make lifestyle adjustments unless it was directly warranted by declining health but were also often too restricted by illhealth to take part in activities outside the home the rate of withdrawal in the study by grayer et al was higher than that in the study by grant et al although they both targeted a similar patient population in terms of age gender and clinical and social problems possible explanations for this are that patients referred to the gpcmhw service had a mean waiting time of nearly 23 days before their initial appointment compared to a maximum of 7 days in the amalthea project other patientreported barriers included transport literacy confidentiality and disclosure in voluntary groups and also appropriateness availability and accessibility of the activities costeffectiveness one study measured the costeffectiveness of the project in this project they used a liaison organisation called the amalthea project to facilitate contact between patients in primary care with psychosocial problems and voluntary organisations the mean cost of the intervention arm was significantly greater than the normal gp care but there were also significantly greater improvements in levels of anxiety ability to carry out everyday activities other emotional feelings feelings about general health and quality of life discussion having used the scoping review framework this review included seven papers representing both peerreviewed and grey literature on social interventions which aimed to link participants from health and social care settings to communitybased resources to improve their health and wellbeing the findings highlight important aspects pertaining to the design and delivery of these interventions as well as patientand servicelevel benefits gained social interventions which propose to link participants from healthcare settings to communitybased resources are also known as social prescribing the interventions included in this review were all developed on the premise that tailored access from health services to wider communitybased resources has the potential to address peoples psychosocial problems the interventions therefore generally targeted participants experiencing agerelated loneliness general anxiety and depression a key theme which emerged from this review was that in almost all the papers it was found that health professionals played an important role in referring patients to the interventions and in introducing the notion of utilising community groups with aspects of health management perhaps because of familiarity with the health professional and because the referral was likely to have been made within the context of regular care this notion was legitimised from the patients perspective proximity to health professionals was therefore considered important for facilitators to develop and maintain an effective relationship with health professionals to achieve successful referrals the review highlights the pivotal role played by the facilitators in delivering the intervention facilitators were trained to screen and assess participants needs and accordingly refer and often accompany them to wider communitybased resources facilitators also needed to develop and maintain relationships with health professionals as well as community and voluntary groups conducting assessments with participants ensured that discussions and identification of community resources were tailored to participants needs and interests thus along with offering information about local groups and services one intervention provided participants the opportunity to develop personal action plans supporting participants to find solutions to their problems was an important component of the facilitation process and enhanced the uptake of activities as the focus of all the interventions in this review was to address psychosocial issues the impact of interventions on participants was measured and reported in terms of psychological and social outcomes the most positive findings from the interventions were reduction in social isolation and increased social engagement for participants such interventions therefore have the potential to counteract the negative impact of longterm conditions on peoples social lives in terms of health benefits there is evidence of a reduction in psychological problems reported as psychological distress mental health problems or anxiety many of the interventions reported positive impacts on patients use of medication and health services little attention was given to participants physical health and there was mixed evidence about the effectiveness of the interventions on improving physical health status it would have been interesting to know whether psychosocial benefits experienced by participants from engaging in communitybased activities cascaded to have a similar impact on their physical health moreover according to one study potential participants physical health can also determine their decision about whether or not to participate in the intervention in the first place but as all the studies did not report on physical health status it is difficult to draw any conclusions in addition the evaluations of interventions only measured shortterm health impact as social prescribing adopts a holistic approach to health and wellbeing a longer followup period for the evaluation of healthrelated outcomes may have alluded to more positive longterm benefits associated with community participation strengths and limitations one strength of this review was the use of the scoping review methodology that enabled a review of a wide range of both peerreviewed and grey literature the iterative thematic analysis of the literature used to identify key components in the delivery of the interventions also further strengthens the review a limitation of this review was the heterogeneity of the interventions and populations within the literature there were also very few peerreviewed papers that examined social interventions that aimed to link people from primary care to communitybased resources similarly two of the seven articles included in the review are comparatively old while one is based outside the united kingdom however as this review focuses on the linking mechanisms of social interventions the authors concluded that both these studies were relevant to the review despite their age and country in which they are based furthermore they shared many similarities with social prescribing schemes such as targeting socially isolated people with the aim of engaging them in their respective communities to improve their health and wellbeing finally the articles included in the review did not differentiate between the impacts of different types of communitybased resources participants were referred to conclusion drawing on resources within the voluntary and community sector is a potentially valuable way to support people with longterm health problems and has long been considered as a way to tackle health inequalities the normality of participating in local activities and its associations with everyday life offers a potentially sustainable way for people to manage their health needs and reduce health service utilisation however it became apparent in the course of this review that very few social interventions like social prescribing schemes have been empirically evaluated they were mainly identified through a grey literature search a number of empirical studies were found on either arts on prescription or exercise on prescription but these programmes did not connect participants to a range of groups which have been identified as a way to address the limits of current selfmanagement support furthermore of the four empirical studies only two were of interventions assessed by a rct suggesting a limited evidence base for interventions of this nature nonetheless from the available evidence this review shows some promising results which are worthy of further investigation in particular there appears to be some credible psychosocial benefits for patients with mental health problems who are referred to community activities the review also highlights the linking mechanisms inherent in such social interventions this could be used to inform further work for service providers who wish to take this approach to support people with longterm health problems

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introduction interstate conflicts usually start with a declaration of war and end with surrender negotiation or an armistice between the belligerents by contrast many modern conflicts are seemingly intractable this trend is particularly evident in the sahelsahara region in north and west africa a battleground for islamists seeking to impose sharia rebels seeking independence transnational traffickers and former colonial powers looking to project influence while many sahelsaharan countries oscillate between periods of rebellion and political unrest and periods of peace and reconciliation the actual location and onset of violence defy prediction long considered a posterchild of political stability mali for example faced a military coup a rebellion a western military intervention and several major terrorist attacksall in less than 2 years by contrast chad plagued by civil war and rebellion until the end of the 2000s has been experiencing an unexpected period of stabilityit is among the very few destinations in the sahara that is still considered safe for tourists against this background this article examines the relationships between alliances and conflicts as a putative explanation for the apparent unpredictability of many modern wars in the sahelsahara social scientists have long been preoccupied with the logic of violence explaining the presence and absence of violent conflict and the onset and diffusion of internecine violence ostensibly these are important questions to answer if we hope to prevent and forestall violent conflict however in the saharasahel these models seem to have little explanatory traction although they vary the preconditions for violent conflict are omnipresent yet violence itself seemingly eludes prediction while actual patterns of violence are volatile recent research on the social determinants of conflicts in political geography has shown that political allegiances in the sahelsahara were fluid and largely not ideologically motivated armed groups split and coalesce unpredictably change names as new opportunities arise and morph as ephemeral coalitions between tribal and ethnic groups a similar volatility characterizes commanders and rankandfile fighters who frequently shift allegiances among regular forces rebel movements and violent political organizations depending on local circumstances the initial objective of this article posits a relational approach to the study of the structure of relationships among state and nonstate actors in doing so it harnesses network theory for which social phenomena such as political violence are necessarily mediated by social interactions drawing on a public collection of data on political violence the article uses network science to represent alliances and conflicts between 179 organizations involved in violent events between 1997 and 2014 owing to the fundamentally relational nature of internecine violence we are particularly interested in the way the structural positions of conflicting parties affect their ability to resort to political violence to this end we combine two spectral embedding techniques that have previously been considered separately one for directed graphs that takes into account the direction of relationships between belligerents and one for signed graphs that takes into consideration whether relationships are positive or negative between groups our second objective is to analyze the spatial patterns of violence across the region by localizing violent events and studying the geographic scales of regional dynamics the literature presumes that borders matter because they circumscribe sovereign territories that impose transaction costs on those who cross but do borders matter to islamist groups in the sahelsahara region if so what are their effects and what transaction costs countervailing or otherwise do they impose on the movement of islamist groups in a geographical environment where populations remain poor and sparse recent research on the spatiality of conflict in the region has established that crossborder mobility was an important component of military strategy armed groups such as al qaeda in the islamic maghreb capitalize on marital political and financial ties throughout the region to attack targets take hostages and evade security forces these general principles of desert insurgency based on mobility speed and range challenge the clausewitzian conception of warfare hold territory and attack the enemys strongest point while the desert is seen by many as a hostile environment that distances and isolates vpos from major population centers and force them to disperse rather than concentrate their forces it can also provide a resource to strike anywhere anytime and without apparent logic focusing on 389 violent events in which nine alqaedaaffiliated groups have been involved we highlight specific spatial patterns that emerge from a longitudinal analysis of events over a tenyear period starting in 2004 due to the transnational nature of conflict we ascertain the countervailing transaction costs that borders represent notably by testing whether national borders limit the displacement of islamist groups or serve as sanctuaries whence attacks are launched the article proceeds as follows the second section reviews the literature on the social and spatial organization of state and nonstate organizations in west africa paying particular attention to the role of networks and national borders the third section presents the data and explains how using network analysis and geographical information systems we structured them into networks and chronological events the fourth section models the structural position of actors in conflict the fifth section addresses the spatial patterns of islamist groups and implications of the findings for theory method and practice previous research conflicts and signed networks greater access to georeferenced data and the use of spatial statistical analysis has advanced the study of social and spatial patterns of armed groups over the past decade while past analyses of wars were limited by a lack of reliable data the proliferation of satellite and disaggregated data has spawned innovative approaches to investigating the onset and diffusion of political violence across time and space the concomitant proliferation of political and economic predictors on which the spatialanalytical approach in geography can draw now includes factors as diverse as the nature of government ethnic divisions poverty income inequality number and morale of troops frequency of droughts and endowment of natural resources some factors that may explain why groups resort to violence are also related to the structure of relationships that connect actors in conflict political violence is a relational process so individuals and organizations are all to varying degrees embedded in networks of alliances and conflicts that enable or restrain action the increasing availability of disaggregated data combined with recent conceptual and computational advances in network science is reason to reevaluate the importance of social network analysis within the field of conflict studies sna is the study of individual actors groups organizations or countries represented by the nodes of the network and the relationships between these actors represented by their links as both a paradigm of social interactions based on graph theory and a method sna seeks to understand networks by mapping out the ties between the various nodes as they are rather than how they ought to be or are expected to be sna is particularly adept at capturing the complexity of conflict situations due to its ability to describe represent and model signed networks ie networks that contain both positive and negative relations positive ties develop to overcome collectiveaction problems enforce trust and ideology coordinate activities at a distance distribute resources or disseminate ideas and decisions political alliances between states are typical of positivetie networks by contrast negative ties develop among actors that dislike avoid or fight one another with various levels of intensity for positive and negative ties sna can be used to study the structure and function of the network as a whole and the role of each node in the group in relation to others maoz and colleagues for example have used a network approach to model the effect of political and economic interdependence on the evolution of interstate conflicts over a century using the case of world war i flint et al and radil et al have shown how alliances or rivalries between states could explain the diffusion of war on a global scale radil and flint have applied the same approach at the african level recent studies have noted that networks with positive ties tend to be structured differently from those with negative ties networks based on friendship alliance and collaboration are known for being denser and more clustered around actors that share similar values than networks containing negative ties because individuals and organizations tend to have more friends than enemies positivetie networks also convey more resources ideas and knowledge than negativetie networks based on hatred avoidance or conflict as a result many centrality measures based on the assumption that social networks serve as conduits for flows of information advice or influence such as betweenness or closeness centrality are unrealistic in the case of actors in conflict for example if the algerian military is the common enemy of both aqim and the movement for oneness and jihad in west africa flows are unlikely to pass from aqim to mujao through the algerian military networks containing negative ties are also well known for having a low level of transitivity a principle that assumes that two actors that share a connection to a third actor are likely to be connected themselves a growing literature in conflict studies and related social sciences suggests that despite their differences positiveand negativetie networks should be analyzed simultaneously one way to incorporate both allies and adversaries is to use structural balance theory which argues that social relations are stable if they contain an even number of negative ties stable groups of three actors for example are theoretically stable if everyone likes everyone else or if two actors are in conflict with a third party over time unstable triads theoretically evolve towards stable triads because instability creates tensions that can only be resolved by altering views behaviors and alliances another approach to signed networks is to model the structural autonomy and constraints of actors in a recent article smith et al argue that an actors political independence is constrained both by its potential to reach other actors resources and by the structural position of allies and enemies being connected to a single ally that is free of threat considerably reduces the autonomy of actors in signed networks while a diversified network of allies enhances autonomy this article adopts a complementary approach instead of assuming that political violence is explained by attributes of the belligerents or by exogenous factors we posit network structure to enable or constrain political violence to do so the first part of our analysis aims at representing how vpos are connected to their allies and enemies using several centrality measures we identify subclusters of actors within which conflict or cooperation is particularly developed and highlight the main structural differences between positiveand negativetie networks since enemies and allies are inextricably linked in reallife networks the second analytical part of the article considers positive and negative ties simultaneously using spectral embedding techniques that place the nodes representing organizations at the position that best balances the pull of allies against the push of enemies we model the balance between the relative effects of having allies and foes simultaneously we take into account the fundamental asymmetric nature of conflicts and consider whether groups attack more or less than they are attacked combining signed and directed networks we expect groups with similar allies and foes and similar aggression patterns to form clusters that concur with their structural position in the social network conflicts borders and safe havens a growing literature suggests that national borders are not only potential sources of dispute between states they also provide a safe haven for vpos that compete with sovereign states borders open markets of opportunity for rebels and jihadists that exploit weak states and their lack of intraregional cooperation of the 59 terrorist groups designated by the us department of state in january 2014 39 are thought to operate from a safe haven many of them in border areas in asia border sanctuaries are mainly found in pakistanand indianadministered kashmir pakistans federally administered tribal areas pakistans north waziristan and baluchistan in the middle east the syrian and iraqi borders are wellknown safe havens to myriad armed groups sunnidominated areas of the syrianlebanon border are used as safe havens by syrian opposition forces whereas shiadominated areas are used by hezbollah to launch attacks or enter syria in south america the colombiavenezuela border and the brazilparaguayargentina triangle have been linked to transnational groups in africa the great lakes region and the liberiasierra leone borderlands have been used by rebel groups to challenge the sovereignty of states while somalia is wellknown as a sanctuary for alshabaab how vpos use borders in the sahelsahara is a matter of scholarly debate some claim that terrorist groups such as aqim have divided africa into zones each led by an emir and that the movements of the most prominent emirs are primarily centered on certain regions this approach explicitly deems sovereign state borders safe havens for traffickers rebels and terrorists others contend that the territorial notion of safe haven was probably an inappropriate concept to grasp the spatiality of transsaharan politically violent organizations while certain vpos have repeatedly mounted attacks in the same area this approach argues that attacks mostly seek to control strategic cities and lines of communication and not to capture and hold territory this principle explains why the aims of many salafist groups are more sociopolitical than territorial all we want is the implementation of sharia reportedly said a member of the ansar dine group in mali we are against independence this is reminiscent of precolonial polities that distinguished between ownership and control of land and where as noted by herbst authority extended everywhere people had pledged obedience to the king daesh has adopted a similar strategy it seeks to control a network of cities roads military bases and oil resources across syria and iraq and promotes the view that all true believers should be brought under a caliphate without necessarily holding a contiguous and fixed territorial entity this article engages this controversy in light of the spatiality of vpos and the effect of sovereign state borders on their movements do borders represent sanctuaries behind which vpos wage turf battles over aspirational homelands or as te lawrence posited a century ago is desert warfare more like naval war in the sense that insurgents are mobile and relatively indifferent to the constraints imposed by their environment we propose that the degree to which groups can move and challenge the territorial integrity of sovereign states is a function of the porosity of borders from the beginning of the millennium until the frenchled opération serval regained control of the main cities of mali in 2013 intraregional cooperation remained weak and each state had its own bordermanagement strategy this uncoordinated response to the rise of vpos in west africa should have an observable effect on their mobility patterns across the region more crossborder movement might be anticipated where borders are not heavily guarded andor easy to cross due to informal arrangements with state authorities than where there is greater capacity to ensure border integrity through effective border patrols and law enforcement research design social network analysis our analysis relies on disaggregated data from the armed conflict location and event dataset which provides a comprehensive list of political events by country between 1997 and 2014 the fifth version of the data was used to select 37 vpos in the sahelsahara region their allies and their enemies excluding nonidentified islamist and libyan militias the scope was limited to events with the following seven referents battleno change of territory battle nonstate actor overtakes territory battle government regains territory riots and protests violence against civilians and remote violence this produced a list of 3231 events involving 179 organizations and 27791 fatalities the acled dataset describes four groups in each incident an attacker a collaborator in the attack a target and a potentially assisting group that may also be a secondary target this data is used to build a social network in which the nodes are groups with positively weighted directed ties between groups that interacted and negatively weighted directed ties between attacker and target for example on january 12 2014 clashes between french troops and malian troops on the one hand and ansar dine and mujao on the other hand claimed 11 lives including islamist leader abdel krim and 60 injured incidents are aggregated so that the ties between any pair of groups reflect all of their interactions there can be both positive and negative ties and in both directions between the same two groups directions are important because they are surrogates for intentionality a group on the offensive makes a conscious decision to attack while the defender has no choice and other groups must decide whether to join in or not these decisions reflect a calculus of advantage or ideological alignment the resulting graph is analyzed in two steps first we map the networks containing negative and positive ties separately and analyze the most prominent actors using several centrality measures because negativetie networks do not serve as conduits for flows of information advice or influence we use degree centrality which simply refers to the standardized number of ties each node has and eigenvector centrality which refers to the number of nodes adjacent to a given node weighted by centrality and indicate whether nodes are connected to other wellconnected nodes for our positivetie network we use eigenvector centrality and betweenness centrality which measures the number of shortest paths from all nodes to all others that pass through that node second we combine both positive and negative ties into a single network and embed this network in a geometric space in such a way that the distance between each pair of points accurately reflects the balance between the pull from collaborating groups and the push from aggression between them these distances are globally integrated by considering not only immediate neighbors1 but neighbors of neighbors and in fact the structure of the entire graph it is this integration that makes the process challenging positive relationships are naturally transitive but negative relationships are not technically the adjacency matrices that describe positive and negative ties are combined into a matrix called a laplacian that combines both kinds of ties and normalizes the representation so that wellconnected nodes are central and poorly connected nodes peripheral this laplacian matrix is transformed to discover the directions in which the graph varies the most and these are used as axes for creating an embedded graph in this representation position and distance are meaningful sets of bad actors such as vpos and good actors such as governmental forces and civil society tend to form polar opposites in some dimension of the representation since proximity represents similaritycommonly known as an alliancedistance tends to represent opposition spatial patterns to understand the spatial strategies of vpos we limit the scope to nine transsaharan organizations that subscribe to an islamist ideology al qaeda ansar dine aqim the armed islamic group al mourabitoune the free salafist group the salafist group for preaching and combat mujao and those who signed in blood affiliated with al qaeda these islamist groups share a common historical and ideological background and form several components of a single flexible network rather than independent entities as reminded by hagen aqim overlaps with a number of nominally independent and locallyfocused groups such as ansar al dine and mujao these groups are part of the larger aq family and cannot be separated from aq and aqim mergers name changes and splits are common for example gspca splinter group of gia of algeriarebranded itself as aqim in 2007 some of its members broke off in 2011 to form mujao while others formed al moulathamoun and al mouakaoune biddam in 2013 mujao merged with al moulathamoun to form al mourabitoune which in 2015 was renamed al qaeda in west africa those groups frequently exchange information funding hostages and conduct joint operations since several of their leaders have historically been members of aqims leadership network and have developed multiple allegiances across organizations our sample does not include boko haram its activities are almost exclusively located in the sahelian part of west africa and its use of political violence differs from other islamist organizations in the region while aqim has urged local emirs to refrain from violence against civilians and encouraged them to gain the hearts of the people boko haram has since its leader was killed in 2009 used indiscriminate violence as its principal political instrument using a geographical information system our first step is to map all violent events in which these islamist groups were involved over the last 10 years the year 2004 is the starting point of the development of vpos that had hitherto been almost exclusively located in algeria these groups their allies and their enemies are responsible for 389 violent events totaling 1434 fatalities through 2014 our next step is to develop two hypothetical scenarios to distinguish distinct spatial patterns the mobility scenario assumes violence follows a linear chain of events groups move from one location to the next possibly across borders without returning to their original location this would reflect the strategy of a group under intense pressure from security forces or alternatively of a group that has mastered movement in an arid environment by contrast the sanctuary scenario supposes a territorial turf whence groups operate across borders and a clear origin of flows once the location of each event is known our third step is to connect violent events chronologically through hypothetical lines and verify if the general spatial pattern of the attacks corresponds to one of the two scenarios described above the mobility scenario where groups move freely across borders or the sanctuary scenario where groups use a particular region as a rear base since the acled database does not contains information about the movements of islamist groups we use dotted lines to indicate that spatial patterns based on the location of violent events do not necessarily correspond to actual physical movement between places but rather to a longitudinal series of events a social network analysis of political violence negativeand positivetie networks we start with a graph that represents each organization as a node that is connected to those actors with which it is in conflict the size of the nodes in figure 1 is proportional to the number of ties three main clusters emerge the nigerian cluster that is polarized by boko haram the transsaharan cluster that is composed of groups affiliated with al qaeda such as gspc and aqim and their enemies and the libyan cluster that is composed of myriad islamist brigades and progovernment forces with a density of only 0023 the network is very sparse which is typical of networks that are made up exclusively of negative ties the number of enemies a group can have is often more limited than the number of potential allies the network also has a low level of transitivity in only 12 of the triads enemies of enemies are in fact enemies while in most cases enemies of enemies are friends finally organizations with adverse attributes tend to be in conflict with one other a tendency known as heterophily this can be tested using the ei index which calculates the difference between external and internal ties for each group of actors divided by the total number of ties the ei index for the network is positive and statistically significant which confirms that vpos clash with organizations that do not belong to the same category at the level of the organization the network is composed of few highly central organizations that makes sense since being in conflict with many adversaries simultaneously is widely regarded as a liability rather than as an asset negative relationships adversely affect the outcomes of vpos military operations reduce their ability to coordinate activities across the region and limit their ability to cooperate to achieve their political or religious goals among politically violent organizations aqim has the highest score in degree and eigenvector centrality which indicates that it has the greatest number of enemies and is connected to other actors that also have many enemies such as the military and police forces of algeria mujao gspc and gia also occupy a prominent structural position due to their conflicts with civilians and armed forces in several countries other prominent actors include boko haram which stands out for being connected to many other actors who themselves have few connections to one other and some libyan groups such as ansar alsharia and libya shield brigade the structure of the network of enemies contrasts strongly with the one showing how organizations involved in violent events have collaborated across the region as depicted in figure 2 the positivetie network is divided into three main unconnected groups of allies one triad connecting an unidentified armed group to boko haram and ansaru and three dyads the main cluster on the left is structured around north and west african military and police forces and their civilian allies which are represented in red and yellow respectively this cluster is indirectly connected to some of the main islamist groups in the region which are represented in green through the secessionist movement mnla mnla was allied with ansar dine in the first weeks of the malian conflict before switching sides and fighting alongside the frenchled military forces in 2013 the two other clusters are related to the libyan conflict one is structured around the armed forces of libya and their progovernment brigades and battalions the other around islamist groups and ethnic and communal militias each cluster has a chainlike structure in which organizations are rather distant from one another the algerian private security forces for example are eight steps away from al mourabitoune the long pathlength distance low density and low clustering coefficient of the network are typical of a structure that is not organized around groups of tightly connected actors this suggests that most governmental forces and vpos tend to build bilateral or trilateral alliances rather than broad coalitions across the region the graph also highlights the lack of regional cooperation between government forces that face similar threats there is no reported tie between the military forces of libya and algeria or between the military forces of cameroon and nigeria figure 2 positive ties between organizations involved in violent events 19972014 notes green nodes refer to islamist groups red to government forces yellow to civilians and blue to other actors military and police forces have the highest eigenvector and betweenness centrality followed by ansar alsharia and the shura council of benghazi revolutionaries both of which hail from libya generally speaking betweenness centrality scoresthat refer to the propensity to bridge clustersare very low even for topscoring nodes which suggests that the networks contain few exceptional brokers only the french military forces play a role in bridging several african armed forces that would otherwise not be connected hence their high betweenness centrality once again the isolation of boko haram in nigeria contrasts sharply with the network of alliances among other sahelosaharan and libyan groups note scores are indicated between brackets spectral embedding now we compute the spectral embedding of the social networks derived from the acled data initially for the sake of simplicity we disregard the direction of the ties the embeddings are shown in figure 3 negative ties resulting from recorded attacks are shown in red and positive ties resulting from alliances or at least common purpose are shown in green the general structure is of a group of opposing poles representing groups whose primary relationship is that they attack or are attacked by groups at the other pole the graph clearly shows how bad actors such as islamist and jihadist groups are grouped opposite good actors both violent and nonviolent the contrast is particularly evident for boko haram and its opposition to governmental forces and civilians from nigeria and cameroon as well as for giagspcaqim and its opposition to algerian armed forces and civilians the graph also shows that the attack patterns of gia gspc and aqmi differ significantly from those of ansar dine mujao and al mourabitoune which are located much closer to the center of figure 3 any measure that considers a group in isolation is unable to distinguish vpos from military or police organizations because both have similar patterns of interaction we therefore compute measures of outward and inward aggression based not on the number of such incidents but on the length of the relevant ties in the embeddings a groups position in the embedding reflects its relationships with all of the groups with which it interacts and therefore the length of the embedded ties is more revealing than simply the number of attacks for example the distance of a group from the center of the embedding reflects not only how many other groups attack it but also the extent to which its enemies are similar to one another thus a long red tie measures not only the existence and frequency of attacks but also their strategic intensity on figure 4 groups are plotted at the same positions as in the spectral embedding presented in figure 3 to denote levels of aggression they measure the outgoing aggression of each group and the incoming aggression to which it is subjected they are colorcoded red means a group generates more aggression than it receives orange means that the group generates some outgoing aggression and green means that there is no outgoing aggression figure 4 spectral embedding showing levels of aggression the vicinity of groups presented in figure 4 allows us to distinguish vpos from national defense forces in other words most of the polar opposites consist of bad actors on one side and good actors on the other and they are structurally distinct bad aggressive actors such as aqim or boko haram tend to be in clusters of net aggressors or isolated good aggressive actors such as militaries tend to be in clusters with orange and green groups neutral actors such as the international committee of the red cross tend to fall in the middle and green victims are also green but tend to be located near their champions northern nigeria and libya are particularly interesting as they involve many vpos with strong structural constraints from the literature we would expect northern nigeria where boko haram is particularly dominant to have more of a dual structure than libya where myriad of violent groups compete for the control of the state and oil resources we find that our intuition was correct as figures 5 and6 show spectral embedding showing conflicts and cooperation for 37 organizations in northern nigeria clearly confirms that boko haram is in conflict with virtually everyone a situation comparable to that of isis in the middle east which opposes all governments and nonstate actorsincluding al qaedain the region figure 5 spectral embedding showing positive figure 6 spectral embedding showing and negative ties for 37 organization in positive and negative ties for 30 northern nigeria organizations in libya note for the sake of clarity ansaru is not shown in libya spectral embedding conducted on 30 organizations highlights the ongoing conflict between proislamist groups and progovernment forces islamist groups on the left of the graph are composed of islamist militias such as libya dawn and libya shield and of jihadist groups close to al qaeda such as the revolutionaries shura council a coalition that includes ansar alsharia the 17 february brigade and the rafallah sehati brigade these groups based in tripoli and in benghazi all oppose the libyan army as indicated by several long red ties among progovernment forces on the right are antiislamist militias such as the zintan militia the alsawaiq battalion and the al qaqa brigade civilians and journalists are located near the internationally recognized authorities of libya spatial analysis of mobility patterns this section examines the spatiality of select islamist groups that have developed attack patterns across the sahelsahara region for strategic and policy purposes we are particularly interested in whether state border strategies and multinational military missions have had a measurable effect on the transborder movement of islamist groups changing mobility patterns the analysis that follows reveals no evidence of a sanctuary pattern in which islamist groups make systematic use of a particular border area however table 3 reveals that the movement of islamist groups changed completely between 2004 and 2014 while the first seven years were marked by an apparent unpredictability of events across time and space the last three years were characterized by a concentration of events due to the outbreak of the malian conflict and the strategies adopted by some states to control their borders this shift occurred in a political environment where the number of violent incidents and victims related to islamist groups in subsaharan africa has been on the rise while only 30 events totaling 201 victims were reported between 2004 and 2008 there were 359 events and 1233 victims between 2009 and 2014 the intensification of attacks significantly reduced the average frequency between violent incidents from an average of 448 days in 2008 to 75 days in 2014 the region has always been characterized by a high level of transborder activity figure 7 confirms that until 2011 islamist groups travelled extensively across borders and in many regions of mali mauritania algeria and niger without much risk of being apprehended after algeria expelled them they were tolerated by the malian government of president amadou toumani touré which sought to capitalize on divisions within tuareg society and on a withdrawal of the state to administer the northern part of the country successive events repeatedly occurred hundreds or thousands of kilometers apart in different countries and irregularly from algeria to mauritania the mauritanianmalian border and niger in 2005 and 2006 the average distance between two events exceeded 500 km which is impressive given the harsh terrain and lack of road infrastructure in particular in the sahara one of the best known movements of this period is also the one that marked the beginning of the saharan expansion of what would become aqim between 21 february and 11 april 2003 32 european tourists were kidnapped in the region between illizi and amguid in algeria by abderazak elpara and abdelhamid abu zeid two militants of gspc as algerian security forces gave chase the terrorists and hostages initially journeyed of over 3000 km to northern mali after having spent several months establishing alliances with leaders of local nomadic tribes they moved to niger through the plains of azawagh aïr mountains and the ténéré desert and ended up in the mountainous area of tibesti in chad where they were killed or captured a second journey of over 2500 km through some of the most inhospitable environment on the planet in 2011 mauritania and algeria undertook a series of joint counterterrorism operations aimed at aqims military bases such an attack took place in the wagadu forest on the border between mauritania and mali in june the central intelligence cell created to facilitate coordination between saharan and sahelian countries known as the combined operational general staff committee first met in bamako in april 2011 nonetheless the level of regional cooperation remained low because mali was not trusted by its neighbors which accused it of colluding with islamist groups henceforth mauritania and algeria would conduct military operations in mali when they deemed their interests to be threatened by the activities of transnational groups the chronological succession of attacks by aqim in 2011 shows a high intensity and percentage of crossborder movements for example aqim claimed responsibility for a bomb attack in bamako the capital of mali on 5 january followed by a hostage taking in niamey niger three days later on february 1 these attacks were followed by an aqim car bomb in the mauritanian town of adel bagrou the abduction of an italian tourist in djanet algeria a day later and the killing of a mauritanian policeman by two members of aqim in the region of legsseiba near the north bank of the river senegal on february 3 the year 2012 contrasts sharply with the period 20042011 because most events transpired in mali and to a lesser extent algeria following the fall of col muammar gaddafi in libya and president amadou toumani touré a provisional alliance between al qaedaaffiliated groups and secessionists rebels of the mnla launched a wideranging military offensive against the malian army over a matter of weeks all major cities of northern mali were seized including tessalit and kidal in the adrar des ifoghas where the offensive started as well as menaka timbuktu and gao new groups such as mujoa and ansar dine were particularly active during this period and started to clash with their former tuareg allies over the cities of the north of the country and main lines of communication our analysis shows that during this period the distance between violent events and borders is the more stable than the preceding period during which average distances to borders varied from 39 to 334 km in 2013 the frenchled opération serval reasserted control over northern mali as french and chadian troops progressed north islamist groups were driven from kona douentza gao timbuktu and were chased out of their stronghold of the adrar of the ifoghas operation panthère launched around tessalit on 18 february 2013 successfully defeated them possibly because the french and their allies adopted some of the principles of warfare that had made islamists and rebels so successful in the region operation panthère relied on a combination of airstrikes artillery and ground combat operations conducted by the french knowledge of the country provided by tuareg guides and chadian desert warfare chadian troops and their highly mobile light trucks proved as effective in mali as they have in the past 30 years in their own country as in 2012 most events in 2013 took place in mali and algeria along a southwestnortheast axis extending from bamako in mali to tamanrasset in algeria contrary to previous military engagements that targeted one country one crisis and one theatre of operations opération barkhane explicitly addresses the regional and crossborder dimension of terrorist activity throughout the region the operation relies on three ports in the gulf of guinea two main airports in the sahel and a series of saharan outposts located at the extreme periphery of chad mali and niger to disrupt crossborder trafficking routes and terrorist networks considering that algeria and libya are beyond the reach of any foreign armed forces and that the french military is stretched to the limit for the time being opération barkhane is the most ambitious military initiative at the regional level state border strategies do borders not matter if they cannot offer sanctuary on the contrary our analysis suggests that borders do matter because countries have put in place management strategies that affect the spatial patterns of islamist groups building on arsenault and bacons distinction between government will and capability to fight foreign terrorist groups four situations can be distinguished states may have the military capacity to challenge transnational groups and choose to do so in the region mauritania is probably the country most similar to this situation despite the small size of its armed forces mauritania took a number of strong military measures to control the flows of islamist groups across its borders develop mobile patrols attack intruders systematically and establish partnerships with local tribes as our analysis revealed this firm attitude combined with a national strategy for deradicalization has occasioned a significant decrease of violent events since 2012 some states may also be in a position to deny foreign fighters access to their territory but choose not to do so for strategic reasons whether algeria would have adopted this strategy is a matter of debate on the one hand having suffered from decades of political violence algeria is strongly committed to combating terrorism in the region and plays a major role in peace negotiations in mali during the malian conflict algeria deployed tens of thousands of troops to secure its borders which are probably the most heavily guarded in the region on the other hand islamist groups would have been unlikely to emerge in northern mali if algerias borders had been hermetically sealed many of the aforementioned groups originally hail from algeria or are affiliated with organizations based there and there is strong evidence that algerian borders are easily crossed by islamist groups to get food and oil supplies through informal arrangements with state representatives the third situation where states may want to disrupt transnational groups without being able to project military power into borderlands characterizes niger the 5700 km border of niger has long been poorly guarded due to lack of men and material aqim and other groups have capitalized on the situation either to take hostages in the region or to move to the south of libya where numerous islamist groups have found favorable conditions finally mali exemplifies a lack of political will and ability to fight foreign islamist groups the gradual withdrawal of the state from the north of the country in the 2000s left malis borders unguarded and frequented by traffickers and militant groups conclusion the article examines the structure and spatial patterns of vpos in the sahelsahara a region characterized by growing political instability over the last 20 years based on a novel approach that combines signed and directed graphs our methodological contribution has been to highlight opposed groups and distinguish among several kinds of aggressors depending on their conflict patterns in settings where groups form shifting alliances and oppositions an approach that takes into account not only the local pairwise relationships but also the global patterns that emerge is needed for situational awareness conventional social network analysis can represent positive ties but not ties where direction matters or where ties represent a negative association furthermore these are not independent properties of a social network and so must be represented together this article has illustrated the effectiveness of extending social network analysis to such settings conventional social network measures fail in these settings for example measures such as betweenness are inappropriate because negativity does flow in the way that positivity is conceived and centrality is not a crucial property when negativity separates nodes far from the center from a theoretical perspective the paper advances theory on the spatiality of islamist groups by showing that sanctuary is immaterial to saharan borders because many islamist groups seek to control the movement of people and goods the inability to garrison a sparsely populated region such as the sahelsaharawhich is the size of the united statesmakes it difficult to hold territory this situation is similar to the one adopted by daesh between syria and iraq and radically different from the territorial objective of such groups as boko haram in africa or the taliban on the afghanistanpakistan border for which the defense of a delineated territory is paramount building on publicly available data we started by mapping how 179 organizations involved in political violence were structurally connected through conflict and alliances our results show that the network that connects actors in conflict has a low density a low level of transitivity and contains few central actors three typical features of negativetie networks aqim is unequivocally the most connected organization both in terms of the overall number of actors with which the group is in conflict and the respective centrality of its enemies in network terms this is a liability divided into several clusters the positivetie network has a long pathlength distance low density and low clustering coefficient a structure that suggests that most organizations tend to build limited alliances rather than broad coalitions across the region we then combined the two networks and modeled the effect of having friends and foes simultaneously using the attack relationships we also measured the level of outgoing and incoming aggression of each group from this approach five categories emerge the first category includes neutral actors represented in the middle of our graphs the following categories include three kinds of groups that cluster together victims groups that are attacked more than they themselves attack and groups that counter violence and thus attack more than they are attacked the fifth category includes violent extremist groups that attack more than they are attacked such as vpos groups that are net attackers are indistinguishable at the level of individual behavior but clearly separate into proand antiviolent extremism based on the groups to which they are close this conclusion is in line with our original assumption that the propensity to use political violence concur with a groups position in the social network the second part of the article mapped a series of 389 events related to nine major islamist groups in the region spatial analysis suggests that violent events involving islamist groups have followed different patterns depending on the period under consideration but reveals no evidence of a border sanctuary while violence was concentrated almost exclusively within algeria until 2004 crossborder movement has since intensified following the establishment of military bases by aqim in mali this suggests a mobility scenario similar to the arab revolt of the 20 th century during which a highly mobile irregular force defeated the immobile and defensive ottoman turkish army our analysis suggests that until the frenchled military offensive of 2013 military operations of transsaharan islamist groups were more like naval warfare than ordinary land operations in their mobility their ubiquity their independence of bases and communications their lack of ground features of fixed directions of fixed points more recently islamist groups have concentrated their operations in northern mali as well as southern algeria leaving mauritania niger and chad relatively unscathed owing to the malian conflict and to a series of state and international military initiatives crossborder movement has been on the wane in some countries which seems to validate our original assumption that islamist groups concentrate on border segments that are less heavily guarded andor where informal arrangements with border officials are possible our results have policy implications for governments and external forces involved in deterring politically violent organizations first unlike their adversaries vpos are socially and spatially connected across the regions so there is a need for collective security institutions that can help countries coordinate build trust and go beyond ad hoc engagements in recent years several sahel strategies have been initiated by organizations as diverse as the european union the united nations the economic community of west african states the african union and the regional coordination framework g5 sahel to address governance security and development in the region building institutional capacity around common interests is likely to pay off in a region that is largely devoid of collective security institutions precedent also suggests that states outside the region will continue to play a supporting rather than a lead role in addition to supporting capacitybuilding efforts already underway western governments should be prepared to mount a comprehensive wholeofgovernment effort in support of local authorities that will minimize their local footprint while optimizing outcomes from a military perspective the fluidity of personal allegiances and mobility of actors across borders in the region calls for a mobile and flexible military response regional volatility notwithstanding operations serval and barkhane suggest that desert insurgents are not impervious to external attack as western armies and their african allies become more mobile and flexible in their regional responses to political violence desert insurgency proves to be a doubleedged sword that can also work against those who know the terrain best

this article examines the structure and spatial patterns of violent political organizations in the sahelsahara a region characterized by growing political instability over the last 20 years drawing on a public collection of disaggregated data the article uses network science to represent alliances and conflicts of 179 organizations that were involved in violent events between 1997 and 2014 to this end we combine two spectral embedding techniques that have previously been considered separately one for directed graphs relationships are asymmetric and one for signed graphs relationships are positive or negative our result show that groups that are net attackers are indistinguishable at the level of their individual behavior but clearly separate into proand antipolitical violence based on the groups to which they are close the second part of the article maps a series of 389 events related to nine transsaharan islamist groups between 2004 and 2014 spatial analysis suggests that crossborder movement has intensified following the establishment of military bases by aqim in mali but reveals no evidence of a border sanctuary owing to the transnational nature of conflict the article shows that national management strategies and foreign military interventions have profoundly affected the movement of islamist groups

introduction in a global context many persons with disabilities are not employed and when they are employed they generally earn lower incomes in response to this problem the indonesian government has tried to provide better employment services but the results are still far from expectations the results of research in indonesia particularly in yogyakarta reveal that public and private organizations in the regions cannot fulfill one percent of the work quota for persons with disabilities as stipulated in government regulation number 43 of 1998 concerning efforts to improve the social welfare of persons with disabilities this is due to the ineffectiveness of law enforcement the amount of training provided but not in accordance with the potential for disabilities and public awareness and concern about disability is still lacking therefore many people with disabilities face problems such as difficulty in getting a job discrimination and inequality when getting a suitable job and justice during work according to the 2018 national socioeconomic survey 1229 of indonesian citizens are considered persons with disabilities with 1112 of them being in the productive age in 20162018 the average income of people with disabilities in indonesia is lower than nondisabled people agefriendly facilities in indonesia are also limited and the existing facilities are not agefriendly so they do not support the mobility of persons with disabilities this situation shows that the handling of disability issues in indonesian employment services is urgent whereas policies related to persons with disabilities already exist namely law number 8 of 2016 this law aims to protect the rights of countries with disabilities among others by setting a quota policy of 2 and 1 of total employment in stateowned and private companies however law enforcement is considered ineffective this study seeks to examine inclusive policies in indonesia that lead to inequality of decent work for persons with disabilities in indonesia method this study uses a qualitative approach secondary data is used to review various documents related to the employment of persons with disabilities this study also uses regulations reports and articles the information extracted from these documents is used to analyze inclusive policies related to decent work equality for persons with disabilities in indonesia results and discussion results based on law no 4 of 1997 concerning persons with disabilities it can be seen that indonesia already has regulations for persons with disabilities where this law is considered the highest law in the country at that time however even so people with disabilities are currently still considered negative namely as people with disabilities therefore the government then ratified the convention on the rights of persons with disabilities along with the issuance of law no 19 of 2011 and began to use the term persons with disabilities this term is also used in the law on disabilities where persons with disabilities are defined as people who experience longterm physical mental intellectual and sensory limitations and experience limitations and difficulties in participating fully and effectively with other citizens based on equal rights this law also regulates the distribution of employment services in indonesia where persons with disabilities are also entitled to employment entrepreneurship cooperatives accessibility public services independent living and free from discrimination despite the policy there are growing concerns about employment for persons with disabilities this situation is unavoidable as many people with disabilities in indonesia have precarious jobs due to underemployment and have few opportunities to advance their careers persons with disabilities also mostly work in the informal sector with relatively lower takehome pay than nondisabled persons because disability issues are complex there are various causes and challenges that can be seen in providing equal employment services for persons with disabilities such as employment services in indonesia which are not yet comprehensive and affordable the absence of unemployment insurance services for indonesian workers and so on which causes persons with disabilities to tend to be very vulnerable in poverty the next challenge is how the current law no 8 of 2016 has not been fully implemented this has resulted in continued employment problems for people with disabilities such as difficulty in finding jobs and earning higher incomes as evidenced by how people with disabilities in indonesia tend to earn below the median income the third challenge is the lack of public facilities for persons with disabilities accessibility is another issue although some cities already have public facilities to accommodate persons with disabilities according to a jica survey public wheelchair corridors required by law may not be available in indonesia and facilities for persons with disabilities are often useless because they do not conform to universal designs the lack of adequate facilities also significantly hinders persons with disabilities from moving and working independently limited access to education for persons with disabilities is the fourth challenge the main obstacle to education for persons with disabilities is the perceived low level of education making it difficult for persons with disabilities to participate in the economy the government also offers vocational training programs for people with disabilities but people with disabilities prefer to look for other jobs because skills and qualifications that are unrelated and uncompetitive unless accompanied by advanced equipment and existing skills make them tend to lag behind others in addition the lack of awareness of persons with disabilities and their employment rights is another challenge this issue of awareness is not the last issue for equal employment services however the four challenges above so far need to be considered because they are important factors in shaping the current situation of persons with disabilities and their work in indonesia if these challenges are not properly addressed it is unlikely that disability will become a more comprehensive and decent work mainstream in employment services in indonesia discussion disability inclusive policies for the indonesian government and society can be seen as a strategy to provide better employment services and build decent work for persons with disabilities if we look closely disability policies are considered to be underexplored in various policies and the results are not feasible to compare for example in terms of poverty alleviation and approaches to other sectors the results are still not feasible however disability inclusive policies are still important because they directly address core disability issues such as lack of awareness about disability and discrimination therefore making an inclusive policy for disability is not a single strategy it needs several comprehensive strategies that may have a wider target group such as the poor and women one of the keys is to include vulnerable groups particularly persons with disabilities in the agenda proposed by the employment service in indonesia on the other hand the government also needs to issue regulations to ensure that law no 8 of 2016 is well implemented at the national level the need for collaboration across ministries and different levels in the government hierarchy as well as creating relationships between actors and the poor is also one of the key success factors in creating better employment services for people with disabilities if you look at the policies of the south african government it can be seen that they carry out policies that emphasize the empowerment of marginalized communities where exclusion is not only related to poverty but also race gender and disability but also contributes to inclusive development by involving lowincome and marginalized groups in this process and preventing their participation from being marginalized we can reduce the risk of low product quality it also supports community ownership which is often critical to the success of inclusive policies nor is norway a policymaker in the form of the asker welfare lab at asker which is a new concept of citizencentred service delivery with all relevant municipal services investing in their wellbeing with external partners this laboratory has an investment spirit and treats residents as coinvestors the aim is to improve the living standards of vulnerable communities thereby improving the quality of life of each individual and member of the program family asker welfare lab currently focuses on three specific target groups families with children suffering from vulnerable living conditions vulnerable youth aged 17 to 25 years and families with children with disabilities then on the economic side economic growth is also considered very important for the welfare of persons with disabilities because it provides resources that help create conditions for more inclusive growth the oecd describes inclusive growth as economic growth that creates opportunities in all sections of the population and distributes the dividends of increasing wealth both financial and nonmonetary equitably to society as a whole transportation systems also help reduce social exclusion by increasing access to private employment education health care and social networks wide public transport coverage is a prerequisite for good accessibility but in reality coverage and access are not always related due to low frequency low station density and inadequate network therefore it is very important to identify the need for accessibility restrictions for vulnerable groups those with low incomes also tend to experience limited transportation options poor quality of transport services and travel in poor conditions this creates a poverty trap other factors such as age and disability can also limit access to activities and services in functional urban areas more effective and reliable public transport infrastructure helps improve labor market performance of minority groups living in poorly connected urban areas in addition an inclusive entrepreneurship policy is also needed to ensure that everyone has the same opportunity to start and run their own business this policy seeks to support people from social groups who are underrepresented in entrepreneurship or disadvantaged in the labor market supporting youth especially unemployed disabled people with targeted interventions could be the next solution many young people need little support to find work those without a high school education and those with health problems or disabilities need more intensive assistance skills are needed to get a decent job social skills have also been shown to be malleable through adolescence and early adulthood and have a profound impact on life outcomes labor market engagement and income and family stability and indeed intensive programs combining training with accommodation mentoring and social support have been shown to have positive longterm effects on labor market participation income and reduced activity careful planning and strategies are needed such as providing adequate facilities creating an inclusive curriculum designing teaching methods that improve practical skills and encourage people with disabilities to become more confident as a part of the community the inclusiveness of all population groups not just women as a homogeneous group can now become the core of policy making its goals and objectives are intended to be universally applicable to all countries and to all population groups within countries some specific goals and targets are explicitly targeted at specific groups such as sdg 88 target on labor rights for migrant workers or sdg 112 target on access to public transportation for women children persons with disabilities and the elderly social accountability also plays a key role as it ensures that everyones voice is heard it is also recognized that the role of citizens in policymaking has changed the relationship between government and citizens and is key for governments to increase citizen trust for example the existence of mechanisms such as free fair and transparent elections a functioning party system access to public information and the involvement of various stakeholders in policy design and service delivery and more importantly policy evaluation is the key to holding governments to account in addition access to justice and legal empowerment is also one of the most important to provide awareness and tools to the public to participate more effectively in open government and consultation initiatives but also shed light on corrupt practices and promote legal and regulatory protection lastly the role of media and journalism by acting as supervisors and as a means of providing information can also be described as a key to accountability to ensure that various individuals regardless of race color gender language religion political or other opinion origin disability or sexual orientation can have access to timely information and accurate without discrimination through this inclusive policy strategy it is hoped that employment services in indonesia will be improved again including in the case that people with disabilities are expected to have decent jobs the process of achieving equality and inclusion also requires the participation of everyone and the results are likely to be visible after a few years however mainstreaming needs to be considered positively as an approach to employment services conclusion from the results of the study it can be seen that employment equality for persons with disabilities in indonesia is still lacking this is triggered by weak law enforcement poor employment services and minimal supporting facilities at work the availability of inclusive policies related to employment is a strategy to provide equitable services for persons with disabilities for this reason it is necessary to have a derivative policy from law no 8 of 2016 so that the legal basis for service implementation becomes clear a nuryakin c muchtar p a bella a rizal h reference mapping persons with disabilities in indonesia labor market economics and finance in indonesia63 hamada n challenge to improve the public employment services in indonesia

the many problems experienced by persons with disabilities such as difficulty in getting a job discrimination and inequality when getting a suitable job and fairness during work indicate that the same service for all citizens has not been fully felt this is also due to the fact that policy studies that are inclusive of persons with disabilities have not yet been fully implemented this study uses qualitative research methods and then describes the results of the research descriptively the final result of this research is a strategy to provide equality for persons with disabilities in employment services

introduction social networks are an important source of credit insurance information advice and other economic and noneconomic benefits and often substitute for limited formal institutions1 but networks are not designed they are the product of many decisions in particular as formal markets expand the incentives to maintain or develop new relationships change this could affect networks in unanticipated ways potentially affecting even those who do not directly benefit from this expansion in this paper we study how the introduction of formal lending institutions changes social networks both empirically and theoretically in our first empirical setting we analyze how the introduction of microfinance affects network relationships in rural communities we show that mf entry leads to a general shrinkage of the network even among those whose characteristics make them very unlikely to be borrowing from the microfinance institution in fact it is they who despite being prima facie uninvolved with microcredit appear to be the most affected losing a considerable number of relationships among themselves because existing models of network formation struggle to rationalize these patterns we develop a new model that can explain these findings our model highlights spillovers stemming from the decision to socialize or not we subsequently replicate these surprising findings in a second independent empirical setting from a randomized controlled trial offering microfinance to urban communities demonstrating both the robustness of these findings and the fact that the loss in links persists even after microfinance is no longer available to these communities the challenge in ascertaining whether formal institutions change informal social structures is that it requires detailed data on networks of informal relationships together with exogenous variation in access to formal institutions our two empirical contexts satisfy both requirements first we analyze the introduction of mf in rural karnataka india using detailed network panel data that we collected over six years in 75 villages these villages were selected in 2006 prior to the first survey wave when none of them had access to microfinance but a microfinance institution bharatha swamukti samsthe was planning to start operating in all of them between 2007 and 2010 bss entered 43 of these 75 villages which we call mf villages however a series of external crises halted bsss expansion and the remaining 32 villages were not exposed to bss prior to our wave 2 survey collected in 2012 we call these nonmf villages we take advantage of this variation along with our extremely detailed network data from the two waves to estimate the impact of mf on village network structure using a differenceindifference strategy second we replicate and extend the karnataka findings leveraging an rct conducted in 104 neighborhoods in hyderabad india using crosssectional survey data that we collected in the rct entry by an mfi was randomized to half of the study neighborhoods control areas began receiving access to spandana two years later but in 2010 spandana suddenly ceased all operations due to the same crisis that halted bss expansion we surveyed all households for a final time six years after initial entry when they had little or no access to microcredit however the households in the early entry neighborhoods had been exposed for twice as long when microcredit was shut down and had received much larger loans we therefore estimate the impact of this differential access to microcredit using data we collected in this survey about each respondents network relationships as described below the advantage of the karnataka setting is that we have highquality network data we know details of link patterns between households as well as the nature of the link furthermore it is a panel and so allows us to condition on preperiod network structure however the setting does not involve an rct and therefore our identification relies on the differenceindifference assumption being valid the hyderabad dataset avoids this issue since initial entry was randomized treatment neighborhoods had exogenously more cumulative access to microfinance than control neighborhoods it also serves as a validation because the hypotheses we test in this data come from the results of the karnataka analysis which were generated before we looked at the network data in hyderabad finally because the survey was fielded 6 years after initial entry and 4 years after the lateentry group received access to mf this illustrates the extent to which these kinds of effects can be durable2 however in hyderabad we only have one crosssection of network information and we only have partial network data to supplement it we collected aggregated relational data and use the new methodology from breza et al to estimate features of the network our ard survey asks each respondent to list their network relationships and to indicate how many of those individuals have a series of traits breza et al and breza chandrasekhar mccormick and pan have shown that these responses contain sufficient information to identify the parameters of a network formation model which can then be used to estimate the key characteristics of the neighborhood network that we need for our analysis breza et al and breza chandrasekhar mccormick and pan show that this method is an effective way of identifying effects on networks comparable to the case where the researcher has full network data the impact of microfinance on network connections can potentially go in either direction as a source of formal credit to poor underbanked households microfinance may reduce their dependence on social networks for informal credit and insurance moreover the required weekly repayment structure of microloans may reduce borrowers liquidity and limit their capacity to lend small sums to their friends on the other hand if households relend a part of their formal loans microfinance could crowd in informal financial relationships 3in both of our datasets we find that the introduction of microfinance crowds out social network relationships the probability of a link between any two households declines by 11 in a mf village compared to a nonmf village in the karnataka sample this is robust to controlling for a rich array of baseline variables we estimate an even larger effect in the hyderabad rct a 22 decline we then investigate how the changes in networks are distributed across two types of households those who are likely to take up microfinance loans and those who are not all of the channels described above suggest that microfinance might affect a borrowers willingness to maintain friendships including with those who do not take up microfinance however prima facie one would not expect effects on pairs of households that are both unlikely to take up microfinance if anything one would have expected links between these households to be strengthened in microfinance villages since they might be losing access to the households that get microfinance but still have needs to borrow and lend to look at this question empirically we need to be able to compare those who are more or less likely to take up microfinance in mf villagesneighborhoods to those in a nonmf village who would have been comparably likely to take up microfinance had it been available in their villageneighborhood to this end we use a random forest model to classify households in all villages into two groups based on whether they would have a high or low likelihood of joining microfinance if it were offered in their village we begin with the karnataka panel by looking at the difference between mf and nonmf villages in the probability that two ls who were linked in wave 1 continue to be linked in wave 2 because l households have a low propensity to borrow from microfinance they are unlikely to experience any direct impact the surprising result is that ll links decline as much as lh links and more than hh links in mf villages relative to nonmf an ll link that exists in wave 1 in a mf village is 58pp less likely to exist in wave 2 compared to a similar link in a nonmf village this decline is if anything greater than the decline in hh links similarly ll links are less likely to form in mf villages again even less so than hh links the crosssectional data from the hyderabad rct delivers consistent results treated mf neighborhoods have 06pp fewer ll links than control neighborhoods and there is no evidence of a greater decline in lh or hh links we then examine the evolution of links that form triangles in the karnataka sample we find that it is the lll triangles that are most likely to disappear in mf villages compared to nonmf villages in mf villages lll triangles are 78pp more likely to have at least one link broken than in nonmf villages more than any other type the difference is greatest and most significant between lll and hhh but even lhh are less likely to break than lll lll triangles are also more likely to entirely disappear in mf villages and the difference from all of the other types of triangles is significant in the hyderabad data we also find that we are significantly less likely to observe a lll triangle in treatment than control villages thus we observe loss of links even among people least likely to be involved in microfinance and in parts of the network that do not directly involve a connection with hs these findings suggest that models of purely local externalities are unlikely to be able to explain our results strikingly even though the direct impact of microfinance is likely to be on financial links the same patterns also emerge when we analyze information links this suggests that there is contagion from one type of relationship to others these types of spillovers both across types of links and across types of households are prima facie inconsistent with models of network formation where the decision to form a link only depends on the payoff to the two parties forming the link and these payoffs only depend on the characteristics of the parties involved in the link and no one else we briefly sketch a set of these models that are standard in the literature in online appendix d these include mutual consent models of directed search stickiness in dropping or forming links and local payoff externalities 4a potential explanation for why preexisting ll links also drop in large numbers comes from a model of network formation with local payoff externalities many models of network formation focus on payoff externalities mele specifically an ll link may be partly sustained by its shared connections to an h that was directly impacted by microfinance however the result that lll triangles are at least as likely to be affected as triangles involving hs rules this out as a sole explanation we develop a new model of network formation that can explain why links between the ls might break at least as much as other links the model we build comes from a simple idea in the model old relationships are maintained and new ones are formed when people socialize in an undirected way a stylized interpretation is that people show up at the town square or a local tea shop to hang out and socialize seeing their current friends keeps those relationships intact and meeting new people sometimes results in new relationships people who do not show up at the town square lose old relationships and form fewer new ones we describe this as a model of undirected search this gives rise to a distinct networklevel externality because the returns to socializing depend on who else is socializing holding fixed the valuation of a certain link or groups of links the fact that in equilibrium others are not searching can have global effects on network density and topological structure for example l types value hl links and thus care about how h types socialize therefore if microfinance changes the socialization of h types that changes incentives for l types to socialize which in turn affects the incidence of ll links specifically access to microcredit might reduce both the demand and supply of informal loans by h types but the hs becoming less willing to lend can have a larger negative impact on ls than on hs which leads to less socializing by ls as ls socialize less there is a larger relative drop in ll links a simple extension of the model to account for the formation of triads generates similar results for lll relationships this model matches the patterns we observe in the data in particular the spillovers to the relationships between l types it also predicts that there should be spillovers across different types of relationships since it is the same town square where people also form other relationships such as advice relationships given that we see network connections shrinking a natural question is whether we see changes in downstream outcomes such as borrowing or the volatility of consumption indeed consistent with the disappearance of the ll links we find in both settings that the l households after the introduction of microfinance borrow relatively less from informal sources in mf compared to nonmf villages finally in the hyderabad sample we can directly measure the impact of increased microfinance exposure on consumption smoothing for highand lowborrowing propensity households this is possible because we have detailed panel information on both income and consumption at the household level we find that in areas exposed to microfinance households with high propensity to use microfinance see little change in their consumption smoothing compared to those in areas not exposed to microfinance however households with low propensity to use microfinance see a large and significant worsening of their consumption smoothing compared to those in areas not exposed to microfinance which is consistent with the network and informal borrowing impacts our research on how exposure to formal financial institutions affects social and economic networks is related to some important recent and ongoing work feigenberg et al find that participation in microcredit creates tighter social relationships among group members binzel field and pande and comola and prina in recent work heß jaimovich and schündeln also examine how policy interventions affect network structure but in the context of a communitydriven development initiative the initiative provided a very large disbursementone half of annual per capita incomeper household in each treatment village and villagers had to collectively decide which projects to execute heß et al collected a crosssection of network data in 2014 and like us document declines in network density and closure which in their case are generated by political maneuvering and elite capture a key difference between cdd and microcredit is that the injection of the former is massive and at the community level whereas microloans are both smaller in size and are only suitable for a small subset of the community so the general equilibrium effects on network structure come from very different sources and for different reasons 6 our study contributes to and extends this line of inquiry a main lesson from our paper is the presence of significant and widespread spillovers in network formation across types of people and types of relationships which is indicative of a global network externality we also use this evidence to build and argue for a new model of network formation that highlights the fact that social networks are not designed but result from the decentralized decisions of individuals as our empirical results highlight in such an environment a shift in the incentives of one group of people to form links can have substantial effects on other parts of the network and groups that they ignore when choosing their own behavior 7 the remainder of the paper is organized as follows in section 2 we describe the setting network data collection the classification of households into h and l types using a random forest algorithm and sample statistics section 3 presents our empirical results motivated by the data in section 4 we develop a new dynamic model of network formation that is consistent with it and discuss why four standard models from the literature are inconsistent with the data section 5 presents impacts on informal borrowing and the capacity for households to smooth consumption section 6 concludes setting data and sample statistics 21 setting karnataka in 2006 the microfinance organization bss provided us with a list of 75 villages in karnataka in which they were planning to start lending operations the villages were spread across 5 districts of the state of karnataka in india prior to bsss entry these villages had minimal exposure to microfinance how individuals social networks change when randomly assigned to receive a savings account in nepal their focus is on postintervention expenditure spillovers taking into account network change due to the exposure to the savings account 6 nonetheless our model could still be useful in understanding the effects in such interventions 7 see jackson for background on inefficiencies in network formation here we see general networklevel externalities of course this does not mean that microcredit should be discouraged but only any welfare analysis needs to take into account the potential for spillovers six months prior to bsss entry into any village in 2006 we conducted a baseline survey in all 75 villages this survey consisted of a village questionnaire a full census that collected data on all households in the villages and a detailed followup survey fielded to a subsample of adults by the end of 2010 bss had entered 43 villages that were not randomly assigned by us but rather selected by the bank we have anecdotal reasons to believe that the choice was not systematic bss planned to enter all of the villages but slowed down and ultimately stopped expanding during the andhra pradesh microcredit crisis for background on that crisis hyderabad in 2006 spandana a large microfinance institutionrandomly chose 52 of 104 neighborhoods in hyderabad to enter after two years the remaining 52 neighborhoods received access in mid2008 the shortand mediumrun impacts of randomized access to microfinance in this setting are studied in banerjee et al the ap microcredit crisis also impacted spandana and its lending activities in hyderabad in 2010 all of the households in the hyderabad sample faced simultaneous withdrawal of microcredit in response to an ordinance halting microcredit loans a third round of data collection was done in 2012 with a sample of 5744 households at the time of the 2012 data collection the treatment neighborhoods had been exposed to microcredit for 6 years and the control neighborhoods had been exposed for 35 years network data was collected during this third round the early treatment neighborhoods had greater microfinance access overall because microfinance borrowers typically receive larger loans each time they borrow microcredit supply is increasing in the length of exposure banerjee et al show that two years after the control group received access households in treated neighborhoods still had 14 more contemporaneous microfinance borrowing and 43 more cumulative microfinance borrowing over the preceding three years however since nobody had access to microfinance at the time of our network survey any changes to network structure that we pick up must be the result of the extra exposure to microcredit before it was shut down some two years before our survey in other words the effect persists despite there being no differences in contemporaneous participation in microcredit data 221 karnataka to collect the network data 8 we asked adults to name those with whom they interact in the course of daily activities in wave 1 collected in 2006 we have the full village census and network data from 46 of households per village in wave 2 collected in 2012 in addition to taking the full village census again we have network data from 8914 of the 16476 households this means that we have network data in wave 1 on 708 of the links and in wave 2 on 988 of the links when we build the undirected unweighted graph that we study9 for the network analysis we concentrate on households that are present in both waves and only look at objects where we are able to discern in both waves whether the structure exists or does not exist we have data about 12 different types of interactions for a given survey respondent whose houses he or she visits who visits his or her house relatives they socialize with nonrelatives they socialize with who gives him or her medical help from whom he or she borrows money to whom he or she lends money from whom he or she borrows material goods to whom he or she lends material goods from whom he or she gets important advice to whom he or she gives advice with whom he or she goes to pray using these data we first look at the financial network above as well as the informational network from above after demonstrating that links across both categories change in similar ways we aggregate the network data as follows we construct one network for each village at the household level where a link exists between households if any member of either household is linked to any other member of the other household in at least one of the 12 ways we assume that individuals can communicate if they interact in any of the 12 ways so this is the network of potential communications the resulting objects are undirected unweighted networks at the household level we also asked in both wave 1 and wave 2 for households to give us a list of all outstanding loans that they have taken the sources of these loans and their terms we use this to create a panel to study changes in borrowing patterns in our analysis we look at all households who existed in wave 1 this involves those who remained and those who split we match households who split in wave 2 to their wave 1 counterpart 11 migrated out though this is not differential by microfinance exposure and 48 wave 2 households inmigrated or split off from existing households again not differential by microfinance exposure 10 222 hyderabad the hyderabad analysis draws on three waves of data these data are also utilized in banerjee et al and banerjee et al the first round of data collection was conducted in late 2007 early 2008 1518 months after microfinance was made available in the treatment group following this first wave the control group also received access to microfinance in may 2008 a second round of data collection was conducted in mid2010 to examine longerterm impacts of access to microfinance coincidentally this wave took place just before the ap crisis mentioned above finally in 2012 approximately two years after the ap crisis a third wave of data collection took place all three waves collected information about household composition income consumptionexpenditure borrowing and entrepreneurship for the third wave only we also measured aspects of households social networks however we could only collect partial network data across the 104 neighborhoods in hyderabad so instead we collected aggregated relational data because we collected this information only in the 2012 wave 3 data the majority of our analysis uses wave 3 only an exception is the analysis of consumption smoothing which leverages the panel nature of the data specifically an average of 55 households in every neighborhood in the hyderabad sample were surveyed and asked a set of network questions first respondents were asked how many links they had within the neighborhood along three dimensions financial social and informational11 this is the directly solicited part of the network information second respondents were asked 9 ard questions of the form how many individuals from your neighborhood do you know who have trait x for instance traits include how many other households do you know where there are 5 or more children and how many other households do you know where any member is a permanent government employee supplemental appendix e1 details both types of survey questions third we asked each sampled household whether they possessed each of the ard traits we use the method of breza et al to leverage ard data to estimate key network characteristics we give a more detailed description of the algorithm in supplemental appendix e2 ard counts the number of links an agent has to members of different subgroups in the population the basic idea is that by combining this information with a model of network formation one can estimate which possible networks would have generated this sample specifically we assume a latent distance model where the probability of a connection depends on individual heterogeneity and the distance between pairs of nodes in a latent social space basically by triangulating the information about how many nodes of each type a given respondent knows we can learn a lot about where the individual is likely to be located in the latent space this allows us to estimate a distribution over possible network configurations that could have generated this sample information we can then generate graphs from this distribution and compute network statistics for each generated graph for many applications that information about the potential networks is enough to draw relevant conclusions 12 here we are mainly interested in the frequency of different types of relationships which is easily recovered from ard note that the way we elicited the ard means that we only have information about one single type of link encompassing all dimensions of interaction both financial and nonfinancial 13 23 sample statistics and covariate balance table 1 panel a shows wave 1 network characteristics by treatment status in karnataka while panel b shows wave 1 household demographics the networks are sparse the average density is 119 the average clustering coefficient is 033 finally these networks have short distances the average closeness is 0379 14 in general the network structure and demographic variables look quite similar between the microfinance villages and nonmicrofinance villages at baseline however the mf villages are larger on average than the nonmf villages 15 we further examine baseline balance on an expanded range of demographic and villagelevel covariates in online appendix table c1 panel a next we turn to hyderabad recall that since we have an endline crosssection we only measure the network characteristics after the intervention to test for balance in online appendix table c2 we show the means of select network characteristics in control neighborhoods in this urban sample the networks are even more sparse than karnataka the average degree is 60 for an average neighborhood size of approximately 200 households average clustering and closeness are also smaller in table 1 panel c we present sample statistics and tests of covariate balance using a set of predetermined neighborhood and household characteristics given that the introduction of microfinance was randomized in the hyderabad sample the covariates are 12 for example breza et al shows that ard data can replicate the results of breza and chandrasekhar as well as if the entire network was observed we also validate ard in the hyderabad dataset specifically in the surveys we directly measured support the likelihood that for any link there exists a third person who has a relationship with both nodes we validate ard by comparing the estimated measure of support using the ard algorithm with the directly elicited survey measure in this way we can show that the ard estimate leads to the identical conclusions 13 the ard algorithm requires information on the total population of each neighborhood unfortunately we were unable to collect this information for 15 of the 104 neighborhoods therefore in specifications that use population as an input we drop these neighborhoods from the analysis 14 in order to deal with the fact that we sampled data in wave 1 we compute average density among the sampled households in wave 1 comparing the share of realized links relative to potential links when we fully observe the potential link we compute the clustering coefficient among the subgraph induced by restricting to sampled households in wave 1 since that is centered around the true parameter it is also worth noting that the correlation among the different link types is 0638 15 in online appendix m we show that our main results are robust to allowing for differential trends by functions of village size balanced in treatment and control again online appendix table c1 includes an expanded set of predetermined covariates classifying nodes as h and l in order to study heterogeneity in effects by propensity to participate in microfinance we need to identify which households would have had taken out microfinance loans in the nonmicrofinance villages or neighborhoods had bss or spandana entered those villages to do this we use a random forest model to classify an individuals propensity to take up microfinance as a function of baseline characteristics in the presence of microfinance we can then use this classification exercise to predict which individuals in the entire sample have a high propensity to borrow we begin with the karnataka setting one obvious determinant of microfinance takeup is from the bss rules only households with a female in the age range 1857 were eligible for microfinance also certain households were identified by bss as a leader household and were specifically informed about the product 16 therefore leaders or people close to them in the network are more likely to have heard of the microfinance opportunity and have taken it up we estimate the random forest model based on household demographics and network characteristics from the microfinance villages on a training sample of 7199 households and then validate the method on a testing sample of 2399 households the features are as follows a dummy for the household being a bss leader which are households with an individual that the microfinance institution would approach when entering a village a dummy for whether the household has a female of eligible age which was a requirement to be able to participate in microfinance the average closeness to leaders which is relevant because as in banerjee et al those who are closer to leaders should be more likely to hear of microfinance the average closeness to samecaste leaders because interactions within caste are more likely and therefore should influence the likelihood of being informed and the share of samecaste leaders in the village the details of the estimation algorithm implemented choices and quality are presented in appendix b turning to the hyderabad setting the strategy is similar though spandana did not have such clear rules for selecting borrowers thus we consider 19 predictors of a households takeup of spandana including demographic characteristics of the household as well as demographic data for the village we again use random forests training a model on 2520 households and then validating the model on a testing sample of 1080 households we then apply the classifier to both microfinance villages and nonmicrofinance villages to classify each household as h or l a major advantage of using random forests is that they naturally allow for nonlinearities and potentially complex interactions between characteristics that could drive microfinance takeup if the likelihood of being a microcredit taker or not is very nonlinear in the characteristics then random forest provides a very sensible and flexible approach alternatives such as logistic regression would not be able to handle such interactions and nonlinearities without typically introducing a very high dimensionality of interaction terms a related advantage of random forest comes from its value in identification because random forests allow for classification via a complicated nonlinear function of the network and relation to leadership positions in the karnataka data where we have baseline network data we can control smoothly for network position and network position interacted with post therefore unobservables correlated smoothly with network parameters are unlikely to drive the karnataka results random forest classification does have a few downsides first because of the highly nonlinear structures that can arise the actual mapping from characteristics to classification are less interpretable than with logistic regression models this is not a major problem in our case since we are more interested in prediction than interpretation second if the true underlying datagenerating process has logodds that are linear in parameters then the random forest may overfit therefore for robustness we also present our main results in appendix k using logistic regression to classify households into h and l types for both karnataka and hyderabad in appendix section b5 we show that random forest outperforms logit in both samples in terms of typical classification quality metrics further all of the results are replicated in the karnataka sample where logit classification is at least comparable to the random forest in hyderabad logit classifies types much worse17 table 2 presents some summary statistics from the classification exercise in panels a and b we look at karnataka data there are notable differences between h and l households although none of these features were used in the estimation we find that h households are much more likely to be scst have smaller houses in terms of room count are much less likely to have a latrine in the household and are much less likely to have an rcc roof all of which suggests that they tend to be poorer finally we see that h households have somewhat larger degrees than l households and the composition exhibits homophily h types have a lower number of links to l types and a higher number of links to h types finally h households are more eigenvector central in the network which is not surprising given that they were selected to be close to leaders who themselves tend to be more central in section 51 we show that indeed h types borrow considerably more than l types in microfinance villages h types borrow rs 1787 more than l types indicating that the classification performs well panels c and d turn to the hyderabad data and look only at the nonmicrofinance villages in panel c in contrast to karnataka we find no significant difference between h and l households in their demographic characteristics turning to network characteristics in panel d we see like in karnataka that h types have fewer links to l types more links to h types and are more central again in section 51 we show that one year after microfinance entered the treated neighborhoods h types had considerably more microcredit than l types in early microfinance neighborhoods changes in networks how does exposure to microfinance change networks we begin with a discussion of how the overall structure of social networks are affected and then the effects on different types of bilateral links as well as triads 31 effect on the total number of links we first look at how introducing microfinance affects the overall structure of the village social networks in the karnataka data where we have a panel but no randomization we use a differenceindifferences framework y α βmicrofinance v × post t γmicrofinance v ηpost t δ x v vt where y computes the density of the network g vt for village v in period t the average closeness or clustering the density is the percentage of links a random household has to all other households in the village so it measures how wellconnected the village is on average 18 the distance in the network is the number of steps through the network it takes to get from one household to another in models where favors transactions or information travel through the network higher distance or lower closeness means that the movement of such phenomena through the network is slower finally clustering is the share of a households connections that are themselves connected economic models of network formation identify clustering as an important feature to sustain cooperation in the hyderabad data where we only have endline data we run a crosssectional specification x v is a vector of control variables which varies according to the specification table 3 panel a presents the results for karnataka columns 13 present the result for network density columns 46 for clustering and 79 for closeness the first column in each category present a simple difference in differences specification the second column in each specification adds to that a vector of baseline controls interacted with textp ost t as well as the controls interacted with treatment and post t these controls include share of uppercaste households number of households in the village network density share of households in selfhelp groups share hindu share with a latrine in the house share that own the household share that have electricity and share that are leaders we add these because differences in the size of the village caste composition or the wealth distribution could potentially have differentlyevolved networks even without introduction of microfinance while the entry of bss does not seem to correlate with much of anything beyond village size we include these controls to ensure that they do not drive the results finally the third column in each specification includes village fixed effects as well as controls for the baseline value of the outcome variable interacted with post to allow for differential time trends by baseline network feature because we only have 150 observations but many controls we use the double postlasso procedure to select the controls 19we find that exposure to microfinance leads to a drop in density by about 1213pp relative to a mean of 114 in nonmicrofinance villages in wave 1 this is an 11 drop in density we dont find any detectable effect of microfinance on the clustering of the village this is true irrespective of whether controls are used without controls we find a significant decrease in the average closeness corresponding to a 053 standard deviation effect however this loses significance in columns 8 and 9 with the inclusion of controls panel b turns to the hyderabad data which uses an endline crosssectional dataset rather than a panel but takes advantage of the random selection of neighborhoods to treatment there we run the following specification y α βmicrofinance v δ x v vt our vector of controls x t are demographic characteristics of the household and the village the same ones used for classification of h and l we again use dpl to select the control variables we find that there is a 22 decline in density we do not find meaningfully significant results on clustering or closeness thus in both settings we find a reduction in the density of the network how are links affected by microfinance in this subsection we explore how microfinance exposure affects the formation of links across types of households our hs and ls bilateral links can be of three types hh lh and ll let g ijvt be an indicator for whether a link is present between households i and j in village v in wave t letting lh ij be an indicator for pair consisting of one low type and one high type and analogously for hh ij etc the regressions we run take the form g ijv2 α βm f v β lh m f v × lh ijv β hh m f v × hh ijv γ lh lh ijv γ hh hh ijv δ x ijv ijv2 where x ijv includes a vector of flexible controls for centrality of both nodes demographic variables all variables that are used in the random forest classification and then interactions of all of these variables with the microfinance dummies the idea behind identification is that the classification type h or l is a complex nonlinear function with many interaction terms of a subset of the features described above as such we can still smoothly control for them and allow the control to vary by whether the village is exposed to microfinance or not this allows us to control for the potentially differential effect of microfinance exposure on households that are demographically distinct and located differently in the network under the maintained assumption that these effects can be capture by linear uninteracted terms the coefficients of interest capture whether being in a microfinance village differentially affects the evolution of a link among types classified as hh hl and ll conditional on all the characteristics above and their interaction with mf we also present regressions without any controls whatsoever to demonstrate that the results are robust to the presence or absence of these detailed controls altonji elder and taber show that if the results do not change when we introduce more and more controls this provides some support for the view that unobservables are not spuriously driving the results we run these regressions in two samples the set of ij such that g ijv1 1 and the set where of ij such that g ijv1 0 in which case we ask about the probability of a new link forming in wave 2 table 4 presents the linklevel results for any type of relationship in the karnataka data in columns 12 we focus on the set of links existing in wave 1 and in columns 34 we focus on the set of unlinked nodes in wave 1 columns 1 and 3 include no controls whatsoever columns 2 and 4 introduce the set of controls variables and their interaction with mf selected by doublepost lasso the key coefficients for testing the hypotheses are the coefficients on microfinance which captures the effect on the omitted category ll links as well as microfinance×lh coefficients and microfinance×hh which ask whether the effects are different for these types of links compared to ll columns 1 shows that ll links break significantly more in mf villages relative to nonmf villages specifically they are 58pp less likely to exist in wave 2 on a base of 482 in nonmf villages the decrease in lh links is very similar while the hh links are somewhat less likely to disappear the results are robust to the inclusion of control variables columns 3 and 4 present similar results for link formation ll links are 23pp less likely to form in microfinance villages on a base of 75 in nonmicrofinance villages again the effect is comparable for lh links while it is less pronounced for hh links all of these results are robust to smoothly controlling for the centrality of nodes involved as well as demographic controls and their interactions with microfinance the relative changes in network structure in the microfinance villages shed light on network formation the fact that the lh links break might reflect the fact that the hs are no longer interested in maintaining their links with the ls now that they have an alternative source of credit but the fact that ll links are equally likely to break is more surprising especially since the ls should have a stronger incentive to hold on to their mutual links precisely because they no longer have access to the links with the hs 20we turn to the hyderabad data in table 5 in this case we have only crosssectional information on networks so we cannot condition on preperiod link status therefore we run the regression in the sample of any possible link ij the microfinance coefficient identifies the effect on ll links and captures a combination of link formation and link destruction column 1 includes only the randomization strata as controls while column 2 additionally allows for any of the household or village level controls used in the random forest classification to be included in column 1 we find a 06 percentage point decline in the probability that an ll link exists in microfinance neighbhorhoods relative to nonmicrofinance neighborhoods we cannot reject that the estimates for lh and hh are the same but they are imprecisely estimated the estimates are quite similar in column 2 after adding controls we next unpack these findings for financial links versus information links table 6 panel a presents the results in the karnataka data where columns 1 and 2 consider the evolution of financial links while columns 3 and 4 consider nonfinancial links columns 1 and 3 restrict to links of each type that existed in the wave 1 data while columns 2 and 4 restrict to pairs of individuals that were not linked in wave 1 the patterns are strikingly similar across financial and information links which is evidence of multiplexing in fact for information links we find that the disappearance of hh links is significantly smaller than that of ll links in the hyderabad data recall that the linklevel information analyzed in table 5 is constructed using ard which defines a link as a relationship occuring on any dimension so we cannot run an exactly parallel specification however we did collect supplemental nodelevel information on relationship type that allows us to explore whether microfinance affects financial and nonfinancial links differentially panel b of table 6 presents householdlevel regressions where the outcome variable is the number of financial or nonfinancial links and the regressors are m f and m f h the main effect of m f identifies the effect of microfinance exposure for l households it is is negative and highly significant on both the number of financial links and the number of nonfinancial links the interaction effect microfinance×h identifies the differential effect of microfinance access for h households those with high propensity to borrow the interaction effects are positive and significant for all outcomes considered the total effect for h households is in fact positive for all outcomes as in karnataka nonfinancial links have similar patterns as financial links consistent with multiplexing and while h households appear to hold steady or even gain links in response to microfinance exposure the l households clearly and unambiguously lose links group relationships in the linklevel analysis we show that ll links relationships between two individuals who experience minimal if any direct impacts from microfinanceare at least as likely to be affected as relationships involving h types one natural place to look first to try to understand this result is local payoff externalities does the decline in ll links stem from these housesholds links to other h households who join microcredit bloch genicot and ray ambrus mobius and szeidl jackson rodriguezbarraquer and tan all propose models where contract enforcement requires groups of nodes rather than simple pairs in jackson rodriguezbarraquer and tan for example two households seeking to exchange favors may not have enough bilateral interaction to be able to sustain cooperation in isolation however if they both have relationships with some other households in common then the relationships can all support each other and provide incentives to cooperate if someone fails to cooperate with one of their friends then beyond losing that relationship they can also lose relationships with all of the other friends that they had in common our network data exhibits such groupings with the rates of a group of nodes being collectively linked far exceeding the rate to be expected if decisions were made independently these interdepencies in link formation may explain the impact of microfinance on ll links if there are payoff externalities l types might value an ll link more when there is a third node involved the introduction of microcredit could destabilize these structures in groups that are composed of both l and h types it could be the case that microfinance directly causes lh links to break which in turn spills over to adjacent ll links in the same group in this world groups only composed of l links should experience minimal impacts the direct testable implication is that if we focus on triangles that existed in wave 1 we should see a larger decline in triangles involving at least one h than in lll triangles we use the following regression specification to test this hypothesis y ijkv2 α βm f v β lhh m f v × lhh ijkv β llh m f v × llh ijkv β hhh m f v × hhh ijkv γ lhh lhh ijkv γ llh llh ijkv γ hhh hhh ijkv δ x ijkv ijkv2 where y ijkv2 is either a dummy for whether the triangle ijk exists in wave 2 in some specifications or whether any link in the former triangle exists in wave 2 in other specifications the vector x ijkv includes flexible controls for centralities of households demographic characteristics previously described for all households all classification variables used in the random forest model and the interactions of all of these variables with microfinance as before we present regressions with and without control variables table 7 presents the results in the karnataka data in column 1 we find that all triad types break faster in microfinance villages relative to nonmicrofinance villages however lll triads that existed at baseline are the most likely to break in microfinance villages specifically they are 78pp more likely to dissolve in microfinance relative to nonmicrofinance villages lhh triangles and hhh triangles are both statistically less likely to dissolve than lll triangles the results are similar if less precise with control variables similarly in column 3 we see that out of formerlylinked triangles we are more likely to see that none of the links survive for lll triangles in m f villages and that this is significantly less likely to occur for llh lhh and hhh triangles table 8 presents the hyderabad results and measures whether microfinance affects the event that a given set of three households are all linked because the likelihood of any potential triangle being fully linked is low we scale all regressors by 1000 for readability 21although the results are noisier than in karnataka we find once again that lll triangles are negatively affected by microfinance in column 1 we are 60 less likely to see any lll triangle in mf neighborhood the effect is the same for lhh and smaller for llh the only difference is that hhh are the triangles who appear to be most likely to be missing in mf villages in summary while there is evidence for interdependencies in the persistence of network relationships in our data we find that microfinance affects lll triangles particularly strongly this suggests that models of local externalities are unlikely to be able to explain our results the next section proposes an alternative model that can better rationalize them a model in this section we present a new model of network formation that is consistent with what we see in the data the model provides new perspectives both on how opportunities to interact arise and on how multiplexing works the externalities in the model do not take direct forms like value of friendsoffriends or support or other link interactions that are often used to incorporate externalities they instead arise more globally in the search process by which people make and maintain friendships we present the model for links and then describe how it can be extended to cover triads as the model is useful beyond the current setting of microfinance we describe it in a general form and then specialize to the twotype microfinance case types and utilities there are n individuals indexed by i j ∈ 1 n agent i has a type θ i from a type set θ let v θθ denote the base benefit that an agent of type θ gets from a relationship with an agent of type θ for example in our context this can come from borrowing and lending activities as we discuss in more detail below the realized utility from a relationship also involves an idiosyncratic noise term ε ij that i gets from being friends with j this could be personality compatibility or some other benefits thus an agent i gets a value v θ i θ j ε ij from a connection with j where ε ij is distributed according to an atomless distribution f a useful expression is e v e v ε ij ε ij v v ´∞ v ε ij df ´∞ v df which denotes the expectation of v ε ij conditional the value of v ε ij being positive this is the expected utility that an agent gets from a relationship with base value v conditional upon being willing to form the friendship an agent of type θ then has an expected utility from d θθ friends of type θ of θ ∈θ d θθ e v θθ 42 efforts and link formation each agent chooses an effort e i ∈ 0 1 which represents the amount of time they spend socializing to form and maintain links in the case of the villagers this could be time spent in the town square or tea shop where they meet with other villagers 22 as will become evident our model is meant to capture both link formation and link maintenance two agents i and j who have chosen efforts e i and e j have probability proportional to e i e j of meeting the model therefore rules out directed search since the probability of meeting is independent of the agents type conditional on their effort time goes in periods t ∈ 0 1 2 let g t ∈ 0 1 n×n be the adjacency matrix representing network at time t if g t1 ij 1 then those agents were connected in the last period and they keep their friendship if they meet with each other during time t keeping the relationship requires seeing each other therefore agents i and j keep their friendship with probability e i e j and lose it with probability 1 e i e j if g t1 ij 0 then agents i j were not connected in the last period and form a friendship with probability e i e j 1 f v θ i θ j 1 f this is the probability that they meet and they both find the friendship of positive value a friendship requires mutual consent in our model thus the efforts of agents do two things they maintain old relationships by continuing an interaction but also allow them to meet new people steadystate equilibrium a steadystate equilibrium is a list of efforts θ∈θ and a corresponding set of expected degree levels θθ ∈θ 2 such that e θ maximizes each agents expected utility and the expected degree levels are in steady state as generated by the efforts 23we prove in the appendix a that in all equilibria all agents of the same type choose the same action and that the equilibrium is unique provided that costs of effort are large enough the requirement that degrees are in steady state and generated by the efforts can be formally represented as follows let n θθ denote the number of agents of type θ with whom an agent of type θ could potentially form friendships if θ θ then this will generally be the number of agents of type θ 24 while if it is of type θ then it will less by one to account for the agent herself out of those agents only an expected fraction of will ever be friends with an agent of type θ given the mutual consent requirement thus let m θθ n θθ this is the effective size of the pool of agents of type θ with which an agent of type θ will be friends over time degree at the end or beginning of a period is then the maintained relationships plus the new ones formed d θθ e θ e θ d θθ e θ e θ which simplifies to d θθ m θθ e θ e θ n θθ e θ e θ thus in steady state the degree is then proportional to the number of available agents of the other type weighted by the probability that there is a mutual compatibility and by the socializing efforts the expected utility of an agent involves the benefits from relationships the costs of socialization 1 2 c θ e 2 θ as well as a benefit just from from socializing u θ e θ an agent may get some value from going to the town square or getting tea etc independently of who else is there overall this leads to a utility of v θ u θ e θ 1 2 c θ e 2 θ base socializing benefit and cost of effort θ ∈θ e v θθ d θθ e θ e θ expected maintenance of existing friendships by effort θ ∈θ e v θθ e θ e θ expected new friendships from effort using the expressions for m θθ and d θθ we can write this as v θ u θ e θ 1 2 c θ e 2 θ θ ∈θ e v θθ n θθ e θ e θ if we take u θ 0 c θ 0 for all θ and e v θθ ≥ 0 for all θ θ then an equilibrium requires that25 e θ min    1 1 c θ   u θ θ ∈θ e v θθ n θθ e θ      44 equilibrium existence and some comparative statics this is a game of strategic complements and for such games equilibria exist and form a complete lattice 26 if u θ 0 for all θ then there exists a corner equilibrium in which all agents exert 0 effort to examine the more interesting case we presume that u θ 0 for all agents so that agents gain some utility from socializing regardless of the connections they form from it in this case for high enough costs of socialization there exists a unique equilibrium which has the property that there are spillovers from a change in the preferences of any type on the effort choices of all other types the following result is proven in appendix a proposition 1 let u θ 0 c θ 0 for all θ for sufficiently large c θ 0s there is a unique equilibrium and it is stable 27 and interior and agents of the same type take the same efforts in addition if e v θθ 0 n θθ 0 for each θ θ 28 and v θθ is reduced for some θθ then e θ decreases for all θ and d θ θ decreases for all θ θ the characterization of equilibrium is as follows let u be the θdimensional vector with entries 1 c θ u θ and e be the θ × θ matrix with θ θ entries 1 c θ e v θθ n θθ then the unique equilibrium is given by e 1 u which we show is welldefined for large enough costs in the appendix a a major implication of the proposition is that a reduction in the returns from any type of relationship decreases all efforts and degrees the decrease in value v θθ for some θθ directly affects their efforts decreasing those then given the strict strategic complementarities there is then a decrease in other efforts and the feedback can lead to a substantial drop in all efforts note that the relative drops in efforts and degrees predicted in proposition 1 are not necessarily ordered across groups degree can fall most among groups of nodes that experience no direct decline in link valuation the intuition is that if marginal benefits to ls from connecting to hs are particularly high then when hs drop effort payoffs for ls from effort can drop even more than for hs leading to an even larger effect on ls see online appendix n for a simulation demonstrating this phenomenon 45 externalities in network formation even though our model does not include direct externalities in payoffs between links the networkformation process still exhibits significant external effects since agents decisions to form links affect others potential payoffs and their network formation decisions this makes a point beyond the current setting network formation can be inefficient not simply because of direct externalities in relationships which is how it is usually modeled 29 but also because meeting people requires effort and this naturally generates strategic complementarities and substantial externalities 27 slight changes in efforts lead to best reply dynamics that converge back to the equilibrium 28 all that is needed for this result is that this holds for a cycle of θ and θ that include all types note also that e v θθ 0 does not require that all people form links just that there is a nonzero probability that any two types could find a high enough noise term to form a friendship 29 this class of models can incorporate inter alia risk sharing information sharing and network support for references see jackson 46 specializing to microfinance we next present a specialized case of the model to analyze how microfinance changes incentives for socialization we first present the steadystate conditions for the case of two types h and l we then discuss how the introduction of microfinance maps to the model parameters specifically the v θθ s 461 two types we now specialize the model to the case of two types θ h l let λ be the share of h types in the population in this case a steadystate is a solution to the equations c h e h u h e v hh 2 e h e v hl n e l c l e l u l e v ll n 1 2 e l e v lh λn e h d hl n e h e l d lh d hl λ 1 λ d hh 2 2 d ll n 1 2 2 the equilibrium vector of efforts and network structure are determined by this system 462 application to microfinance an example how does the entry of microfinance affect these parameters here we present a rationalization for the payoffs based on informal borrowing and lending in particular let the values v θθ be interpreted as financial payoffs from borrowing and lending this tells us how v hh v hl v lh v ll change in response to hs getting microcredit lending produces a net return of r which represents the effective expected interest rate from informal loans less the opportunity cost of funds borrowing leads to a return net of repayment of b which represents the difference between the interest rate charged by a network friend and the opportunity cost of foregoing that loan generally we expect b 0 and b r 30 as otherwise such relationships make little sense whether r is positive or negative is not obvious since there are clearly social expectations to help out friends in need and may depend on context a household can be in one of three states of the world they have money to lend they need to borrow or neither an h household has a probability α h of having money to lend and a probability β h ≤ 1 α h of needing to borrow and with the remaining probability 1 α h β h neither occurs there are similar probabilities α l and β l for the l types the base payoff to an agent of type θ ∈ h l of being matched to agent of type θ ∈ h l is then v θθ α θ β θ r β θ α θ b as in the general model we assume that expected utility is additive across all relationships and that pairwise payoffs v θθ are independent of other friendships 31the introduction of microfinance changes these parameters there are several likely channels by which the introduction of microfinance affects the payoff parameters of h types from linking to others access to microcredit might impact both the demand and supply of informal loans by h types if access to microcredit substitutes for informal loans then we would expect β h to decrease if alternately the weekly required repayments are burdensome to households they may have to cut back on lending smaller sums to others in the village and may even start borrowing small amounts to repay the loans when cash is short leading to a decline in α h and perhaps an increase in β h in addition if there are complementarities between formal and informal loans because receiving a mf loan allows the household to overcome a nonconvexity 32 β h could go up in contrast if relending of formal credit to network partners is common a type h may have a probability α h ≥ α h of being able to lend once she gets access to microfinance her probability of needing to borrow may also go down to β h ≤ β h if microfinance loans are a substitutes for network credit in any case we maintain that the ls needs for borrowing and lending are unaltered by the introduction of microfinance let ∆β h β h β h and ∆α h α h α h be the changes in the probabilities that the h types have borrowing and lending needs after microfinance by our previous assumption ∆v ll 0 let ∆ θθ denote the resulting change in v θθ to get a feeling for how this depends on ∆α h and ∆β h note that for small values of ∆α h and ∆β h we get approximations ∆ hh ∆ ll 0 ∆ hl α l ∆β h b β l ∆α h r ∆ lh α l ∆β h r β l ∆α h b as we describe above the arrival of microfinance may impact the valuations through a range of mechanisms different mechansims imply that ∆β h and ∆α h could each be positive or negative making it very hard to say anything general about the signs of these expressions for example consider the special case in which α l α h β l β h and α h ∆β h β h ∆α h 0 in this case ∆ hh 0 meanwhile as discussed above we expect b r to be positive then ∆ hl should be positive whereas ∆ lh should be negative as long as ∆β h 0 and ∆α h 0 33 given that different valuations move in different directions the prediction of how the different types should respond is unsigned however one obvious special case is when both α h and β h go down in this case as long as both b and r are positive it is easy to see that all of v hl v lh and v hh must go down thus proposition 1 applies implying that e h e l d hh d hl d lh d ll should all fall however the relative declines in degree across groups are unsigned in online appendix n we use simulations to show that it is indeed possible that ll links may be most affected given the decreased effort of hs as well as the hs lower propensity to want to link with ls given their decreased borrowing needs if this payoff drop is large enough for ls given their original benefits from connections to hs this can lead to a larger drop in ls efforts and hence in ll links 47 extensions of the model the simple model can be extended in several directions first the model is solved in steadystate adding a population of unlinked agents to the population of the unmatched is straightforward as is having agents exit second our basic model also has no place for triads which we previously saw to play a key role this can be added directly simply by having triples meet if they are all present in the town square the extension is straightforward and thus omitted for more detail on such an extension in such a model analogous to the pairs case above it would be direct that ll and lll could decline more than their counterparts third note that it is plausible that when one aspect of a relationship becomes less important there is some risk that the entire relationship breaks up since there is a fixed costs of maintaining a relationship by adding other types of links that are maintained and formed at the same time as financial links the model can generate similar effects on other links as well as we saw above in table 6 when we look at advicebased links the effects are more or less of the same magnitude in proportional terms and in the same direction as the financial links 48 alternative explanations in this section we try to address two issues first can we account for the facts without going to a model with undirected search while maintaining our assumptions about changes in payoffs second are there alternative assumptions about changes in payoffs that can help us account for the facts in combination with a simpler model of network formation 481 alternative models of network formation in appendix d we discuss four other models of network formation variations of which are already in the literature we show why one needs a model that goes beyond those models to generate the patterns in our data as such our work contributes to the literature on network formation by introducing a model that combines features of different existing models and showing why that combination of features is needed to match what we observe in the data previous models of network formation that involve explicit choice by agents 34 have three flavors models in which people have the opportunity to connect with whomever they want subject to reciprocation dutta and mutuswami bala and goyal currarini and morelli jackson and van den nouweland herings mauleon and vannetelbosch jackson rodriguezbarraquer and tan boucher models in which there are exogenously random meetings and then conditional upon meeting people choose with whom to connect jackson and watts christakis fowler imbens and kalyanaraman könig tessone and zenou mele and models in which people put in some effort to socialize which then results in some random meetings but then relationships are formed as a result of those efforts without further choice cabrales calvóarmengol and zenou canen jackson and trebbi first the empirical patterns that we observe here require a model with some externalities in the efforts to search and meet which are not present in or the basic point is that any model that gives agents full control over who they try to link with which is what fails with undirected search cannot explain why ll and lll relationships drop in response to a decrease in hs willingness to link to ls 35 our model relies on the idea that individuals put effort into trying to meet but cannot choose who they are meeting the reason hs lower effort less than ls is that they are more optimistic about actually linking with those who they meet if on the other hand the ls could costlessly meet with each other or they meet people at random at no cost and can decide who to pair with ll and lll links should go up second models in class allow for search efforts but then do not involve the choices of whom to connect to as are present in and this choice of whom to connect to is important in adjusting the incentives and the relative rates at which hl links form compared 34 there is also a large literature of network formation that involves no strategic choice but just a stochastic model of network formationevolution for some description and references those models are not equipped to match the data here 35 recall that the base model does not include friendoffriend effects while models with such local spillover effects can indeed generate the fact that ll and lll relationships drop they cannot explain why ll and lll relationships drop more than lh and llh as we discuss in appendix d3 to hh or ll links which is important in our analysis 36 thus the model that we introduce is a hybrid of these three classes effort is needed to meet others and affects the relative rates at which people are randomly met but then choice is involved conditional upon meeting thid in addition our model has two other features that help us to match the data one is that effort is not only needed to meet new people but also to maintain existing relationships as the patterns we observe in the data exhibit similarities both in terms of which relationships are retained and which new ones are formed the second is that socializing affects the opportunities to form multiple types of relationships at the same time and so relationships are naturally multiplexed the combination of all four of these features efforts to socialize with rates of meetings dependent on relative efforts mutual choice required to form relationships conditional upon meeting effort needed to maintain relationships and multiple types of relationships formed at the same time allows us to capture all of the nuances and rich patterns that we observe in the data in appendix d we discuss why dropping any one of these features would fail to capture some aspects of the data 482 alternative models of match value we have so far assumed that match value depends only on types and does not depend on the pattern of matching it is possible for example that matches are substitutes so that when many lh links break the value of ll links may go up this would predict an increase in ll links which goes in the wrong direction it is also possible though perhaps less likely that links are complements perhaps when an l can no longer borrow from the hs she gives up the entire project and therefore also stops borrowing from other ls however in this case the ll links break because some lh links have disappeared and therefore the effect on ll links will be smaller than the effect on lh links in proportional terms a similar possibility is that an l might want to link with another l because that second l is in turn linked to an h and this is valuable for another reason but as above in this case the ll links are breaking because lh links have disappeared and so again the effect on ll links would be smaller than the effect on lh links in proportional terms see appendix d32 for more details another possibility is that the reason ll links drop is that ls recognize that even if they dont participate in microfinance it is available to them this is probably true for some of them but because we use microfinance eligibility to determine who is an l it is less true for them than for the h an h is therefore more likely to break their link with an l on these grounds than another l yet another alternative is based on the idea that the very fact that hs tend to socialize with hs in microfinance meetings would provide a force unique to participants hence hs to form new links this might crowd out their other links but that would predict that lh links should decline by more than ll links we do not find this we further examine this alternative in online appendix h we show that our main results hold even if we condition on all pairs where neither member joined microfinance even under this restriction the h classification has content hs are more suitable for microfinance by construction and therefore even nonborrowers have higher option value from future access to microfinance37 however we acknowledge that these results are only suggestive given that actual microfinance takeup is endogenous another possibility is a slight variant of our undirected search model where the h types simply do not have time to meet with the ls anymore notice our general form of the model allows for this a final possibility is that the entry of microfinance leads to rapid economic growth in the village so that both h and l type dont need to maintain informal relationships any more this is not only inconsistent with the extensive literature on microfinance which finds little impact of microfinance entry on average village or neighborhood level outcomes such as consumption investment or business profit for a metaanalysis but it is also inconsistent with the household finances and borrowing that we see going on in the villages 38 moreover per se this explanation would also not account for larger effects for the l households informal credit and insurance 51 impact on borrowing patterns next we examine how both microfinance and informal borrowing respond to the arrival of microfinance in both the karnataka and hyderabad data we have rich borrowing information and we can measure the impacts of microfinance on several different types of household borrowing if the loss in network links corresponds to a drop in informal financial transactions then informal borrowing should respond in a manner similar to our network results above we have data on the amount borrowed by source for the entirety of our sample we begin by regressing the amount borrowed on dummies for microfinance village post and household type in the karnataka sample y ivt α β 1 mf v × post t γ 1 mf v × h iv × post t γ 2 h iv × post t γ 3 mf v × h iv δ 1 mf v δ 2 h iv δ 3 post t δ x ijv ivt where again y ivt is the amount borrowed from the stated source table 9 panel a presents the results for the karnataka data in column 1 we find that l households do borrow from mfi the coefficient is 477 rupees however h borrow much more than ls do column 2 finds that that l households lose more from their informal network than they gain from microfinance they lose rs 1045 in loans from their entire network after their village is exposed to microfinance the h households lose additionally more but this corresponds to their additional borrowing from mfis panel b of table 9 turns to the hyderabad data here we present impacts on borrowing measured in the first postmicrofinance survey wave 1518 months after microfinance was introduced in treatment neighborhoods39 y ivt α β 1 mf v γ 1 mf v × h iv δ 2 h iv δ x ijv ivt starting with column 1 we find no impact of mf on borrowing for l type in this case but a large and significantly greater impact for h types we again observe a decline in informal borrowing for l types all informal borrowing declines by rs4341 relative to a control mean of rs36347 here this decline is almost entirely offset for the h types though the difference between the two is not statistically significant taken together the evidence suggests that exposure to microfinance has an adverse effect on the network borrowing of the ls that is large enough to dominate their small potential gains from microfinance this is especially striking because all else being the same we would have expected their borrowing from friends to go down less than that of the hs or even to go up to the extent there is relending 52 impact on risk sharing one important role of village networks is risk sharing both through gifts and through soft loans whose terms are statecontingent udry moreover new policies can spillover onto others through risk sharing relationships 40 in light of our finding that access to formal credit results in the loss of network links and a reduction in informal borrowing it is natural to investigate whether risk sharing is also reduced if a households ability to buffer income fluctuations through informal risk sharing is worsened when their village has access to microfinance the loss of network links could have a direct negative impact on welfare microfinance practitioners often argue that even if borrowing households do not become richer because of the loans they should at least be better able to smooth risk through continued access to credit however nonborrowing l households may see a worseining of risk sharing and consumption smoothing as they have fewer links without any direct benefits from microfinance fortunately the hyderabad data contains panel information on both income and consumption 41 which allows us to run standard omnibus tests of risk sharing the loss of network degree is greater for the l types than the h types in contrast any direct benefits from microfinance borrowing are by construction lower for the l types relative to the h types thus we expect that risk sharing should worsen for l households in treatment compared to l households in control the predictions are less clear for the h types who may be able to smooth income risk using microfinance to test this prediction we estimate a version of the standard regression from townsend which allows the passthrough of income to consumption to differ by treatment status differentially for h and l types the subscript i indexes households v indexes villages and t indexes time microfinance villages are denoted with m f the term α i is a householdfixed effect which as well as controlling for the households timeinvariant pareto weight in a risksharing regression absorbs the main effect of treatment status and of type the term γ vt is a areatime fixed effect which captures the aggregate shock to a particular neighborhood in a given survey wave we estimate the following long differences specification using the first and third waves of the data 42 40 angelucci and de giorgi for example analyze the progresa cash transfer program in mexico and find that even noneligible households consume more moreover angelucci et al trace these impacts through the kinship network albarran and attanasio also analyze the interplay between policies and risk sharing highlighting the potential for risk sharing to go down due to improved outside options 41 recall the hyderabad data only contain network information collected in 2012 but income and consumption were collected in 20078 2010 and 2012 42 as noted by hayashi et al long differences may perform better than oneperiod differences if income changes are dominated by transitory measurement error or transitory wage changes or if income is known one period in advance moreover in our setting the second wave of data was collected at a point in time when both treatment and control areas had access to microfinance which may limit our ability to detect treatment effects on risksharing results using all three waves of data are qualitatively similar but less precise consistent with the measurement error concern noted by hayashi et al c ivt α i γ vt β 1 y ivt β 2 y ivt × m f v β 3 y ivt × h i β 4 y ivt × m f v × h i δ x ijv ivt the coefficient β 1 measures the extent of income passthough for l households in control areas the prediction that risk sharing should worsen for l households in treatment compared to l households in control is tested by the coefficient β 2 the coefficient β 3 captures the extent of income passthough for h households in control areas finally β 4 measures any differential treatment effect on risk sharing for h households 43table 10 presents the results in column 1 we consider total per capita household expenditure in column 2 we consider nonfood per capita consumption which is typically more discretionary and therefore more responsive to shocks we find that l households in control areas experience an inr 0059 drop in nonfood consumption for a inr 1 drop in income a 59 passthrough rate however for l households in treated areas the passthough increases by 0080 thus the loss of network links for l households is economically consequential in terms of worsened ability to buffer income fluctuations the estimates are qualitatively similar for total consumption but slightly less precise the remaining coefficients in table 10 consider how these patterns differ for h types we find that microfinance causes the passthrough of income into nonfood consumption for h types to decrease by 0107 rupees relative to the effect for l types for these types microfinance causes no detectable change to income passthrough in summary these results demonstrate that while h households ability to buffer income risk is unaffected by microfinance exposure this is not true for l households for them the loss of network links arising from microfinance exposure has negative consequences their ability to smooth income fluctuations is worsened markedly given the lack of microfinances effect on income these results show that the reduction in links for l types is in all likelihood welfare reducing conclusion by studying the introduction of microcredit to just a subset of communities in two different settings we established that not only did the social networks change in response but those who were least likely to take up microcredit experience substantial losses in links even in groups where no one was involved in microcredit this is accompanied by a loss in the ability to borrow from informal networks for those households and a reduction in their ability to smooth risk the results were first obtained in one setting and then confirmed in a second independent one to explain the data we developed a model in which agents put in effort in order to socialize whom they meet has an undirected component and agents engage in mutual consent to build links such a model features a global externality beyond the typical externalities directly embedded in payoffs when access to microfinance reduces a borrowers desire to maintain and form links with others even those unlikely to join may reduce their own effort to maintain and build links this is for two reasons first these low types who are linked to potential borrowers consequently have lower returns to such links second because of the reduction in overall linking effort even relationships where the direct payoffs are unaffected by microfinance can be affected in equilibrium those who are unlikely to be involved with microcredit may end up with the greatest losses in links the fact that our model provides patterns consistent with the data of course does not imply that it is the right or only mechanism behind the empirical observations it will take further research to develop a full understanding of the forces underlying our empirical observations nonetheless the facts in particular the evidence of negative spillovers on the nonbeneficiaries have wideranging and important implications the previous literature has shown that there may be important benefits from microfinance on participant households beyond the loans themselves especially in terms of strengthened network connections but if this comes at a significant cost of weakened connections in the rest of the community this could worsen the aggregate ability of a community to buffer risk regardless of the explanation for the changes the more general lesson these findings illustrate is that social networks can involve spillovers externalities and complex relationships so that changing one part of the network can have quite extensive and unanticipated consequences as a result interventions into a community can change the social structure and interactions in ways that no one intended with potentially large costs for some nonparticipants being mindful of these possibilities is important in designing effective policies c the network characteristics in panel a are calulated for an unweighted symmetric graph of households a link is based on whether there is any of 12 relationship types between two nodes tables the 5 limit column shows how big the difference between treatment and control would have needed to be to be significant at the 5 level the pvalue column shows a test of significance on the difference between treatment and control in karnataka there are 75 villages in our sample and 43 received microfinance in hyderabad 102 villages were subject to randomized assignment of microfinance in panel c we exclude 15 villages where the number of households are topcoded as these would bias the estimates of all these statistics panel a columns 12 restrict to financial links while columns 34 restrict to nonfinancial links columns 1 and 3 consider links that existed in wave 1 while columns 2 and 4 consider pairs of nodes that were not linked in wave 1 panel b all columns include a full set of controls centrality controls are a vector of flexible controls for centrality of both nodes household characteristics are caste and a number of wealth proxies including number of rooms number of beds electrification latrine presence and roofing material household predictor variables consist of all variables that are used in the random forest classification in every case we include interactions of all of these network demographic and classification variables with microfinance notes these tables present the effect of microfinance access on the loan amounts borrowed from various sources panel a pertains to karnataka and tracks loan amounts from microfinance institutions friends family banks and moneylenders all of its columns control for surveyed in wave 1 fixed effects the average rate of inflation over the period between waves in karnataka was 8 meaning a total of 65 panel b pertains to hyderabad outcomes are measured in the first survey wave here all specifications include demographic household and village controls subject to doublepost lasso standard errors are reported in parentheses pvalues are reported in brackets mfi microfinance institution shg selfhelp group appendix a proof of proposition 1 we show there is a unique equilibrium and characterize it here letting each agents utility be fully dependent upon their label i from our discussion above it follows directly that a best response must satisfy 44 given the bound that e j ≤ 1 and the fact that u i 0 it follows that for sufficiently large c i and is strictly between 0 and 1 thus taking c i to be sufficiently large for each i we let u be the ndimensional vector with entries 1 c i u i and e be the n × n matrix with ij entries then the characterization of equilibria can be written as e u ee which has a solution of e 1 u given that e has nonnegative values that are less than 1 and so is invertible note that two agents of the same type take the same effort by the symmetry of the expected utility in type and uniqueness of equilibrium overall rewriting u to be the θdimensional vector with entries 1 c θ u θ and e to be the θ × θ matrix with θ θ entries the unique equilibrium is given by e 1 u the result on the comparative statics follows from proposition 16 in van zandt and vives noting the strict monotonicity of the best responses in the payoffs and actions of others and the interiority of the equilibrium

formal financial institutions can have farreaching and longlasting impacts on informal lending and information networks we first study 75 villages in karnataka 43 of which were exposed to microfinance after we first collected detailed network data networks shrink more in exposed villages links between households that were unlikely to ever borrow from microfinance are at least as likely to disappear as links involving likely borrowers we replicate these surprising findings in the context of a randomized controlled trial in hyderabad where a microfinance institution randomly selected neighborhoods to enter first four years after all neighborhoods were treated households in earlyentry neighborhoods had credit access longer and had larger loans we again find fewer social relationships between households in earlyentry neighborhoods even among those exante unlikely to borrow because the results suggest global spillovers which are inconsistent with standard models of network formation we develop a new dynamic model of network formation that emphasizes chance meetings where efforts to socialize generate a global networklevel externality finally we analyze informal borrowing and the sensitivity of consumption to income fluctuations households unlikely to take up microcredit suffer the greatest loss of informal borrowing and risk sharing underscoring the global nature of the externality

life events and sa stressful events at any point in the life course may have important consequences for psychosocial and physical functioning in later life life events such as the death of significant others may negatively affect a broad range of domains of functioning including emotional cognitive physical and social functioning and disease the reason that life events are linked to such a broad range of outcomes is that they not only elicit stressful emotional and physiological responses in individuals but also disrupt daily routines moreover a negative life event is often the culmination of a more or less lengthy process of stress accumulation which may explain their considerable effects on health and functioning as such it is has been demonstrated that not only recent but also events in childhood or adolescence can bear lifelong consequences for health in old age the large majority of previous studies have demonstrated effects of life events only on single health outcomes within different study populations although this is valuable for assessing particular emotional or physical responses to stressors we cannot infer from this literature to what extent life events affect the overall aging process sa is fundamentally a multidimensional concept which aims to assess the quality of overall human aging and integrates three key domains of functioning in old age that is physical mental and social functioning thus one aim of this study is to estimate the effects of life events on overall functioning as reflected by a multidimensional and longitudinal measure of sa we are aware of two studies that investigated effects of life events on sa hsu found that recent events such as widowhood offspring loss and divorce were negatively related to various single indicators of sa however this study did not include earlier life events and did not estimate effects of life events on overall individual functioning li and colleagues found that a higher number of experienced life events during the life course were negatively associated with a composite measure of sa in a bivariate model but not after adjusting for gender and age this was possibly due to age andor gender being strongly associated with both the number of life events and sa the effects of particular events on sa remained unclear our study extends these two studies by including multiple life events in childhood and adulthood moreover we advance understanding of inequalities in sa by situating the occurrence of life events within individual socioeconomic conditions early and later in life life events within the dynamics of socioeconomic conditions exposure to chronic stressors and stressful life events is not merely due to chance but is patterned by socioeconomic conditions persons with a low sep tend to be exposed more often to sources of chronic stress such as economic adversity adverse working conditions and deprived living environments within this context of elevated chronic stress stressful life events such as family disruption or unemployment are also more likely to arise moreover persons with low sep often possess less coping resources and have less access to social support to offset or avoid accumulation of stressors a higher exposure to stressful events may therefore be one crucial mechanism linking sep to sa this structural perspective on social stress implies that studies should clarify the interrelated roles of sep and life events in childhood and adulthood and how these affect the aging process in the current study we investigate several pathways linking sep and life events in childhood and adulthood to sa our approach may clarify at least three issues first many earlier studies have neglected the fact that not all types of life events are similarly affected by sep although studies show that lower sep groups are exposed to a higher number of life events on average the exposure to particular events such as widowhood divorce and assault not necessarily differ between socioeconomic groups and divorce may be more prevalent in higher rather than lower socioeconomic groups in our study we therefore investigate seven specific life events rather than summing the number of experienced life events as a proxy for lifetime stress exposure second many studies did not explicitly examine the social selection hypothesis which states that exposure to stressors may negatively affect sep rather than vice versa for example parental divorce and parental death in childhood have been shown to negatively affect educational occupational and financial attainment later in life life events in childhood may also make people more susceptible to particular life events later in life for instance children whose parents have divorced have been shown to divorce more often themselves it has not been studied before whether such mechanisms indirectly affect sa therefore our study examines both the possibility that sep affects life events and that life events in childhood affect adulthood sep or stressful events in adulthood third previous studies of socioeconomic inequalities in sa suggest that the direct effects of adulthood sep on sa are stronger than those of parental sep however measures of childhood and adulthood socioeconomic conditions often differed in previous studies limiting a clear comparison of their effects on sa it is known that different components of sep may influence partly different indicators of sa this suggests that multiple indicators of sep are required to accurately capture the overall effects of sep on sa in our study we use comparable and multiindicator measures of childhood and adulthood sep in summary the present study answers two research questions to what extent do particular life events affect sa and how are socioeconomic inequalities in sa shaped by differential exposure to life events between groups with different sep specifically we test three hypotheses summarized in a lifecourse model hypothesis 1 stressful life events in childhood and adulthood negatively affect sa whereas higher parental and adulthood sep decrease the likelihood of experiencing such events in childhood and adulthood respectively hypothesis 2 life events in childhood negatively affect adulthood sep and therefore indirectly and negatively affect sa parental problems in childhood increase the likelihood of divorce in adulthood and therefore indirectly and negatively affect sa hypothesis 3 higher parental sep and higher adulthood sep positively affect sa additionally higher parental sep positively affects adulthood sep and therefore indirectly and positively affects sa method data and study sample we employed data from the nationally representative longitudinal aging study amsterdam in 19921993 3107 respondents were included in a random sample of individuals aged 5585 years respondents lived in 11 municipalities in the netherlands that reflect the national sociogeographic variation the oldest old and men were oversampled in 3year cycles data were acquired during interviews at home in written questionnaires and in medical interviews our operational definition of sa was developed earlier and is based on data from the baseline measurement in 19921993 and followup measurements in 19951996 19981999 20012002 20052006 and 20082009 inbetween waves on average about 12 of the respondents died and 8 could not be contacted were too frail to participate or refused to participate calculation of trajectories of functioning constituting the measurement of sa was performed only for respondents who had data for at least two waves for a specific indicator of sa for these respondents 16year trajectories were calculated using maximum likelihood estimation the final study sample included respondents for which at least eight trajectories of sa were calculated the present analyses are based on the same study sample measurements successful aging the successful agingindex is based on nine indicators of physical mental and social functioning the index ranges from 0 to 9 and essentially expresses the number of indicators for which individual respondents had a favorable 16year trajectory the premise of this index is that the more favorable trajectories one has the more successful one was here we provide a summary description of the composition and calculation of the saindex details can be found in the online supplementary material and in previous work the saindex is based on the widely adopted rowe and kahn model of sa but incorporates several suggestions for extending this model and its measurement first and foremost lay perspectives on sa led us to exclude the absence of disease as a requirement for sa and to include holistic and subjective indicators such as selfrated health and life satisfaction excluding chronic diseases was done because few older adults age without them and many older adults feel that having a chronic disease does not preclude successful aging second success was based on longterm trajectories rather than a crosssectional measurement of functioning allowing limited functional decline as well as recovery from decline to signify sa third we expressed sa on a continuum rather than as a dichotomy which allows sa in one domain despite less favorable functioning in other domains the following nine indicators are included in the saindex functional limitations reflects the extent to which respondents can perform six daily activities selfrated health assesses respondents health in general depressive symptoms are measured by the center for epidemiologic studies depression scale satisfaction with life reflects how satisfied respondents are with their life lately cognitive functioning is measured by the mini mental state examination social loneliness is assessed with a fiveitem subscale of the de jonggierveld loneliness scale social activity reflects the frequency of participation in thirteen types of organizations per month finally emotional support given and instrumental support given measure how often respondents talked to their nine most frequently contacted network members about their personal experiences or feelings and how often they helped them with daily tasks in and around the house more details are available in the online supplementary material for each of the sa indicators latent class growth analysis in mplus 60 was conducted to identify subgroups of respondents with a distinct type of trajectory for each indicator trajectories with stable high levels of functioning limited decline or recovery from a low level of functioning were evaluated as successful trajectories trajectories were calculated separately for men and women detailed results are available in supplementary material the saindex was constructed by summing the individual posterior probabilities of belonging to a successful class for each of the nine indicators thus ranging from 000 to 900 this score reflects the number of successful trajectories of functioning adjusted for the statistical uncertainty underlying latent class membership sum scores for respondents with one missing indicator were divided by eight and then multiplied by nine life events we selected life events that rank highly in terms of distress and influence on peoples daily lives are likely to occur more often in particular socioeconomic groups and had a prevalence 5 in our sample all life events occurred before the baseline measurement in 19921993 in line with the notion of childhood and adolescence as sensitive periods we narrowed down our definition of childhood events to those that took place before the respondent was 18 years old parental death in childhood expressed whether one or both parents had died in childhood this event was included because low sep is associated with early mortality parental problems in childhood expressed whether respondents reported divorce of parents severe discord between parents or other problems at home during childhood this event was included because of inconclusive evidence on whether divorce more often occurs with lower sep or rather with higher sep adulthood familyrelated life events included divorce widowhood and death of a child expressing whether respondents had experienced this at least once during their lives because lower sep is associated with higher mortality and because of social reproduction of sep we expected a higher prevalence of widowhood and the loss of a child with lower adulthood sep occupational life events included unemployment and occupational disability these events reflected whether respondents ever received unemployment or occupational disability benefits for at least 3 months because unemployment benefits do not apply when employees voluntarily resign we assume that unemployment was involuntary we expected such events to occur more often with lower sep groups due to less secure and physically more demanding jobs socioeconomic position we assessed parental sep by fathers education mothers education and fathers occupational prestige for adulthood sep we included respondents education occupational prestige of their longestheld job and partners education education of parents respondent and partner were measured in years occupational prestige was based on job type coded into a prestige scale before exporting the prepared data set to mplus we acquired complete data on sep by averaging sep values from 20 imputed data sets obtained by multiple imputation in spss comparison of results between models with original and imputed data revealed no significant differences in estimates proportions of data imputed were 4 for fathers and own occupational prestige 6 for fathers education and mothers education and 31 for partners education we imputed partners education because we aimed to measure sep representative for adulthood rather than at baseline finally we constructed indices of parental and adulthood sep by calculating the mean of the three standardized sep indicators the resulting mean scores were standardized again such that a change of one unit in this final sep index equals one standard deviation with a mean of exactly zero statistical procedure we first estimated the total effect of each predictor on sa in separate regression models adjusted for baseline age only then on the basis of our hypothetical model we constructed a path model including all available variables starting with solely the effect of parental sep on sa we gradually increased model complexity until the full path model was specified in this process we checked all estimated paths for values that might indicate model misspecification for example high standard errors and negative variances we encountered no such problems in the path model singleheaded arrows indicate an assumed causal direction where the dependent variable is regressed on the independent variable doubleheaded arrows assume no causal direction between variables and only adjust for their potentially associated residuals the latter was done for divorce and widowhood and for unemployment and occupational disability because both sets of events are likely to be mutually exclusive the path model was adjusted for baseline age because the saindex was calculated separately for men and women and sep and the prevalence of life events differed between men and women we tested for each path whether the effect differed between genders if we found such a difference we estimated the path separately for men and women if coefficients did not differ we constrained the path to be estimated equally adjusted for gender path analyses were carried out with mplus version 6 because the full model includes combinations of dichotomous and continuous variables we used a weighted least squares with mean adjustment estimator standard errors and statistical significance of indirect effects were obtained using bootstrapping with 1000 bootstrap draws this method provides more accurate estimates and more power to detect significant indirect effects than the baron and kenny approach and the sobel test because the direction of indirect effects is apparent from multiplying the coefficients of each element included in them we used onetailed significance testing for indirect effects reflected by 90 bootstrapped confidence intervals effects of continuous on dichotomous variables were expressed as probit coefficients where a positive value expresses a higher likelihood of the event with higher sep and a negative value expresses a lower likelihood with higher sep in order to provide a robust estimation of model fit we evaluated three goodnessoffit indicators the root mean square error of approximation the comparative fit index and the tucker lewis index these indicators are relatively insensitive to sample size and favor parsimonious models over complex ones to further explore the effects of sep and life events on sa we conducted nine logistic regression analyses estimating the independent effects of sep and life events on the odds of having a successful trajectory for each separate indicator of sa a dummy variable expressing whether the respondent ever had a paid job was added in order to retain those who never had a paid job in the analyses detailed results can be found in supplementary material results descriptive analyses the mean age was 690 for men and 694 for women on average men had a higher number of successful trajectories of functioning than women the prevalence of life events varied between 54 for unemployment and 382 for widowhood we observed gender differences in the prevalence of parental problems in childhood widowhood unemployment and occupational disability about 415 of men and 383 of women experienced none and 52 of men and 40 of women experienced three or four out of seven life events on average men who reported three or four life events had 15 successful trajectories less than men who reported no events this difference was about 17 for women total effects analysis of total effects adjusted for baseline age only in separate models showed that all life events except for death of a child had negative effects on sa parental sep had no significant effect on sa and adulthood sep had a positive effect on sa which was stronger for women than for men lifecourse model hypothesis 1 model fit indices for the full model indicated good fit to the data the first part of hypothesis 1 predicted negative direct effects of life events on sa this hypothesis was supported except for death of a child the estimates of the effects of life events on sa indicate the absolute difference in sascore between those with and without the event for instance respondents who reported parental problems in childhood had on average 31 successful trajectories less than those who did not report this event further negative effects on sa were found for parental death in childhood divorce widowhood unemployment and occupational disability the second part of hypothesis 1 expected higher parental and adulthood sep to decrease the probability of experiencing stressful life events in childhood and adulthood respectively and as such to indirectly and positively affect sa contradicting these expectations we found that respondents with higher parental sep were more likely to have experienced parental problems in childhood and parental death in childhood the indirect effects of higher parental sep through these life events on sa were negative and statistically significant also contradicting hypothesis 1 respondents with higher adulthood sep were more likely to have ever divorced and more likely to have ever been unemployed the resulting indirect effects of adulthood sep on sa were statistically significant and negative supporting the latter part of hypothesis 1 older adults with higher adulthood sep were less likely to have ever been occupationally disabled or to have ever lost a child the indirect effect from adulthood sep through occupational disability on sa was positive there was no significant indirect effect of adulthood sep through death of a child on sa lifecourse model hypothesis 2 the first part of hypothesis 2 expected a negative indirect effect of childhood events on sa through their expected negative effects on adulthood sep in support of this hypothesis parental death in childhood negatively affected adulthood sep and the indirect effect of this event via adulthood sep on sa was statistically significant and negative we found no support for the second part of hypothesis 2 stating a negative indirect effect of parental problems in childhood on sa through increasing the likelihood of divorce the effect of parental problems on divorce was positive but not statistically significant we also tested whether threepart indirect effects involving parental sep adulthood sep and life events were statistically significant this was the case for three of such pathways the pathway from parental sep via adulthood sep via divorce on sa was negative parental sep also indirectly affected sa through adulthood sep and unemployment and through adulthood sep and occupational disability lifecourse model hypothesis 3 the first part of hypothesis 3 stated positive direct effects of parental sep and adulthood sep on sa in the full model we found no significant direct effect of parental sep on sa and a positive direct effect of adulthood sep on sa these results support hypothesis 3 only for adulthood sep the effect of adulthood sep on sa in the full model including life events was stronger than the effect without adjusting for life events this suggests suppressor effects of life events on the association between adulthood sep and sa additional analyses showed that the relatively small inequalities in sa by adulthood sep in the unadjusted model were due to a higher exposure to divorce and unemployment in older adults with higher adulthood sep finally the latter part of hypothesis 3 stating a positive indirect effect of parental sep on sa through adulthood sep was supported sensitivity analyses in sensitivity analyses on separate sa indicators we found that all life events were associated with at least one indicator of sa and that each single indicator of sa was affected by at least one life event for example widowhood was associated with lower odds of having a successful trajectory in five out of nine indicators of sa and depressive symptoms and instrumental support given were affected by four out of seven included life events inequalities by adulthood sep were present in six out of nine indicators of sa and largest in cognitive functioning and emotional support given detailed results can be found in the online supplementary material discussion this study was the first to examine the effects of stressful life events and sep in childhood and adulthood on a longitudinal and multidimensional measurement of sa while disentangling how these social and individual factors may shape one another contributing to the stateoftheart literature on sa social stress and life events our study yielded two principal findings first we observed that six out of seven included life events had a negative effect on sa experiencing multiple of these events may substantially affect the extent to which one ages successfully striking was the observed negative effect of parental problems in childhood on sa confirming that even earlylife events may influence trajectories of functioning several decades later second we found evidence that both earlyand laterlife socioeconomic conditions partly shape sa albeit through complex and partly unexpected pathways we found that both lower and higher sep were associated with higher risks of experiencing particular life events those with lower adulthood sep were more often confronted with occupational disability but those with higher parental or adulthood sep were more likely to have experienced family disruption in childhood divorce and unemployment relatively unprecedented in the literature on sa our analyses of indirect effects demonstrated that although higher sep remained a robust positive predictor of sa it may also bring along particular disadvantages taken together our results demonstrate some of the limits to the extent that individuals are capable of determining their chances to age successfully disadvantaged socioeconomic conditions in childhood and stressful events such as parental divorce and widowhood are factors that are largely uncontrollable by an individual this calls for more research on the relative importance of controllable versus uncontrollable factors for sa such studies may provide indications of which policies or interventions are most likely to succeed moreover our findings indicate that some efforts to increase sa in the population should focus on how adults can build resilience toward the sometimes inevitable stressful experiences and conditions in life building on social stress theory our study also contributes to rowe and kahns recent call to investigate how social institutions may shape opportunities or barriers to sa we provide striking examples of how individual stress exposure can be shaped by cohortspecific institutional arrangements and norms that are linked to sep first in line with previous studies we found a higher prevalence of divorce with higher sep this can be explained by the observation that decades ago couples with more cultural and economic resources could better afford to break prevailing social norms against divorce than couples with less resources however due to changes in legal and normative barriers against divorce the socioeconomic distribution of divorce has shifted to being more prevalent with lower sep second our finding that women with higher education were more often unemployed can also be linked to norms that have been changing during the previous decades in the 1950s higher educated women were much more likely than lower educated women to combine marriage motherhood and employment against the prevailing gender norms consequently their longer participation in paid labor might have made them more likely to have ever been temporarily unemployed although particular social norms and institutional arrangements may thus have changed our results urge researchers and policy makers to analyze how contemporary societal developments affect the patterning of sa by gender and sep finally while playing a minor role in our analyses the negative effect of the death of a parent in childhood on adulthood sep suggests that social selection hypotheses should be taken into account in lifecourse studies of sa limitations a number of limitations of the present study should be discussed first we could investigate only a limited selection of life events we did not include life events such as childhood abuse physical assault or discrimination which might also impact on sa and be influenced by sep disregard of such events was either caused by unavailability of data or very low prevalence second retrospectively reported life events may suffer from recall bias specifically the observed increased probability of particular life events with higher sep might be partly due to better recall in respondents with higher sep however most events included in our study are rather severe ones which may have minimized problems with recall evidence from a previous study also shows no sep differences in recall of childhood circumstances nevertheless differential recall bias by sep cannot be ruled out and may perhaps partly account for particular findings from our study for which the existing literature provides few explanations for example a higher exposure to parental death in men with higher parental sep third the conceptual advantage of measuring sa longitudinally rather than crosssectionally was attained at the cost of sample attrition respondents who were excluded from our sample were relatively old and had lower health and education however they did not differ significantly in occupational prestige additionally selective attrition within the final sample was minimized through using the maximum likelihood procedure in estimating the trajectories of sa therefore we do not expect severely biased conclusions as a final limitation we emphasize that the extent to which our data allow causal inference is limited our conclusions regarding social causation and social selection thus are tentative conclusion responding to the new directions for research on sa provided by rowe and kahn our study has advanced understanding of how social factors and individual experiences across the life course influence sa we showed that individual opportunities to age successfully are partly shaped by stressful life events in childhood and adulthood and that such events may be partly triggered by socioeconomic conditions furthermore we demonstrated that each socioeconomic context the advantaged and the disadvantaged may bring along a higher risk of particular stressors that influence sa our results also suggest that the social patterning of particular stressful life experiences may be driven by cohortspecific cultural and institutional arrangements that should be acknowledged in research policy and interventions focusing on inequalities in sa supplementary material please visit the article online at oxfordjournalsorg to view supplementary material conflict of interest none declared

objectives building on social stress theory this study has 2 aims first we aim to estimate the effects of stressful life events in childhood and adulthood on successful aging sa second we examine how unequal exposure to such life events between individuals with different socioeconomic position sep contributes to socioeconomic inequalities in sa method we used 16year longitudinal data from 2185 respondents aged 5585 years in 1992 in the dutch nationally representative longitudinal aging study amsterdam measurement of sa was based on earlier work in which we integrated trajectories in 9 indicators of functioning into an index of sa using path analysis we investigated direct and indirect effects of parental and adulthood sep as well as of selfreported childhood and adulthood life events on sa results almost all included life events had negative direct effects on sa parental sep had no direct effect on sa whereas adulthood sep had higher parental sep increased the likelihood of parental problems and parental death in childhood resulting in negative indirect effects on sa higher adulthood sep had both positive and negative indirect effects on sa through increasing the likelihood of divorce and unemployment but decreasing the likelihood of occupational disability discussion sep and particular stressful life events are largely but not entirely independent predictors of sa we found that high and low sep may increase exposure to particular events that negatively affect sa findings suggest that low childhood sep and stressful life events are interrelated factors that may limit individual opportunities to age successfully

this research discusses the utilization of instagram as a means of promoting and preserving javanese culture on the instagram account of bpnb diy the aim of this research is to understand the utilization of instagram as a tool for promoting and preserving javanese culture on the bpnb diy instagram account and to comprehend the supporting factors and barriers to its utilization the research method used is descriptive research with a qualitative approach the data collection techniques include observation interviews and documentation data analysis techniques utilize miles and hubermans analysis consisting of three stages data reduction data display and conclusion drawing the research results indicate that bpnb diy has effectively utilized instagram as a means of promoting javanese culture the activities conducted include uploading javanese cultural content collaborating with cultural communitie organizing contests and thematic events using relevant hashtags the impact of this promotion includes an increase in the number of cultural enthusiasts as evident from the number of followers comments and instagram insights however there are challenges faced such as a lack of understanding of how to use instagram effectively inactive participation from the community and a shortage of creative resources proceeding sylection issn 29642817 volume 03 no 01 pp 819830 riki afriandi eka anisa people flew iosifidis explained that some of the impacts of globalization can be seen from the easier it is for western values to enter indonesia both through the internet television media and print which are widely imitated by the community this is reflected in the waning appreciation of local cultural values that give birth to lifestyles such as individualism one of the cities rich in art and culture in indonesia is the city of yogyakarta the city is also known as the city of students there are many quality universities nationally so that many attract students from outside yogyakarta to study in this city so that there are so many students or students who come from various ethnic groups and different cultures buddhayah is the plural form of buddhi the cultural sense or culture derived from sanskrit is related to human mind and reason latin colere in explaining that culture which in english means culture is processing or doing it can also be interpreted as cultivating the land or farming the word culture is also sometimes translated as culture in indonesian balai pelestarian nilai budaya di yogyakarta is a cultural heritage preservation center located in yogyakarta indonesia it is a unit under the directorate general of culture of the ministry of education and culture of the republic of indonesia bpnb di yogyakarta aims to preserve and promote the cultural heritage of yogyakarta and its surrounding areas instagram was first developed in san francisco by kevin systrom and brazilian michel mike krieger when they both chose to focus on creating a multifeature html5 checkin app in the burbn project for mobile photography on march 5 2010 systrom finally closed the 500000 grant he received from baseline ventures and andreessen horowitz josh riedel then joined systroms company as community manager one of her colleagues shayne sweeney joined in november 2010 as an engineer and jessica zollman was hired as a community evangelist in august 2011 in january 2011 instagram added a hashtags feature to help users find photos that were similar to each other this hashtag feature became known as tags instagram also encourages users to create specific and relevant tags when publishing their photos on february 2 2011 it was announced that instagram raised 7 million from various investors including benchmark capital jack dorsey chris sacca and adam dangelo under the deal instagram is said to be worth about 25 million on april 3 2012 instagram for android was finally released the app was downloaded more than one million times in less than a day that same week instagram raised 50 million from venture capitalists to share the company a process that sent instagrams value up to 500 million instagrams rapid rise was also seen when the following three months instagram received more than one million ratings on google play instagram became the fifth app ever to reach one million ratings on google play the gold deal came to instagram at a time when an acquisition offer came from facebook with an offer to buy instagram for about 1 billion in cash and stock in april 2012 this offer comes with a policy to let instagram remain independently managed britains office of fair trading approved the deal on august 14 2012 followed by the closure of an investigation by the federal trade commission in the united states on august 22 2012 allowing the deal between instagram and facebook to continue the agreement was finally official on september 6 2012 instagram comes from the meaning of the entire application the word insta comes from the word instant like a polaroid camera which in its time was better known as instant photos social media with the concept of social sharing can also display photos instantly like polaroids in its appearance as for the word gram comes from the word telegram where the way telegram itself works is to send information to others quickly similarly instagram can upload photos using the internet network so that the information submitted can be received quickly based on the opinion helianthusonfri in his book instagram handbook said instagram social media is a social media that has services only uploading images photos and uploading videos to be published to both instagram social media accounts themselves or other social media such as facebook twitter and so on marketing medium through instagram goods services are offered by uploading photos or short videos so that potential customers can see the types of goods services offered promotion is designed to sell a product promotion is communication carried out by marketers and customers promotion consists of five types namely advertising sales promotion public relations personal sales direct marketing from the various promotions above this study only focuses on the desired promotion the desired promotion is to want to achieve certain achievements get the information well and get the desired feedback promotion is a communication between sellers and buyers that comes from the right information that aims to change the attitude and behavior of buyers who previously did not know to know so that they become buyers and still remember the product promotion comes from the word promote in english which is interpreted as developing or reminding this understanding when connected with the sales field means as a tool to increase sales turnover promotion is a variable marketing mix that has a role in an effective marketing strategy the variables used are summarized in 4p george belch defines social media as a group of internetbased applications built on web 20 ideas and technologies that enable the creation and exchange of usergenerated content social media is an umbrella term for webbased software and services that allow users to gather online to exchange ideas discuss communicate and participate in all forms of social interaction the interaction carried out can be in the form of text audio images video and other media carried out either individually or in any combination this can involve creating new content recommendations and sharing of existing content review and rate products services and brands discuss the hot topics of the day pursue hobbies interests and needs sharing of experiences and expertise that in reality almost anything can be distributed and shared through digital channels be it government agencies ministries nongovernmental organizations grahanm avery organizations risa stated that social media changes the way an organization communicates with its community and the government is not exempt from public pressure to use it the phenomenon that occurs today is that there are many communities organizations or agencies that share information and communicate with other social media users as a form of performance transparency conveying important information to educate the public as well as socializing existing programs most use official social media accounts because with official accounts the information submitted is certainly valid and easy to interact with users who are followers of nongovernment communities and so on some examples of social media platforms that are often used as official accounts are youtube and instagram napoleoncat is a social media marketing analyst company based in warsaw poland the company reported that until november 2019 the number of active instagram social media users in indonesia increased by 226 percent reaching 61 million users almost a quarter of indonesias total population are instagram users the number of instagram users in indonesia with the female gender is more dominant it was recorded that the number reached 508 percent while male users are only 492 percent the most instagram users come from the age range of 18 years to 24 years with a total percentage of 373 percent or around 23 million users in this age range female instagram users are still dominant with a percentage of 195 percent compared to men who are only 179 percent the second largest users were in the age group of 25 years to 34 years with a percentage of 339 percent contrary to the previous age group this age category is actually superior to male users at 179 percent while female users are only 161 percent the lowest category of users is around the age of 65 which is only 16 percent in the previous research entitled utilization of youtube and instagram social media as a means of cultural preservation and tourism promotion of kraton jogja kraton jogja in using its two social media platforms especially platforms related to visual and audiovisual by utilizing various features on instagram and youtube almost all features both old features and the latest features are always used to produce content furthermore this account is always active on both platforms on instagram itself the intensity of activity can be said almost every day this is shown by what is uploaded into the feed and instagram story the two studies entitled the use of instagram social media as a culinary business marketing media in online communities deliciousbali researchers concluded context and content focus on attractive displays to get attention and also pay attention to the combined content of existing text and images and represent what is informed to the recipient of information the context and content aspects that are fulfilled in this case can be seen from how deliciousbali pay attention to uploading photos videos and writing interesting captions communication establishes interaction in this case interaction between admin and followers the interaction built so far is a positive interaction with the active admin deliciousbali provide answers to questions asked by followers through the comments column the three studies entitled utilization of instagram social media as a promotional media to increase social engagement at bintoro coffee shop researchers found that training activities on the utilization of instagram social media as a promotional media to increase engagement at bintoro coffee shop have provided several benefits the perceived benefit is the increasing ability of kedai binkop in editing ig story and ig feed using canva then the increasing ability of kedai binkop in social media marketing strategies this training resulted in three ig stories and four ig feeds that were used as instagram content in addition it can be seen from the results of instagram insights that there is a significant increase in accounts reached and accounts that interact during the last 14 days of training the limitation in this devotion is the lack of supporting facilities such as zoom pro and canva pro less conducive training grounds and lack of participants furthermore for future service plans video editing training can be carried out at the binkop coffee shop in order to create even more interesting instagram content method the type of research that researchers will use is qualitative research that explains the phenomenon profoundly explained that the qualitative approach is a process of research and understanding based on methodology that examines a social phenomenon and human problems the research method used is the descriptive method that is the author provides an overview of the conditions situations that are the subject and object of research result and discussion culture is a thing that is passed down from generation to generation for this reason it is necessary to preserve culture so that culture is not lost in society bpnb diy is one of the institutions that is active to preserve javanese culture of jogjakarta and innovate by using social media in the form of websites instagram tv etc in this study will discuss how bpnb diy conducts javanese cultural preservation activities in jogjakarta consisting of jogja batik dance culinary shadow puppet art traditional ceremonies karawitan music art cultural attractions and others the following are efforts to preserve javanese culture carried out by bpnb diy through instagram social media presenting the results 1 content packaging in bpnbdiy instagram now has various features to upload various content the bpnbdiy account takes advantage of various features available on instagram such as reels feeds instastory the use of existing features will be adjusted to the situation and conditions promoted the goal is that uploads in the bpnbdiy account have a high enough engagement value and can right on target if the bpnbdiy account is promoting an event or a javanese culture that has more value if it shows the surrounding conditions and content processing activities with cultural themes then the feature used is reels through this feature the culinary conditions and conditions are depicted through videos with a duration of 30 seconds and can be accompanied by additional music the addition of music can add to and support a culture that is being promoted if the culture or event being promoted does not have activity and interaction and focuses on that culture then the feature used is feeds by uploading a photo while the instastory feature is used to notify users that dapurbalikpapan account has just uploaded content in feeds and reels instastory is also used to upload content that is advertorial and needs to be seen by many people 2 caption writing in instagram uploads although instagram is a social media that focuses on visuals instagram can also facilitate its users to write various writings additional information and support in uploading content through captions users and content creators both culturally and publicly themed can be creative in conveying the content of promotional messages in its application bpnbdiy account participate in writing captions in each upload generally promotional messages written by bpnbdiy are informative explanations about the event or cultural content being promoted inaddition the bpnbdiy account in writing the caption will include complete and additional information about the event or cultural content that is being promoted such as reviews of the event or cultural content that is being promoted contacts that can be contacted the address of the event the time of the event taking place hashtags that match the upload and if the event is in collaboration with the community or the individual also has an instagram account then bpnbdiy will tag in the upload writing detailed and complete captions about an event or cultural content can be useful as a support for the existing visual display because without detailed and complete information instagram users can find out and description and more information about the uploaded cultural content in accordance with the statement of djafarova rushworth states that instagram can be used as a promotional medium instagram is a social media that can be useful as a medium of communication with the public especially customers because instagram has another function which is to facilitate marketing and be able to attract the attention of instagram users instagram as a social media that focuses on visuals so the aesthetic appearance of uploads on an instagram is the initial key to attracting the attention of its users if users have been interested in seeing the visualaesthetic appearance of a promoted cultural content then users will read a caption containing detailed information and promotions writing detailed captions about the culture being promoted has the function of an information source for its users through the addition of detailed information instagram users can know clearly and have a deeper picture of the culture being promoted a conduct cultural seminars webinar stands for web seminar which is a seminar or learning activity carried out online through an internetbased website or application this seminar technique allows participants from various places to follow the event online webinars can be done in various forms such as presentations discussions workshops and so on webinars can also be attended by participants from various walks of life both academics practitioners and the general public in the webinar participants can interact with resource persons through the features provided such as chat or question and answer webinars are becoming increasingly popular in the digital age because they are effective and efficient in conveying information and can reach participants from various places webminar art culture path spice java seminar is one of the efforts to provide teaching to the community through discussion and delivery of material on november 4 2020 a webminar was held through the zoom application by bpnp diy in collaboration with the directorate of javanese cultural development and utilization this webminar was carried out online by inviting several resource persons to provide material in accordance with the ability and capacity of the speakers the first is dr sri margana an academician from the faculty of cultural sciences ugm the second speaker was danang swastika a practitioner of javanese culture the third speaker is sinarto s bpnb diy invites speakers to be able to provide their material during the covid19 period at this time it was difficult to carry out discussion activities due to the covid19 outbreak but bpnb still carried out and avoided direct contact so that the seminar was carried out online this activity was carried out online and received a good response from the community b use relevant hashtags one of the advantages possessed by an instagram is that it has a hashtag or hashtag feature the bpnbdiy account in each upload will include various hashtags generally the hashtags used are bpnbdiy kancabudaya the hashtag bnpbdiy shows the upload is from bpnb diy kancabudaya is a special hashtag owned by bpnbdiy and shows that the content and events of the cultural theme have been promoted and become recommendations from bpnbdiy while the hashtag is pa ing widely used by bpnbdiy account itself is kancabudaya kanca budaya is a term that is often used in cultural activities in yogyakarta based on the search results kanca budaya is a series of cultural events organized by jayadipuran culture and art in 2022 with the theme meniti centhini kanca budaya itself is often used by bpnb diy on instagram social media this hashtag is used to make it easier for instagram users to find out what activities have been carried out by bpnb diy c collaboration with javanese cultural community bpnb diy collaborates with one of the radio stations rakosa radio a radio station based in yogyakarta indonesia this radio station has a frequency of 1053 fm and can be listened to online through various platforms such as tunein online radio box live online radio jogjastreamers oiradio and the radio rakosa fm jogja application on the google play store rakosa radio broadcasts various programs such as news sports music and talk shows this radio station is quite popular in yogyakarta and has many loyal listenersin this collaboration activity bpnb diy conducts a broadcast entitled better know history and culture which in this case will present a presentation about history and culture packaged by colleagues from rakosa radio every 730 wib d upload javanese cultural content on may 20 2020 when facing the covid19 pandemic bpnp jogjakarta continued to carry out activities to preserve javanese jogja culture by making a kethoprak performance entitled aja mulih disik kethoprak itself is a complete folk art because kethoprak contains various other elements of art in a kethoprak performance in it there are elements of karawitan dance dagelan tembang artistic system and even acting art collaborating to play a playthe activity is in collaboration with a kethoprak artist who is an expert in his field the show just started with the first episode the activity lasts 12 minutes 45 seconds which was uploaded on bpnb diy instagram media so that it can reach all circles e holding contests and thematic events keroncong is a small musical instrument similar to ukulele and indonesian music style that usually uses keroncong musical instruments a traditional keroncong orchestra or ensemble consists of a flute a violin at least one but usually a pair of keroncong a cello in the pizzicato style a string bass in the pizzicato style and a singer the name keroncong probably comes from the rattling sound of tambourines as heard in background music created by interlocking instruments played on or off the beat these background rhythms outrun vocals or often slow melodies and are created usually by two ukuleles a cello a guitar and a bass bpnb diy held a keroncong competition with the theme of keroncong symphony in the past present and in the future which will be held from may 20 to june 6 2022 this activity is carried out by bpnb diy to preserve keroncong culture and attract spectators who come during the competition create a discussion the use of instagram media by bpnb diy in promoting javanese cultural content and activities can also be analyzed using the 7c framework from rayport and jaworskithe 7c framework theory argues that there are seven frameworks in underpinning internetbased marketing communication practices namely context content community customization communication connection and commerce what is the application of the 7c framework in the diy bpnb promotion process 1 contexta aestheticsinstagram display is attractive layout is well organized and easy to understand the arrangement of content both in the form of photos and videos that are displayed is interesting and can attract attention functional the website focuses on existing functions based on research by context consists of three indicators language message content completeness of information the conclusion of the context of the toeri 7c framework is the context that focuses on how technical writing in this case photo captions on the bpnbdiy instagram account are clear so that information reaches followers or followers well 2 the content of the website is a combination of text and images that already represent what is informed to customers based on previous research the content indicator in question is an image or video the conclusion with the research is that the content display content in the form of photos and videos from the bpnbdiy account can look professional or known as istagramable so that it gets likes and comments from followers 3community in this framework an inertation appears on the diy bpnb account the interaction between users on instagram can be seen from several people or communities posting using certain hashtags to make it easier for people to find javanesethemed content community is one of the strengths of instagram because both provide features that make it easier for someone to see search and share images 4customization in this section occurs in diy bpnb accounts customization is the ability of users to adjust the display as desired and biased to choose what they want to see or not want to see instagram is more about utilizing the features that have been provided bpnb diy still uses instagram because of its ability to display content especially images and videos more interesting and effective especially instagram whose appearance is intended for visual content 5communication the more frequent communication between bpnb diy and users is through instagram either through direct messages or through comments and likes on every bpnb diy content post 6connection the advantages of social media such as instagram make it easier for users to manage content refers to the degree to which the website can connect with other websites based on research by maintain and continue to develop relationships that have been carried out and consumers are interested in visiting social media accounts when there are notifications of events the connection also shows how a social media account can facilitate the reach of speeding up information at one time the posting process can be automatically published or for example when we click the link to find a location we can immediately be directed to the google maps application to find the location 7commerce socialmedia used by bpnb diy has not been able to process buying and selling transactions its use is only limited to sharing information and interaction in addition to the seven elements in the 7c framework there are supporting and inhibiting factors that also affect the use of instagram in promoting javanese culture on this based on the results of interviews with instagram managers bpnbdiy researchers found supporting factors for the use of instagram social media on bpnbdiy accounts namely the instagram site is one of the free and popular sites that can be downloaded by everyone the ease of features provided by instagram easy and fast in disseminating information and wider customer targets factors inhibiting the use of instagram social media on the bpnbdiy ress account namely not all followers give likes and comments on every upload of the bpnbdiy account this is because the time and tastes of other instagram users are different so there are some uploads whose topics are less raised the spread of negative feedback or comments from other instagram users cannot be prevented quickly this is because there is only one person who manages a bpnbdiy account and not every time he sees instagram and can respond to negative feedback or comments in addition bpnbdiy account managers cannot select other instagram users negative uploads or comments to be displayed or not displayed because the feature does not exist on instagram conclusion based on the results of the study it can be concluded that the bpnbdiy account has used promotion through instagram social media by utilizing instagram features related to promotion in the form of advertising public relations maximizing in doing promotions in promotional activities from linking the elements of promotion mix above utilizing features from instagram as for the use of instagram in the promotion process there are 7 features in the form of photo uploads captions comments geotaging likes hashtags and also followers based on the results of research conducted by researchers the instagram feature plays a big role in every promotional activity the use of instagram as a promotional medium makes it easier to spread its visuals to attract attention and interest and affect the greatest attraction for tourists to come and visit and spread about javanese culture in each feature utilized in the promotion process researchers associate the promotion mix researchers concluded that the use of instagram as a promotional medium by bpnbdiy accounts has been done well in the future for bpnbdiy accounts the four promotional mixes will be better in the promotion process the existence of features on instagram adds to the advantage of promoting bpnbdiy accounts because it is easier and more efficient this proves that instagram is an online social media that is very appropriate in carrying out promotional activities

indonesian society is a plural society this can be seen from the diversity of culture natural environment and geographical area the diversity of indonesian society is reflected in various artistic expressions khan et al 2020 furthermore it can be said that various community groups in indonesia are also able to develop their arts typical of their regions where the arts they develop can be a model of knowledge in society donohue et al 2018 one of the challenges and opportunities of society in cultural development today is globalization globalization is a symptom of the spread of certain values and cultures throughout the world the forerunner of the spread of world culture can be traced from the travels of western european explorers to various places in this world oswald a j mascarenhas 2019 in essence in the current era globalization has brought cultural nuances and values that affect the tastes and lifestyles of the people anwar et al 2022 through an increasingly open and accessible media people receive various information about new civilizations coming from all corners of the world meanwhile we realize that not all citizens are able to judge where we are as a nation for example there is so much new information and culture brought by the media both print and electronic media that often feel foreign from the 2nd view of life or the norms that apply in indonesia yohana et al 2020 the ease of accessing all forms of information in the era of globalization related to the rapid development of communication technology allows cultural contact to no longer be carried out through direct physical contact rachmawati et al 2021 so that ordinary cultural contacts which are physical or individual begin to shift towards mass cultural contact which involves a large number of

zhou spinrad valiente fabes liew 2005 thompson meyer 2007 in short experiences in the family may have important consequences for an individuals future close relationships such as marriage accordingly the goal of the current study is to evaluate the longterm significance of positiveengagement behaviors in the family of origin positive engagement refers to an interpersonal style characterized by transparent communication warmth and support it entails conflictresolution strategies that emphasize clear communication and cooperative problemsolving in the present analyses we evaluate the extent to which overall levels of positive engagement in adolescents families of origin as well as adolescents unique expressions of positive engagement in observed family interactions statistically predict these individuals marital outcomes approximately 20 years later when they are adults the present work is informed by the development of early adult romantic relationships model of particular relevance the model posits that the interactional characteristics of families influence the younger family members later competencies in intimate relationships bryant and conger presented three routes through which behaviors in the family of origin may additively combine to affect later relationship outcomes observational learning socialization and behavioral continuity the observational learning perspective asserts that individuals imitate patterns of interpersonal behavior that were modeled and reinforced most frequently in their families of origin the socialization perspective proposes that interpersonal patterns are acquired via the individuals direct interactions with either their parents or their sibling during adolescence finally the behavioral continuity perspective states that individuals interaction styles in adolescence persist into adulthood because they help to shape the environmental circumstances that individuals are exposed to across the life span whereas the first two mechanisms suggest that exposure to familylevel dynamics contributes directly to outcomes in later romantic relationships the latter implies that such outcomes are due to the stability of individuals interaction styles across the life span in an early test of the dearr model conger cui bryant and elder evaluated whether behavior among family members from adolescents families of origin predicted warmth in those adolescents earlyadulthood dating relationships this study used a subset of data from the iowa youth and families project a large ongoing longitudinal study of development from early adolescence to adulthood conger et al found that observed levels of nurturing parenting by the adolescents mothers and fathers were positively associated with the adolescents expressions of warmth towards their dating partners during emerging adulthood these effects held when controlling for qualities observed in parental marital interactions the conger et al findings suggest that observed family interactions are related to future competencies in romantic relationships however the behavior observed in family interactions may reflect familylevel relationshipspecific andor individuallevel processes therefore an important next step is to clarify which of these processes account for associations between familyoforigin interactions and later experiences the social relations model provides a methodology for quantifying the relative importance of each of these processes we recently revisited the iyfp data from 1989 to 1991 and used the srm to partition the variation in positive engagement behaviors in family interactions in these analyses we found that variability in positive engagement behaviors between family members was primarily a function of the family climate and individual differences this pattern of systematic variation suggests that familylevel and individuallevel factors are most likely to predict subsequent behaviors in adulthood previous research has uncovered associations between childrens treatment by their parents and their future adulthood outcomes in srm terminology the unique aspects of parentchild interactions are called relationship effects however our research found little evidence of variation in relationship effects for positive engagement between parents and their children instead parents positive engagement behaviors with their children were mostly a function of the family mean and the parents actor effects this suggests that the overall family climate may be responsible for at least part of the association between expressions of positive engagement in parentchild relationships and later outcomes in adulthood the research presented here uses insights from ackerman et al to extend conger et als findings much farther into adulthood in doing so we use the analytic framework provided by the srm to derive our primary predictor variables the majority of the focal individuals whose dating relationships were studied in conger et al are now husbands and wives in their early thirties thus we can examine whether behavioral patterns in the family of origin are carried over to the adult role of marital partner in addition we can disentangle the effects of the average expression of positive engagement in the family of origin from adolescents dispositional expressions of positive engagement this allows us to quantify the relative contributions of family dynamics and behavioral continuity processes linking positive engagement in an adolescents family interactions to his or her subsequent marital behavior evidence for the plausibility of either process would be indicated by the presence of a statistical link between the corresponding operationalization of the familyoforigin process and later marital outcomes because the dearr model presumes that these processes should operate in an additive manner however evidence supporting one process does not necessarily rule out the operation of the other finally because we have observational and selfreport data from the focal adolescents spouse we can evaluate whether the familyoforigin experiences for the focal person are associated with relationship outcomes for her or his spouse method participants data were drawn from approximately 400 families participating in the iyfp the project began in 1989 when focal participants were recruited in the 7 th grade all families in this initial sample were caucasian resided in iowa and included a father a mother the focal individual and a sibling who was within four years of age of the focal individual the primary predictors in this paper are based on familyoforigin scores for positive interpersonal behavior derived from videotaped conflictresolution interactions that occurred during each of the first three years of data collection the primary outcomes for this paper are based on data from a single wave of interviews conducted during 2007 and 2008 outcomes include the marital behavior and reports of relationship satisfaction from the 288 focal individuals that were married at this wave of data collection 1 focal individuals ages ranged from 30 to 33 years and their spouses ages ranged from 23 to 53 years of the 288 focal individuals 563 were women and 837 reported being parents procedures and measures familyoforigin samplein each of the first three waves of data collection the focal individuals were observed with three other family members as they engaged in a 15minute conflictresolution task that was videotaped family members discussed issues that caused conflict within the family with the goal of finding possible resolutions independent coders evaluated these interactions on five indicators of what we term positive engagement using the iowa family interaction rating scales listener responsiveness assertiveness prosocial behavior effective communication and warmthsupport each rating was made on a 5point scale that ranged from 1 to 5 coders provided a score on each dimension for every dyadic combination within the family resulting in 12 scores for each indicator for example coders rated the focal individuals effective communication toward the father the mother and the sibling likewise separate ratings were provided for the other dyadic combinations fm fi fs mf mi ms and sf sm si a composite score for positive engagement for each of the 12 dyadic combinations was computed by averaging across the five rated dimensions following the logic of the srm and based on results in ackerman et al our two key predictor variables were created from these dyadic scores to provide a conservative test of the family dynamics path we computed the family mean omitting any scores involving the focal individual thus the family mean was the average of the fm fs mf ms sm and sf scores 2 the individuals actor effect representing the focal individuals unique tendency to be engaged with all of hisher family members over and above the family mean was computed by averaging the positive engagement expressed by the focal individual towards hisher family members adjusting this value to control for the fact that the focal individual never has him or herself as a partner and then removing the family mean to provide an estimate of the focal individuals unique expression of positive engagement that is not confounded with the normative level of positive engagement in hisher family these variables were computed for each of the three waves and then averaged across waves 3 married samplefrom 2007 to 2008 married focal individuals and their spouses completed selfreport questionnaires measuring conflict and relationship satisfaction and they engaged in a 25minute videotaped interaction task in which they discussed qualities of 1 focal adolescents who were married were not significantly different from those who were not married on the family mean t 074 p 461 focal adolescents who were married were also not significantly different from those who were not married on the actor effect t 066 p 511 2 the pattern of results with the individuals behaviors included as part of the family mean were very similar and are available upon request from the first author 3 the six dyadic scores for positive engagement were used to compute the alpha for the modified family mean at each wave wave 1 wave 2 and wave 3 the three scores depicting the focal individuals expressions of positive engagement towards their mothers fathers and siblings were used to compute the alpha for the individuals actor effects at each wave wave 1 wave 2 and wave 3 stability coefficients for the modified family mean from 1989 to 1991 ranged from 27 to 39 stability coefficients for the individuals actor effects from 1989 to 1991 ranged from 27 to 41 note that analyses conducted separately by wave yielded largely similar results their romantic relationship problems in their relationship and future plans the selfreported negative behavioral interactions questionnaire included eight items assessing the frequency of negative interpersonal behaviors during the past month sample items included get angry at himher and criticize himher or hisher ideas ratings were made on a 7point scale and were scored such that higher scores reflected more negative interactions average scores were computed for focal individuals and their spouses the quality of marriage index assessed participants satisfaction with the marriage using a 5point scale example items included we have a good relationship and our relationship is strong all items were reverse coded and composites were computed by averaging across the five items such that higher scores indicated greater marital satisfaction individuals α 96 spouses α 97 videotaped interactions between focal individuals and their spouses were rated by trained coders on scales from 1 to 9 using the same five positive engagement dimensions used in the family of origin composite scores of positive engagement for the focal individual and hisher spouse were generated by taking the average of their corresponding five dimensions coders also rated the degree to which focal individuals and their spouses expressed hostility angry coercion and antisocial behaviors towards each other and the mean of these three dimensions was used to create an index of behavioral hostility for the focal individual α 87 and spouse results table 1 presents descriptive statistics for the study variables altogether four marital outcomes were assessed for focal individuals and their spouses observed positive engagement behaviors observed behavioral hostility selfreported frequency of engagement in negative interactions and selfreports of relationship satisfaction multilevel modeling analyses were used to evaluate how well positive interpersonal behavior expressed by adolescents and their family members in 1989 to 1991 predicted the adolescents interpersonal outcomes around 20 years later we used mlm because the focal individuals and their spouses outcomes were substantially correlated two predictor variables were included in the primary analyses the focal individuals unique interpersonal style during adolescence and the overall family climate note that unlike many dyadic analyses in which both partners supply data for the predictors as well as the outcomes in the current analyses we only had predictor information from the focal individuals table 2 shows the mlm results as can be seen the family mean and the individuals actor effect were both significant predictors of individuals expressions of positive engagement in their marital relationships moreover these effects were also significant predictors of the spouses positive engagement thus there was evidence to support the plausibility of both family dynamics and behavioral continuity processes as explanations for an association between familyoforigin positive engagement and later positive engagement behavior in romantic relationships table 2 also shows that focal individuals who came from families characterized by higher positive engagement expressed less hostility towards their spouses and their spouses displayed less hostile behavior towards them this same pattern extended to questionnaire reports of negative behaviors in marital interactions the family mean also statistically predicted greater relationship satisfaction for both partners finally the individuals actor effect predicted their spouses relationship satisfaction as well in sum these results show that positive interpersonal behavior in the family of origin is associated with functioning in committed romantic unions across substantial intervals of time 4 discussion the present study assessed the degree to which observed expressions of positive engagement in individuals families of origin statistically predict characteristics of their future adult marital relationships at a most basic level our findings highlight the association between an individuals positive family climate during adolescence and the quality of his or her subsequent marriage the current results are therefore consistent with the dearr model with respect to the developmental significance of experiences in the family of origin although the dearr model specifies that two mechanisms observational learning and socialization underlie the connection between exposure to family dynamics in the family of origin and later relationship outcomes the current analyses cannot definitively distinguish between them indeed we believe that these two mechanisms are unlikely to be independent as observational learning is almost certainly a part of socialization 5 despite this inability to distinguish observational learning from socialization we were able to investigate the relative contributions of processes involving exposure to family dynamics in the family of origin and those related to behavioral continuity in the statistical prediction of marital outcomes in so doing we found that familylevel factors are related to aspects of adult marital relationships over and above the continuity of individual differences it is especially noteworthy that the family mean showed robust links with all of the marital outcomes that we examined this is not to say of course that behavioral continuity processes were not in operation indeed the current study also provides evidence for the continuity of individual differences given that the actor effect for the focal adolescent predicted some of the relationship outcomes we investigated in particular there was an association between the focal individuals unique familyoforigin expressions of positive engagement and the degree of positive engagement that they exhibited towards their spouses 20 years later this finding converges with other research demonstrating continuity in interactional styles such as shyness and explosive temperaments the current results extend this literature by using observational data to measure the continuity of positive engagement behaviors perhaps one of the most striking results from this work was that a positive family climate during adolescence for one partner is associated with marital outcomes for the other partner recall that the family climate variable does not include any data from the focal individual therefore it is somewhat remarkable that it was correlated with the behavior and satisfaction of that individuals spouse approximately 20 years in the future individuals who grew up in warm supportive and engaged families expressed more positivity and less 4 we performed additional analyses to investigate whether the gender of the focal individual moderated any of the effects of the family mean or the individuals actor effect on the outcome variables and found no evidence of such moderation 5 one particular debate concerns whether marital discord itself is related to adult relationship dynamics above and beyond parentchild interactions to evaluate this possibility we included an additional variable in each of our analyses that reflected the average of the mothertofather and fathertomother relationship effects from 1989 to 1991 this variable representing the unique elements of the marital relationship as defined by the srm did not predict many adult relationship outcomes however there was one exception focal individuals who came from families in which their parents were especially positively engaged had spouses who reported less frequently engaging in negative behavioral interactions with them this finding is somewhat surprising given that the parental marital relationship should predict the targets outcomes rather than the spouses outcomes negativity towards their spouses and their spouses did likewise it is possible that family dynamics foster a supportive interpersonal style that later evokes similar behavior from a spouse alternatively individuals who grew up in families with a positive and warm climate may have sought out partners who provide a similar relationship environment we suspect that both selection and evocative processes may account for the connection between one individuals experiences in her or his family of origin and a spouses thoughts feelings and behaviors investigation of these possibilities constitutes an important direction for future research despite our use of a multimethod prospective longitudinal design this study was not without limitations one limitation was the use of a primarily caucasian sample from rural communities it remains to be seen whether the same results would generalize to samples of other ethnicities and geographical locations another limitation entails the restriction to families of origin that included a mother a father and at least two children we based the derivation of our predictor variables on results that were observed for families with this structure and it is possible that singleparent families and other family structures have different interpersonal dynamics finally we must emphasize that this is an observational study and we cannot claim that experiences in the family of origin truly cause later marital outcomes experimental evidence would be needed to make such claims nevertheless the temporal ordering diminishes the plausibility of common alternative explanations likewise the multimethod design and the length of time elapsed between assessments makes a sharedmethod variance explanation for the findings less tenable in sum past research has consistently shown that growing up in a family characterized by an aversive emotional climate is associated with a host of negative interpersonal outcomes later in life the current research provides evidence that growing up in a warm supportive and interpersonally engaged family is associated with positive marital outcomes for both the individual and his or her partner approximately 20 years later thus the current study provides compelling evidence for the interpersonal legacy of a positive family climate means standard deviations and zeroorder correlations between variables

this research evaluated how well overall levels of positive engagement in adolescents families of origin as well as adolescents unique expressions of positive engagement in observed family interactions statistically predicted marital outcomes approximately 20 years later data for familyoforigin positive engagement were drawn from approximately 400 families participating in the iowa youth and families project iyfp during three waves of data collection from 1989 to 1991 the primary outcomes were based on data from the iyfp in 2007 to 2008 and included marital behavior from 288 individuals and their spouses individuals unique familyoforigin expressions of positive engagement were linked to the degree of positive engagement they exhibited towards their spouses a positive family climate during adolescence for one partner was also associated with marital outcomes for both partners overall the results suggest that a positive climate in the family of origin may have longterm significance for subsequent interpersonal relationships families are often considered an important context for the development of patterns of interacting in future intimate relationships eg

streetlevel practitioners do not provide public services alone although many studies have focused on individual practitioners and their behavior streetlevel decisionmaking is increasingly understood as a collective practice specifically recent studies have provided important insights into one of the clearest manifestations of a collective element evident in much of the presentday streetlevel work deliberation deliberation is a practice in which streetlevel practitioners jointly explore work problems and discuss possible solutions this is a topic of importance in research and practice as many streetlevel bureaucracies have pushed toward increasing cooperation with a variety of peers both within and across organizations and sectors deliberation has the potential to improve the process of streetlevel decisionmaking by producing a higher degree of consistency across decisions by increasing responsiveness and creative solutions for citizens and by making work more purposeful even though deliberation is receiving increased attention only few studies have closely examined its everyday dynamics a comprehensive understanding of the situated performance of deliberationhow streetlevel practitioners actually engage in deliberative practices as part of their everyday workis still lacking recently møller took an important first step she put the spotlight on deliberative routines by showing which routines streetlevel workers use to reach shared decisions although routines are typically taken for granted we have known for a long time that both formal and informal routines help to structure streetlevel practices a more thorough sophisticated comprehension of routines for deliberation therefore would help us to understand the process and organization of deliberation in this article we draw on insights from a strand of research on routine dynamics theory rdt rdt defines organizational routines as repetitive recognizable patterns of interdependent actions every time a routine is performed it creates the opportunity for individual variation and over time routines can be subjected to structural changes this approach provides an analytical lens through which to elucidate the shared sequence of activities of deliberative routines as part of everyday situated work so as to contribute to a processual and situated understanding of deliberation in short we seek an answer to the question how and why are deliberative routines performed and developed in particular ways in everyday streetlevel work using the rdt lens we analyze data from an extensive ethnographic study of child and family services in the netherlands that includes the observation of 92 performances of a deliberative routine analysis of policy and organizational documents and 42 interviews with streetlevel practitioners their managers and municipal policymakers our analysis demonstrates the processes through which streetlevel practitioners practically creatively and reflectively use deliberative routines in their everyday work contributing to a theory of deliberation we elucidate how and why a deliberative routine is performed develops over time and deviates from the routine design with this we further develop møllers recent innovative theorizing in this journal more in particular we posit two types of factors that inform how practitioners perform a deliberative routine contextually their intentions and endsinview on the one hand and seemingly mundane contextual factors like the frequency with which deliberative routes are available the duration of routes their physical location and the relationships among participants orient practitioners actions on the other correcting their image of routines as static inert practices we show that streetlevel routines are used dynamically and potentially reflectively and that they are likely to be subject to constant change our analysis suggests that deviating from an initial design can help streetlevel practitioners successfully accomplish a routine and their work in general but that it also comes with serious risks for equal treatment and accountability finally furthering the debate on management of streetlevel practices we argue that enabling deliberation is a promising yet complex management practice that requires an ongoing dialogue among practitioners streetlevel managers and local policymakers in the following section we discuss the current literature on streetlevel work and deliberation and argue that there is a need to further expand our understanding of routines in streetlevel deliberation specifically regarding the role of deliberation we then present the research context of child and family services in the netherlands along with the studys ethnographic research methods followed by the findings finally we discuss the implications for theory and practice as well as their limitations and conclude by suggesting avenues for future research theoretical background streetlevel practitioners make an important contribution to policymaking through the discretion they exercise this exercise of discretion however is highly influenced by interaction with peers in light of this scholars have recently drawn attention to the role of deliberation in streetlevel work although deliberation can be a cognitive individual practice in which practitioners balance motivations for a specific service or treatment in these studies the concept specifically refers to deliberation as an interactive social practice of exploring and discussing encountered problems and possible solutions among streetlevel practitioners and others working in streetlevel organizations studies have argued that deliberation helps to diminish experienced uncertainty and provides emotional support by engaging peers practitioners mobilize others knowledge skills repertoires experiences and perspectives which helps to filter idiosyncratic judgments embedded assumptions and moral dispositions practitioners might involve managers to gain a mandate for their actions or involve peers to collectivize responsibility another purpose of deliberation is to explicate reasoning often with explicit reference to legal frameworks and professional knowledge contributing to the accountability of decisions lastly deliberation serves reflection an iterative practice that is necessary to develop customized and responsive solutions and improve work practices more structurally although several studies have observed the function of deliberation only few have examined the nature of deliberation in detail deliberation can occur in designated meetings or in ad hoc exchanges between peers and can range from very formal to very informal whereas formal meetings have the risk of becoming too timeconsuming and inefficient informal meetings can inhibit transparent and accountable decision processes and outputs furthermore the presence of supervisors can endanger psychological safety whereas peers might contribute to the feeling of safety that is needed to discuss alternatives to standard practices at the same time peers create social ties and exert social pressure possibly leading to the exclusion of relevant perspectives and the sustenance of groupthink and the collective enactment of injustice lastly the degree of latitude and the nature of autonomy that practitioners experience influence whether they either turn to their existing repertoire and established relationships in an effort to work efficiently and effectively or are more likely to develop new routines and relationships with other professionals several scholars have proposed tomore or less from the topdownorganize deliberation at the streetlevel to better regulate decisionmaking whereas previous streetlevel procedures and policy rules aimed to control the outcome of streetlevel decisionmaking peer review and procedures for group decisionmaking have been proposed to restructure the process of streetlevel decisionmaking perceiving it as an opportunity for new forms of procedural justice similarly lipsky suggests building peer review and support into the weekly routines of practitioners taking those ideas a step further møller observes that deliberation is highly routinized and introduces the concept of deliberative routines organizational routines that enable deliberation during which one or more cases are discussed and potentially decided upon the leveraging of the potential of these managerial tools she warns require s reflexive awareness and skillful orchestration møller and goldman and foldy also point to the need to trace deliberation and determine the influence of time place and space following these suggestions we extend theories of deliberation and deliberative routines by systematically analyzing a multitude of performances of deliberative routines demonstrating their situated and processual nature and the role of time and place in their performance and development this in turn allows us to make additional suggestions for how deliberation can be organized and managed long ago streetlevel literature uncovered practitioners routines in the form of informal practices used to cope with everyday dilemmas routine activities are said to form the bulk of streetlevel work together with ordinary nonroutine cases which cannot be handled promptly but fall within the range of situations that streetlevel bureaucrats are familiar with by and large streetlevel literature has understood routines in terms of heuristics that enable streetlevel bureaucrats to cope with the pressures they experience saving time and cognitive resources routines are treated as inert tacit unquestioned work activities being perceived as structure and highlighting their static and institutionalized nature streetlevel theories have hardly reflected upon the way organizational routines come into being how they work how they relate and how they might change we draw on rdt in organizational theory to better understand the performance and development of deliberative routines this strand of research puts its focus on shared practices and defines routines as repetitive recognizable patterns of interdependent actions carried out by multiple actors by foregrounding actions this approach draws attention to how the routinized character of most social activity is something that has to be worked at continually by those who sustain it in their daytoday conduct in the everyday performances of routines lie the possibility for variation or improvisation in response to the specific situation and the specific actors involved these variations might be necessary to accomplish the same pattern yet variation intentionally or unintentionally might also lead to the production of new or different patterns possibly deviating from the way they were designed which we refer to in our study as routine development with this perspective of routines rdt offers four important insights for further analysis of the routinized performance of deliberation first it draws attention to the dynamic or processual nature of routines providing insights into how and why routines remain stable or change by looking at the internal dynamics of routines second rdt specifically analyzes routines as situated practice arguing that context and routines are mutually constituted as they are performed enacted reproduced and changed in this way rdt draws attention to the material spatial temporal and social features that form the organizational context of the routine and how these inform routine performances and development third a further theoretical contribution lies in its observation that externally defined goals do not determine actors actions just as practitioners intentions and their orientation toward organizational goals also inform routine performance actors develop endsinview meaning ends that they have in view in a specific routine performance that are constitutive of their actions these endsinview can be informed by and aligned with the preestablished organizational goals referred to as purposeful action or they can be directed toward coping with the immediate circumstances unrelated to the preestablished goal or overall longerterm outcome referred to as purposive action fourth rdt has demonstrated that each time a routine is performed there is an occasion for reflective talk this collective reflection might merely concern the mismatch between actions that are needed and the routineasdesigned thereby justifying the need to adjust actions to meet the circumstances however it becomes especially interesting when reflective talk concerns variations in the routines pattern its evaluation and leads to the decision to perform the routine differently in the future research context and methods research context within the more general context of increased cooperation and attention to deliberation in the delivery of public services we should say something about the nature of and current developments in child and family services where this study was conducted whereas before 2015 responsibility for different domains of child and family services in the netherlands was dispersed over three levels of government as of 2015 the responsibility for the whole continuum of child and family servicesranging from educational advice to child protection and from behavioral therapy to services for mental or physical disabilitieswas integrated and decentralized to municipalities the decentralization was accompanied by considerable austerity measures the national youth act of 2015 specified that services should aim to be customized capacitating integrated preventative demedicalized and local this development does not stand on its own as many european welfare states are undergoing similar developments preceded by an extensive collaborative process with government agencies professional associations beneficiaries and other stakeholders the national policy design included much discretionary space for municipalities and suggested teamwork and collective decisionmaking to strengthen professional discretion at the local level within this larger context this study was conducted in the municipality of dunetown and its local child and family center dunewater dunetown commissioned the cjg which was already responsible for child health services to provide primary educational advice and assign child and family services either to a specialized provider or to their own primary services within cjg dunewater approximately 60 streetlevel child and family practitioners forming six teams are responsible for allocating and providing child and family services within these teams practitioners with various disciplinary backgrounds are expected to work together to develop solutions for complex family problems these practitioners all have a higher professional degree in pedagogical or social services their varied expertise ranges from streetcorner work educational advice child health care child mental health services legally mandated child protection and probation services dunewater is an atypical organization as it has taken various innovative and exceptional measures to promote and legally formalize discretionary room the practitioners have wide degrees of discretion to allocate customized services including the legal mandate to allocate services and corresponding expenditures on behalf of the municipality and few formal procedures or rules for accessibility there are two types of teams in cjg dunewater team 1 functions as a front office dealing with questions from families and other professionals it is also their responsibility to judge requests for support from either parents or other child welfare providers and then allocate appropriate child and family services team 2 provides primary educational advice to families they are responsible for supporting a network of local schools and social organizations so that possible problems are flagged and referred to them at an early stage when support is no longer adequate or when a school within their network asks for help they are responsible for allocating child and family services both types of teams work in separate offices located in the area in which they work the teams work independently with little managerial interference a team of coaches supports the practitioners with their university degree in pedagogical science or psychology and work experience these coaches have ample expertise in the treatment of children and can therefore be consulted for either complex cases or professional development furthermore the coaches are involved in organizational and policy developments relatively new the role of coach was developed to support practitioners confronted with increased discretionary room and demands for customization all in all the practitioners at cjg present multiple traditional characteristics of streetlevel bureaucrats as they are directly responsible for communication with and allocation of services to clients and are faced with budget and time scarcities in doing so simultaneously the practitioners are given considerable discretionary space not only to deal with clients but also to deal with time and budget and they are in the midst of a process of professionalization all emerging developments in streetlevel organizations given the attention to collaboration and organization within interdisciplinary teams the goal to develop customized solutions and the large degree of granted discretionary room in practitioners work at cjg dunewater we expected deliberation to be important for the practitioners therefore this is a wellsuited case to explore the situated performance of deliberative routines generating and accessing data this study is based on organizational ethnographic fieldwork such fieldwork with its focus on longterm engagement and its reliance on observation allows for the study of everyday actions that actors engage in as part of their work practices ethnographers observe and analyze the context in which activities are enacted contributing to an understanding of the situatedness of everyday work practices ethnographic methods are specifically apt for analyzing routines and any changes therein as ethnographers draw close enough to observe the precariousness of such processes stay long enough to see change occurring and are contextually sensitive enough to understand the twists and turns that are part of organizational life … observational data were collected during approximately 300 hours of observation between december 2016 and december 2017 exploratory conversations indicated that some deliberations were planned and had a formal nature whereas others were unplanned and informal two strategies for observation were therefore employed the first involved regularly asking the practitioners and managers which meetings were planned and attending and observing those the second entailed a daily presence at the office to observe the unplanned and informal interactions over the course of four months 16 practitioners from two teams were shadowed during the course of their regular work day the two teams represented the two different types of teams opening up the possibility for ethnographic comparison such a comparison encompasses looking for possible differences exceptions or inconsistencies that could shed light on or challenge possible interpretations of the findings to understand deliberation as part of the larger work routine the fieldworker observed phone shifts house visits and facetoface meetings with families interactions with other service providers and schools and registration and referral practices the observations were supplemented with dozens of daily informal conversations with those involved to clarify their actions during observation and informal conversation detailed field notes were made and speech was written down as much as possible policy and organizational documents were analyzed to map how deliberation was envisioned designed and organized in addition the fieldworker conducted a total of 42 semistructured interviews 15 with practitioners and 27 with their managers and municipal policymakers the practitioners who were interviewed were the same individuals that we observed to further grasp the intentions of activities that determined the allocation of services in general and the activities of deliberation in particular we interviewed every cjg manager and involved municipal policymaker to understand the management of streetlevel decisionmaking the organization of deliberation and registration and their own participation and role in deliberation interviews were recorded and transcribed verbatim the different data were brought into conversation with each other for triangulation and negativecase analysis finally interactive sessions to discuss the findings with the different groups of actors in later stages of the project served the purpose of member feedback data analysis analysis of the data was done abductively in an iterative cycle between data and theory initial analysis began during fieldwork this first phase consisted of multiple rounds of open and more focused coding after fieldwork had finalized we realized that there was a limited understanding of the situated use of deliberation in the streetlevel theories so we decided to analyze the data from that point of view the second phase of analysis started with an initial routine design based on a central policy document we then analyzed the observation data and identified 92 performances of a deliberative routine we ordered these performances chronologically and compared the actions that were taken looking for differences similarities and changes over time through an iterative process of comparing the different performances which can be understood as a crosscase analysis we grouped refined renamed and regrouped the actions that together formed the situated use of the routine and the deviations from the initial routine design next we searched for explanations for the differences between the design and the actual performance we did this by comparing the two teams and their different deliberative patterns and by combining the observations with interviews that gave insight into the endsinview and other motivations of the practitioners this went hand in hand with a theoretical exploration of routine dynamics finally we sought to explain how developments came into being all the while we engaged in a dialogue in which the second author challenged the fieldworker to think through alternative descriptions and explanations of patterns arising from the analysis findings at cjg dunewater practitioners engage in deliberation as part of allocating child and family services in the following four subsections we analyze how deliberation is embedded in an initial routine design spurring its everyday use how practitioners use the deliberative routine in their work and which five deviations become new patternsinuse how two types of contextual factors contribute to the everyday use and deviations from the deliberative routine and how new routine patternsinuse develop through two types of processes between the first two sections we have included an example of situated use of a deliberative routine we finish with a process depiction of the performance and development of the routine deliberation in routine design before we can properly analyze how a deliberative routine is performed and developed in streetlevel work we need to understand how deliberation was envisioned and organized at cjg dunewater for this we reconstructed the initial routine design through which deliberation was embedded in practitioners key practice of allocating child and family services allocation is an important part of practitioners work as it defines which citizen receives which type of care from whom to accomplish allocation cjg dunewater developed a guideline that includes a description of organizational goals and an organizational routine to be used the guideline was commissioned and developed by five municipalities in the region at the beginning of 2015 shortly after the cjg had assumed its new tasks and responsibilities it was developed together with child health care practitioners child protection practitioners and general health practitioners and was intended to standardize decisionmaking in the region and manage expenditures while contributing to the purposes of the decentralization of child and family services providing support that is timely capacitating collaborative and where possible demedicalized and local furthermore an important aim was to promote demandoriented customization in which allocation was not based on indications of whether a family fits existing treatments from existing contracted providers but on customization the idea was that this could be achieved if practitioners start from the question what commitment and expertise contribute in this case to capacitating the family to deal with their problems and is in this situation necessary to achieve results for the child and family lastly central to cjg decisionmaking is the principle of three pairs of eyes in which the practitioners decision is made with the family and is supported by deliberation with other professionals included in the guideline was a deliberation form that the cjg developed to achieve and document deliberation which included a list of topics to be discussed and ample space to write down what was discussed per topic the routine design for allocation as suggested in the guideline consists of five steps question clarification deliberation matching filling out the deliberation form and finally registering referring and informing the family in question clarification the practitioners are expected to explore and frame the familys question together with the family deliberation involves professional reflection on the case to develop an understanding of what the family needs and what support will help satisfy that including an exploration of alternative solutions through matching the practitioner chooses whether existing services fit the question and contacts the corresponding provider to check the match and availability the explicit advice is to do matching after deliberation so as to reflect on what the family needs and not on what is provided the fourth step consists of filling out the deliberation form lastly the practitioner registers the case in the online registration system refers the family in the registration system to an internal practitioner or external provider and informs the family about this allocation we have displayed the sequence in figure 1 in the guideline two routes were defined for deliberation the first route direct desk deliberation centralizes interaction between peers the cjg organized the practitioners in multidisciplinary teams sharing a general base of professional knowledge and skills but also having individual expertise the organization in teams was intended to enable and stimulate regular and onthespot deliberation there was no protocol to indicate which team member to deliberate with or when the cjg also designed a second initial route the collective coach conferences during which the practitioners make use of their assigned coach and several peers the guideline indicated that the coach had to be involved in complex cases customized or specialized solutions and in cases where the safety of the child might be at stake in addition shortly after that policy was implemented the cjg added a third meeting the access assembly would bring together a municipal policymaker a manager a coach and several expert practitioners to solve and learn from complex cases this meetings purpose was to instigate the learning capacity of the organization the idea was that it could be used to discuss and figure 1 the initial design for the deliberative routine decide on novel solutions in specific cases but also to identify more systemic problems in contracting regulation and policy scheduled every 2 weeks practitioners were expected to submit a case and a corresponding request beforehand for the meetings agenda with the routine design cjg dunewater embedded deliberationand therewith the possibility to develop customized solutionsinto the larger routine from thereon the design needed to be put into practice situated performance of the deliberative routine online we offer lindas case this case illustrates how the deliberative routine works this case is but one of 92 performances of the deliberative routine that we observed analysis of those 92 cases complemented by interview data helped us expose patterns of routine performance that deviate significantly from the way it was designed we identify five types of deviations developing new deliberative routes combining deliberative routes blurring steps limited use of the deliberation form and incomplete documentation and changing participation in routes these deviations became the new patternsinuse 2 years after the guideline was designed we modeled the situated performance of the routine in figure 2 first in everyday performances new routes came into use in addition to the existing direct desk discussion collective coach conferences and access assemblies one of the new routes was the casual coach call which consists of an informal talk with a coach often quickly after having received a request the coach call followed some of the suggestions for collective coach conferences as they were used for the same issues and the coach partly followed the deliberation form yet they were oneonone not registered and brief another route that was used was the mobile management meeting an informal oneonone talk with a manager often performed soon after receiving the request and handled by phone generally the practitioners involved managers when they had doubts or questions about existing regulations and rulebreaking about financial coverage or contracting or when there were issues with municipal policymakers there were no suggestions for when or how to use this route for another new route one of the two teams included deliberation about cases in formal team meetings held every week these team talks were rather similar to direct desk discussions as they only involved peers and were flexible and accessible yet they were different because they included more participants were more extensively documented and were conducted within the limited time frame of the meeting in rare cases practitioners involved a policymaker in what we call a policy chat policy chats occurred mostly when policy or contracting rules were unclear these chats were conducted by phone or email were short and lacked suggestions that guided the interaction finally in some cases the practitioners did not deliberate at all this happened when there was a freely accessible type of support available and families were referred there without needing allocation practitioners also did not deliberate when practitioners from other providers requested an extension of existing treatment the routes are diagrammed in figure 2 a second deviation from the guideline entails the combination of routes many routes were combined with either direct desk discussion or team talk indicating that practitioners often first deliberated with a peer before deciding to deliberate with an individual coach manager or policymaker or with a collective in which coaches managers or policymakers participate access assemblies and policy chats were rarely performed as a single route but tended to be combined and finally there were cases that were discussed in almost all routes sometimes going back and forth between them third in contrast to the way the routine was designed on paper deliberation was not a clearly demarcated step in the larger routine the initial design emphasized a clear boundary between deliberation and matching to ensure new solutions would be tried rather than having the practitioners think only in terms of existing treatments and providers in practice we observed practitioners blurring these steps because in part discussing possible new solutions necessarily entailed knowing which providers and services existed and were contracted whether they had availability what specific services entailed to establish a fit and a possible new solution stacking existing services similarly practitioners went back and forth between deliberation question clarification and registration while attempting to successfully allocate services in specific cases thus in everyday performances deliberation was used partly simultaneously and partly in combination with the other steps fourth the deliberation form that was supposed to guide and document deliberation fell into disuse although the practitioners themselves believed they applied the deliberation form and felt no need to consult or register it in practice differences were observed in the extent to which the topics on the form were actually discussed for example in lindas case the practitioners thoroughly discussed possible contributions and solutions and considered the families concerns and preferences however less explicit attention was paid to their knowledge of effective interventions costs and contractual forms in general as the deliberation form was not consulted treatment of the topics became less structured only the more formal routes included the making and registration of minutes including motivations and considerations that were discussed in others only the final decision with its motivation was documented a last deviation was changing participation in the routes this happened particularly to the access assembly which the municipal policymaker started to attend less frequently the policymaker wanted to restructure and decrease communication with the cjg and become less involved in individual family cases explaining i was the main point of contact now i am more distanced i consult with the management sometimes join a meeting to discuss complex cases … it was too much it is better now we have to do it together think along were still searching how to organize it properly the five deviations we have identified show a complexification a simplification and an informalization of the deliberative routine in whichat first sightimportant elements seem to be lost including particular perspectives time to discuss cases extensively the discussion of specific topics and proper documentation the question is why the deliberative routes developed and deviated from the routine design we teased out various factors that play a role factors contributing to the performance of the deliberative routine several factors emerge from the data that help us understand why the situated performance of the deliberative routine diverged from the routine design first practitioners performed the routine in certain ways based on the ends they pursued the central organizational goal was the allocation of customized services the guideline suggested a routine design to enable this goal yet customization implied all kinds of new complexities for practitioners decisionmaking which in turn created new purposes that practitioners set for themselves as endsinview these were sometimes aligned with or related to the complexities of the goal of customization whereas at other times they were less related to them additionally the routine design did not always contribute to achieving the goal when aspects were missing or made too complex a first endinview informed by the goal of customization and consecutive discretionary space was to make sense of cases in this new and more complex situation which was different than initially envisioned discussing the necessary treatment before considering existing treatments and providers proved to conflict with actual case processing practitioners did not start from a blank sheet but created an overview of existing treatments and providers experiences with them their suitability and their availability in their discussions with others a practitioner explains in this case we found that the existing treatments the existing providers none of them offered what this boy needed it was only after establishing this after this realization that we started to develop something new also deliberation matching and registration regularly led to demands for a clearer understanding of the clients needs and situation and possibly also refinement of the clients questions consequently the order of routine actions as designed slowly became more complex in practice a second endinview that developed in light of customization was to acquire additional perspectives additional perspectives allowed them to explore alternative customized solutions for example during a direct desk discussion the practitioners discussed the possibility of combining treatments for a multilayered request of a family in the midst of an antagonistic divorce yet desired more expertise to decide whether part of the treatment could be done internally through primary educational advice third customization spurred practitioners to search for a mandate in terms of additional financing and alternative contracting for this purpose practitioners often included deliberation with a manager or policymaker at the end of the process fourth practitioners attempted to deal with increased uncertainties resulting from the farreaching decisions they had to make both for the family and in terms of budget decisions that often had to be made without clear rules and sometimes even by breaking rules during one observation a practitioner confided i just got off the phone with the municipality but the answer remains vague ill call name manager again because i dont know what to do with this the latter three endsinview drove practitioners in their performance of new routes and in the combination of routes accomplishing deliberation in itself became an endinview the guideline prescribed deliberation but proved to be an incomplete answer managers and policymakers had not yet really settled on the right organization of deliberation either as illustrated by the managers participation in informally added routes this was further aggravated by practitioners informal deviations that lacked standards to begin with leading to occasional searches for the proper space to deliberate about specific issues in their efforts to move things along they made phone calls until they reached someone who could provide them with a definite answer beyond the goals of customization and deliberation the practitioners were eager to complete the routine in an organized comprehensive and timely fashion one practitioner explained i dont really like putting it off for a very long time i just want to have an answer myself … i ask my questions to the people i think can provide a normal answer quickly performing the routine in the quickest possible way helped them keep their work organized as they always had a pending list of allocation requests waiting to be completed the practitioners also preferred to allocate services timely to help the family without letting them wait a practitioner explained we dont have to do it this quickly look you have six weeks from request to allocation and that is workable but i dont like to let the family wait sometimes its urgent but even if its not i wouldnt want to wait that long for an answer either we observed that practitioners often first discussed cases with the team member that was present asking do you have a moment to think along when direct desk discussion did not suffice they generally preferred an immediate phone call over waiting for the next scheduled meeting finally the timely completion of the routine could also lead to its simplification the practitioners did not refer to the deliberation form or fill it out as they believed the questions on the form were already integrated into their everyday performance in principle the questions from the form we already do that in our conversations we are already going to fully consider the questions whether help has been provided before has it been good or not have parents been satisfied with it … you know one way or another those questions that reflection is completely within us the endsinview that influenced the practitioners exercise of the routine were partly informed by the new requirement to customize and the new requirements to deliberate combining a prioritization of the client with organizing their work other factors that oriented practitioners performancesand their divergence from the routine designcould be called contextual these factors included the frequency of available routes the duration of routes the physical location of and the relationships among participants in routes the endinview of a timely completion of the routine was partly informed by the contextual means for example team 2 spent much time outside the office at families homes or in interdisciplinary meetings with professionals from other organizations they walked in and out of their office and irregularly encountered colleagues for deliberation for team 2 the formal team meeting provided a fixed moment to include multiple perspectives in their otherwise physically dispersed work routine team 1 used direct desk discussion for the same purpose as a practitioner from team 1 explained we work in shifts together so we always have someone in front of us to quickly deliberate with in addition as a coach was often present at the office team 2 made use of the casual coach call as a shortcut to reflect or simply fulfill the requirement of deliberation we often heard a variation on the sentence as you are here can we discuss… team 1 preferred to call the coach on the phone for a quick answer with the consequence that documentation was limited finally team 2 rarely used the access assembly because it was held in team 1s office team 2 therefore attempted to solve cases as much as possible through collective coach conferences and only attended the access assembly when it was absolutely necessary thereby explaining the development of route 51 finally the participants in specific routes and the relationships practitioners have with them constituted an important means that oriented the performance of the deliberative routine peers provided the opportunity to ask for help and created confidence about possible solutions a practitioner explained when im in doubt i always involve a peer as long as i feel a little bit of doubt a glimpse i always deliberate with my peers and that is why it is very nice that you are always in pairs another practitioner said were a small team … and were well attuned to each other there is very little that we dont know of each other we share things like that the deliberations in direct desk discussion or team talk prepared the practitioners to reflect on a case with superiors the importance of involving peers over other means can also be observed in team 1s scarce use of the collective coach conference the practitioners expressed their discomfort with their coach as they felt she disapproved of the issues they submitted as a result they preferred to make casual coach calls to other coaches or phone peers from other teams with specific expertise to avoid having to deliberate with their coach practitioners relationships thus contributed to their choices for routes and the combination of routes all in all the way the routine was performed and the choices that were made had real consequences for the process through which important decisions on the allocation of services were made the performance of the deliberative routine along with their deviations was instigated by practitioners pursuits to make sense involve multiple perspectives acquire a mandate and deal with uncertainty in complex cases of customization additionally practitioners also needed to manage their work load complete the routine in a timely fashion and simply complete the process and make a decision all of it importantly guided by contextual factors such as the time place and relationships of those involved in the deliberation patterns and reflectiononaction during our observations several new patternsinuse were developing which allowed us to identify and analyze the two processes through which such patterns come into being in the first process practitioners deviated from the guideline in specific performances the specific diversions were repeated in subsequent performances by other practitioners who were informally yet collectively altering the routine in the process this happened for example with the use of the access assembly over time we observed the decreasing presence of the municipal policymaker thereby reorienting the practitioners use in the beginning the access assembly was used regularly and it resulted in quick decisions slowly with the absence of the policymaker cases were routed through policy chats mobile management meetings and then back into the access assembly as decisions failed to be made without the right participants and consecutive expertise and mandate practitioners complained to each other and became reluctant to use the assembly in the following months practitioners started to refrain from submitting cases they experimented with using alternative routes directly which in several cases resulted in quicker decisions a new pattern of the routine started to develop through repetition and retainment of the deviations a second process through which new patternsinuse developed was through collective reflection on the deliberative routine in these reflections practitioners talked about specific routine performances and the recurring pattern they had observed discussing advantages and disadvantages of what was happening and what they did in these reflections practitioners decided to make changes to the routine but such changes were not formalized for example while discussing cases in team talk members of team 2 voiced issues they had experienced stating i cant talk well under time pressure or we have to introduce cases carefully this led the team to discuss the practice of team talk some practitioners argued that the team meetings were already pressed for time and that spending time on deliberating cases might not be efficient moreover they expressed their concerns about the need to properly introduce and discuss the cases and the lack of time to do so during team talk although most agreed with both issues some argued that the plurality of opinions in team talk was very valuable to their work in addition by maintaining team talk the practitioners had multiple opportunities over 2 weeks to deliberate ensuring a timely answer and not having to swim in a vacuum the issue remained unresolved during the specific discussion but received further attention in the months that followed in sum either through processes of deviation repetition and retainment or through processes of reflective talk practitionerstacitly or consciouslychanged the pattern of the deliberative routine what is interesting here is the role of cjg managers in these processes managers were sometimes participants in the deliberative routes and in that capacity also participated in the individual and repeated variations of the deliberative routine this was not translated into a new formal guideline possibly also due to the absence of managers and policymakers in the collective reflections on routine performances and patterns at this point we can take a final step in our analysis by developing a more abstract depiction of how the deliberative routine was performed and evolved a process depiction of deliberative routines performance and development what we see is that the motivation for streetlevel practitioners to perform a deliberative routine as part of their everyday work is a routine design the initial design as we encountered it starts with a particular organizational goal and especially an organizational infrastructure together with more or less specific guidelines and other artifacts to pursue such a goal guidelines however are action sequences on paper practitioners perform them in a specific context dealing with specific cases in part what this means is that practitioners are dealing with tensions between the routineasdesigned and what is feasible in practice moreover it means that practitioners are developing new parts of the routine to better serve the intentions that develop in action which can be more or less informed by and in line with preestablished goals and the immediate circumstances speedier routes in the deliberative routine for instance help to better serve the clients and keep work manageable what was kept separate or offered as alternatives on paper might be combined in practice to deal with complexity and ambiguity leading to more complicated pathways some elements of an original routine might be dropped as they do not fit into the way work is actually done or just seem purposeless to practitioners the shaping role of practitioners intentions and particular endsinview are included in figure 3 in dealing with the immediate circumstances the temporal social and spatial contexts guide the modifications contextual factors and endsinview influence each other for example the notion of durationwaiting and physical location of a deliberative route are related to the need to develop a solution quickly both to keep work orderly and comprehensible and to help families quickly our study shows us how new routine patterns emerge this patterning is often the result of the repetition and retention of specific deviations as changes to the routine at times reflective talk about routines plays a part in this process reflective talk can be prompted by the situated use itself or by the newly emerging pattern it can be part of performing the deliberative routine or it can get shape outside the time or space of the deliberative routine either way it can be an important force in developing the deliberative routine figure 3 the process of deliberative routine performance and development discussion and conclusion deliberation in streetlevel work is increasingly recognized as contributing to shared responsive and consistent decisionmaking it is also acknowledged that how deliberation is performed shapes the outcome of public service delivery therefore it is important to expand present knowledge on the daytoday performance of deliberation as embedded in the larger routines of streetlevel decisionmaking although research on streetlevel deliberation has touched on its temporal spatial relational and purposive aspects we significantly extend previous research we do this by asking an important question that had remained partly unanswered how and why are deliberative routines performed and developed in particular ways in everyday streetlevel work following møller in focusing on deliberative routines and making more extensive use of insights from rdt we elucidate how and why a deliberative routine is performed how it develops over time and how and why this deviates from the routine design contributing to a theory of deliberation in streetlevel literature we posit two types of factors that inform how practitioners perform a deliberative routine in a specific context dealing with specific cases first streetlevel workers make use of the intentions they have and the ends they have in view for themselves or for a particular performance these intentions and endsinview inform how deliberation is performed quite possibly resulting in particular stable variations of a routine and new patterns of the routine as such in a particular performance of deliberation larger organizational goals embedded in the routine design are accompanied by and might compete with goals the practitioners have and which might or might not match those of the organization more specifically aiming for customized services has contributed to certain purposeful endsinview such as the different sensemaking processes the need for additional perspectives and mandates and dealing with new uncertainties and ambiguities besides purposive endsinview such as the timely and organized completion of the routine this explanation goes beyond personal motives coping or pursuing predefined goals rather arguing that intentionality develops in action furthermore it goes beyond either prioritizing clients needs or saving cognitive and temporal resources showing how these are intrinsically connected in the ends that practitioners pursue second seemingly mundane contextual factors play an important role in the performance of deliberative routines and in the emerging endsinview the frequency with which deliberative routes are available the duration of routes their physical location and the relationships among participants in routes orient practitioners actions endsinview and contextual factors develop in tandem as deliberative routines are inherently situated enacted in and inseparable from their sociomaterial context the intentional temporal spatial and relational aspects of everyday streetlevel work should therefore be carefully considered in the study and practice of streetlevel deliberation a second contribution to a theory of deliberation in streetlevel decisionmaking comprises new insights into how the everyday performance of deliberationinformed by factors uncoveredmight lead to deviations from the routine design and possibly to the development of new routine patterns we identified five deviations developing new deliberative routes combining deliberative routes blurring steps limited use of the deliberation form and incomplete documentation and changing participation in routes individual variations can over time alter the pattern of the deliberative routine through repeated performance streetlevel practitioners structure the deliberative routine as a patterninuse this might lead to formal or informal modifications in addition new deliberative patterns might also arise as the result of collective reflection what is interesting to notice here is that most of the recent interest in increased deliberation in streetlevel work has focused on the way streetlevel decisions have become the object of group discussion we argue that the deliberative routines within which decisions are made themselves are reflected upon as well in sum the image of routines for deliberation that arises from our observations is a dynamic one we see practitioners as a group practically creatively and reflectively using deliberative routines to reach an organizations purposes as well as their own keeping some routine elements intact while structurally altering others beyond a thorough sophisticated understanding of the situated performance and change of deliberation this study contributes to streetlevel literature in general by providing a nuanced and complex description of organizational routines in public organizations correcting their image of routines as static inert practices we show that streetlevel routines are used dynamically and potentially reflectively and that they are likely to be subject to constant change over time lipsky for instance although using the concept of routine extensively offered little help in understanding the development of routines over time the emergence of its ends and the dynamics of peer interactions in it our indepth investigation helped us understand streetlevel decisionmaking as jointly developed and available walking routes at the streetlevel as collective patterns they have a stabilizing effect yet simultaneously each time a routine is performed is an occasion for variation for retention of that variation and thereby new patterning looking at routines allows for an analysis of streetlevel decisionmaking as shared sets of everevolving action patterns performed in a particular sequence embedded and informed in everyday streetlevel work with its spatial temporal and relational aspects our active employment of rdt with its emphasis on process dimensions of performing organizational tasks its consecutive detailed analysis of action sequences and the resulting potential explanations for why routines develop offers an additional contribution to our understanding of streetlevel innovation creativity or improvisation contextual factors and the prioritization of particular ends might shape how practitioners innovate and repair policy finally this study contributes to both streetlevel deliberation studies and streetlevel management studies by demonstrating the potential of organizing and promoting deliberation topdown embracing certain goals promoting guidelines and flowcharts and setting up an organizational infrastructure through the creation of dedicated multidisciplinary teams and meetings for deliberation all contribute to promoting deliberation as a central part of practitioners everyday routine to encourage this streetlevel managers and local policymakers should pay attention to the context in which deliberation is to be performed taking into account the mundane aspects of time space and relationships they should acquire a keen understanding of the everyday routines of their streetlevel practitioners and the ends that their practitioners have in view when they perform their actions we can apply these insights to theories of streetlevel management more generally which have emphasized the need for managementbyenabling recent research indicates that decisionmaking processes can be structured through professionalization peer review and collective decisionmaking procedures even more recently it has been argued that the development of routines could be a management tool our insights show the possibilities and complexities of structuring streetlevel decisionmaking processes through routine design and highlight the importance of paying attention to the situated and sequenced nature of streetlevel actions we would also like to point to the need for regular dialogue as a vital element of managementbyenabling increased discretionary room and an emphasis on deliberation depend on local policymakers streetlevel managers streetlevel practitioners and governed publics to frequently interact to demarcate the playing field and help to make routines run smoothly this can be facilitated by organizing a periodic dialogue in which relevant actors diagnostically reflect monitor and adjust the elements that structure streetlevel work by doing so systemic problems in streetlevel work can be detected early and change can be initiated in local policy procedures organizational structures routines and accountability requirements in turn scholars of streetlevel decisionmaking need to pay more attention to the interactions between streetlevel practitioners on the one hand and local policymakers and streetlevel managers on the other to better grasp and develop theories of managementbyenabling that allow for streetlevel creativity and improvisation in their everyday deliberation situated performances of and changes to a deliberative routine have consequences for the actual shape of policies we know from the literature that deliberation helps to diminish experienced uncertainty and provides emotional support filters idiosyncratic judgments that are embedded in assumptions and moral dispositions and has the potential to fuel the development of customized and responsive solutions applying these existing insights to our analysis makes us wary that the choice for a certain route might enhance but can also inhibit the positive effects of deliberation deviations in the performance of deliberative routines could lead to feeling social pressures to falling back on existing repertoires and relationships or to excluding relevant perspectives due to professional turf wars ignorance conformity and groupthink specifically the exclusion of racial gender class or ethnic perspectives might create serious risks for the equal treatment of already vulnerable citizens in addition the choice for informal deliberative routes obfuscates how decisions have come about who has been involved and whether a thorough discussion has been part of the decisionmaking process and lastly the deliberative processes and the necessary work to maintain them comes with emotional work of its own possibly creating new uncertainties for practitioners to understand how practitioners deal with emotions and social pressures relationships with peers are important to further look into it is well possible that the longterm development of relationships and identities among peers and between peers and managers plays a role in the patterning of routines over time but our data do not allow us to confirm or deny this the risks and high probability of practitioners deviating from routine design for deliberation raises questions regarding the extent to which we can or should trust practitioners to organize their own work and make customized decisions discretion has important responsive potential while inhibiting discretion has proven complex and has often had perverse effects of hidden invisible streetlevel practices and outcomes our analysis of the intentionality of routine performance shows that predefined goals cannot simply be imposed to orient practitioners actions therefore we do not argue for less discretionary room to prevent the risks of routine change that we mentioned above so as to achieve more equal more purposeful or more accountable streetlevel actions rather we believe that practitioners discretionary room should be structured and managed to prevent its own perverse effects creative collective discretion both in customized decisions and in the organization and repair of work processes requires managers to devote ongoing attention to it and to engage in a constructive dialogue with their streetlevel colleagues furthermore granting discretionary space is not without obligations and we should look into ways to realize better registration and documentation practices by practitioners whether they enjoy much discretionary room or not in bringing about better registration and documentation practices we need to take into account not only the purpose of procedural accountability but also look into how it aligns with and can contribute to practitioners intentions effective registration has the potential to simplify practitioners work when it serves as a mnemonic device or even to make practitioners work meaningful for instance when it prevents clients from having to tell their story to many different care providers the further structuring of practitioners routine change forms of creative discretion and registration practices requires additional research limitations and suggestions for further research this ethnographic case study of child and family services in the netherlands has allowed us to observe the situated performance of deliberation in everyday work through participant observation over an extended period of time combined with interviews and document analysis we mapped patterns and variations purposes and ambiguities of how a deliberative routine was brought into being and changed this study and its design however have a number of limitations we observed 92 performances of routines allowing comparison between them but all these performances occurred within one organization within a specific type of streetlevel work and within specific local and national contexts our findings can therefore be insightful for other cases but their transferability depends on similarities and differences within other research settings child and family services in the netherlands are in the midst of an important transformation having been decentralized recently pursuing customized services deliberation became a central element of streetlevel decisionmaking for which child and family services in the netherlands provided a wellsuited case to explore the situated performance of deliberative routines the practitioners professional background made them familiar with peer review and casuistry possibly spurring their embracing of deliberation local characteristics such as the relative independence of and minimum overview by managers and the relinquishing of many of the standardized procedures have contributed to quite large degree of freedom to deviate from the initial routine design and develop new patterns for which we expect this to be a relatively atypical case yet as cooperation with a variety of peers across organizations and sectors and the customization of public services seem to increase across contexts and as deliberation among streetlevel practitioners is ubiquitous we believe our findings do have relevance well beyond our case the question remains then how exactly deliberative routines are performed and developed in other settings we therefore encourage additional comparative research in other local settings other domains and other countries to expand our knowledge of the processes comprising deliberative routine performance and development although it might take different shapes we expect that in other settings the situated performance of deliberative routines is in big part shaped by contextual factors and particular endsinview possibly leading to new patterns and opening the possibility for reflection the depiction of the process of situated performance and development of deliberative routines that we have described could therefore serve as an analytical tool to further explore deliberation in different streetlevel contexts specifically we believe further research is needed that examines how to structure and manage streetlevel deliberation specifically when there is a relatively large amount of discretionary room relatedly future research should scrutinize the interactions between streetlevel practitioners managers and policymakers and thoroughly analyze managerial attempts to facilitate change at the street level additionally a more systematic understanding of practitioners reflections could be developed and how that spurs both streetlevel decisionmaking and the development of deliberative routines finally research is needed to understand the emotional work that streetlevel practitioners enact in order to maintain their internal deliberative processes to provide customized services we conclude with the hope that by offering an empirically grounded process depiction of situated performance and development of deliberative routines and by raising awareness of its consequences and risks this study provides a basis to further explore these issues for both research and practice data availability because of the sensitive nature of the work observed confidentiality promised to research participants and the very limited possibility to anonymize our ethnographic data data cannot be shared beyond what appears in the manuscript and its appendices the online appendices include notes on positionality an overview of research participants interview guides an overview of the analytical process data coding examples and a detailed case description supplementary material supplementary data are available at the journal of public administration research and theory online conflict of interest the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article

deliberation is ubiquitous in streetlevel work scholars and practitioners increasingly promote it as it has the potential to improve existing practices and procedures and provide customized yet consistent services little is known however about the situated performance of deliberation in streetlevel work drawing on routine dynamics theory and based on an ethnographic study of streetlevel decisionmaking in child and family services in the netherlands including document analysis 300 hours of observations and interviews in two teams in one organization we uncover the performance of deliberative routines and their development over time demonstrating how contextual factors and the prioritization of particular ends play a role in these routines we contribute to a better understanding of the dynamic and reflective performance of streetlevel deliberation in addition providing a more nuanced view of routines and elaborating on some possibilities for enabling management thereof we contribute to a better understanding of the complex and iterative organization of streetlevel work